(a) Available actions. The Department is authorized to take any of the following actions after a determination that a client has engaged in conduct described by this Chapter: - (i) Refer the client to educational intervention to correct inappropriate or dangerous utilization of services;
- (ii) Recover overpayments from the client, to the extent permitted by law;
- (iii) Restrict the client's future participation in Medicaid to receiving services from the provider or providers designated by the Department. Medicaid payments shall be limited to the designated provider, except for payments for emergency care; or
- (iv) Any other action allowed by state or federal law.
(b) Decision to impose sanctions. The decision to take action pursuant to this Section shall be made by the State Medicaid Agent, or other designee, who shall consider, among other things: - (i) The nature and extent of the client's violations; and
- (ii) The client's history of previous violations.
(c) Grounds for referral. The Department may refer a client pursuant to Section 5(b) of this Chapter for actions including, but not limited to: - (i) Fraud, theft or abuse in obtaining services;
- (ii) Alteration or duplication of the client's Medicaid identification card;
- (iii) Permitting, authorizing or assisting a non-client to use the client's Medicaid identification card to obtain services;
- (iv) Using another client's Medicaid identification card to obtain services;
- (v) Alteration or duplication of a prescription;
- (vi) Knowingly misrepresenting material facts regarding the client's physical or mental condition for the purpose of obtaining services;
- (vii) Knowingly furnishing incorrect information regarding eligibility to a provider;
- (viii) Knowingly furnishing incorrect information to a provider to obtain services which are not medically necessary; or
- (ix) Obtaining services by any false or incorrect pretenses.
(d) Notice of sanctions. After determining to impose sanctions against a client, the Department shall send written notice to the client by certified mail, return receipt requested. The notice shall include: - (i) The notice requirements set forth in Chapter 4 as applicable; and
- (ii) The client's rights to request reconsideration of that determination pursuant to Section 20 of this Chapter.
(e) Effective date of action. The effective date of the action shall be specified in the notice.
048-16 Wyo. Code R. § 16-10