(a) The Department shall be responsible for the detection of suspected fraud, theft, or abuse of services.
(b) The Department is authorized to investigate, or to refer to appropriate agencies for investigation, suspected fraud, theft, or abuse of services identified pursuant to this section. An investigation shall be for the purpose of determining if: - (i) The identified practice is lawful and/or in compliance with existing rules and regulations and state and federal laws;
- (ii) Fraud, theft, or abuse of services exists and can be documented;
- (iii) Sufficient evidence can be developed to support the recovery of overpayments, the imposition of sanctions or any other civil or criminal action permitted by law; or
- (iv) The matter should be referred for additional investigation or other action by a law enforcement agency or Medicaid Fraud Control Unit (MFCU).
(c) The Department's investigation may include, but is not limited to: - (i) Examination of medical, financial, or patient records;
- (ii) Interviews of providers, their associates, agents or employees, or contractors;
- (iii) Verification of a provider's professional credentials, the credentials of the provider's associates, agents, employees, or contractors;
- (iv) Interviews with clients;
- (v) Examination of equipment, supplies or other items used in a client's treatment;
- (vi) Examination of prescriptions;
- (vii) Random sampling and extrapolation pursuant to Section 8 of this Chapter; and
- (viii) Examination of financial records, including, but not limited to, insurance claims or records, or records of any other source of payment.
(d) Sources of information. For purposes of performing its duties under this Chapter, the Department may use information from sources including, but not limited to: - (i) Units of state, local or the federal government;
- (ii) Other third-party payers of health services, including health insurance carriers;
- (iii) Professional review organizations;
- (v) Computer reports based on Medicaid claims data generated by the Department, Medicaid Management Information System, or the fiscal agent; or
- (vi) Contractors hired by the Department to assist in the administration of the Medicaid program.
(e) Post-investigation actions. After the completion of an investigation, the Department shall either: - (i) Determine that no further action is warranted;
- (ii) Take action pursuant to this Chapter; or
- (iii) Refer the matter to law enforcement, the Wyoming Attorney General, Health and Human Services (HHS), Prosecution Recovery Investigation Collection and Enforcement (Price), the MFCU, or other appropriate authorities for possible civil or criminal action.
048-16 Wyo. Code R. § 16-4