(a) Authorization. The Department shall recover claim overpayments submitted by a provider and paid by Medicaid. The Department may recover overpayments from a clinic, group, corporation, professional association, or other organization of any current or former member of that practice. The Department may also recover overpayments from an individual provider that was formerly part of a clinic, group, corporation, professional association or other organization.
(b) General Procedure. - (i) Notice of overpayments. After determining that a provider has received overpayments, the Department shall send written notice, by certified mail, return receipt requested, to the provider. In addition to the requirements for notice of adverse action contained in Chapter 4, the notice shall include:
- (A) The amount of the overpayments; and
- (B) The basis for the determination of overpayments.
- (ii) Reimbursement of overpayments. A provider must reimburse the Department for overpayments within thirty (30) days after the provider receives written notice from the Department of the overpayments. Neither the filing of a request for reconsideration nor a request for an administrative hearing shall stay the effective date of the adverse action.
- (iii) Methods of recovery of overpayments. If a provider does not timely reimburse the Department, following final administrative action, the Department shall recover the overpayments by:
- (A) Withholding all or part of Medicaid payments:
- (I) Payments shall be withheld at one hundred percent (100%);
- (II) Payment arrangements can be made if the provider can demonstrate that one hundred percent (100%) withholding will result in an undue hardship, with the approval of the State Medicaid Agent or his or her designee;
- (B) Initiating a civil lawsuit against the provider; or
- (C) Any other method of collecting a debt or obligation permitted by law.
- (iv) Overpayments involving providers who are bankrupt or out of business. The Department must notify the provider that an overpayment exists in any case involving a bankrupt or out-of-business provider and take reasonable actions to recover the overpayment during the sixty (60) day recovery period in accordance with 42 CFR § 433.318. The Department shall also take action to be listed as a creditor in bankruptcy proceedings.
(c) Department claim adjustments/denials. - (i) Time of claims adjustment. The Department shall make a claim adjustment after Medicaid payment has been made, in which case recovery of the adjusted amount may be made pursuant to this Section.
- (ii) Denial of improper claims. The Department shall deny claims which are improperly submitted or which contain errors of any kind. Such claims may be resubmitted, subject to applicable federal and state requirements.
- (iii) No reconsideration or administrative hearing. A provider may not request reconsideration or an administrative hearing regarding a claims adjustment/denial.
(d) Repayment of credit balance. - (i) A provider shall repay any credit balance within thirty (30) days after the date such credit balance is identified by the Department or the provider.
- (ii) A provider credit balance can be collected from the same provider under another provider number if that provider number is listed with the same tax identification number.
- (iii) Lump sum adjustment. If an identified credit balance is not timely paid to the Department, the Department may recover the balance pursuant to this section or as otherwise allowed by the Department's Medicaid Rules.
- (iv) No reconsideration or administrative hearing. A provider may not request reconsideration or an administrative hearing regarding a credit balance.
(e) Medicaid allowable payment. - (i) Compliance with Wyoming Medicaid rules. A provider must comply with the Medicaid allowable payment provisions of the Wyoming Medicaid Rules.
- (ii) Payments which exceed Medicaid allowable payment. Any payment which exceeds the Medicaid allowable payment for the service shall be recovered pursuant to this section.
- (iii) No reconsideration or administrative hearing. A provider may not request reconsideration or an administrative hearing regarding a recovery of payments which exceeds the Medicaid allowable payment.
048-16 Wyo. Code R. § 16-12