(a) Available sanctions. The Department is authorized to take any of the following actions after determination that a provider has engaged in conduct described by this Chapter: - (i) Educational intervention;
- (ii) Recovery of overpayments;
- (iii) Postpayment review of claims;
- (iv) Prepayment review of claims;
- (v) Suspension of payments;
- (vi) Suspension of provider agreement;
- (vii) Termination of provider agreement;
- (viii) Conditional future provider agreement;
- (ix) Additional sanctions; or
- (x) Referral to appropriate State regulatory agency, licensing agency; or MFCU.
(b) Decision to impose sanctions. When making a decision to impose sanctions, the State Medicaid Agent, or other designee shall consider: - (i) The nature and extent of the provider's violations;
- (ii) The provider's history of previous violations;
- (iii) Actions taken or recommended by other State regulatory or licensing agencies; and
- (iv) The steps taken by the provider to reduce the possibility of future violations.
(c) Grounds. The Department is authorized to impose sanctions against a provider for: - (i) Suspected or substantiated fraud, theft or abuse of services in submitting claims;
- (ii) A pattern of presenting false or duplicate claims or claims for services not medically necessary;
- (iii) A pattern of making false statements of material facts for the purpose of obtaining overpayments;
- (iv) Failure to comply with the provisions of the provider agreement;
- (v) Remedies imposed by CMS or the Department;
- (vi) Lack of requested documentation;
- (vii) Situations that pose a threat to the health, safety, or welfare of the clients or general public;
- (viii) Suspension or termination of state licensure or any certification required to provide services;
- (ix) Lack of or repeated failure to provide documentation of Medicaid services;
- (x) Inability to collect overpayments;
- (xi) Failure to maintain current contact information as described in Chapter 3;
- (xii) Exclusion by the Office of Inspector General;
- (xiii) Lack of claims activity for one (1) year;
- (xiv) Termination/exclusion under Medicare, CHIP or another State's Medicaid program;
- (xv) Refusal to grant access to records as required by Chapter 3; or
- (xvi) Violation of Medicaid, Department, or other State or Federal statute, rule, or law relating to provisions of services.
(d) Notice of sanctions. After determining to impose sanctions against a provider, the Department shall send written notice to the provider by certified mail, return receipt requested. The notice shall include: - (i) The notice requirements set forth in Chapter 4 as applicable;
- (ii) The provider's right to request reconsideration of that determination pursuant to Section 20 of this Chapter; and
- (iii) That the failure to request reconsideration shall preclude any further appeal of the decision to impose sanctions.
(e) If the sanction specified in Section 17 of this Chapter has been imposed, and after all administrative and judicial appeals and any applicable appeal periods have been exhausted, the Department shall send written notice to the public, known beneficiaries, known entities where the Provider was receiving payment for services, MFCU, Utilization and Quality Control Quality Improvement Organizations, the appropriate professional society, the appropriate state licensing agency, CMS, Office of Inspector General (OIG), and any other appropriate authority. Such notice shall include the sanction, the findings of fact which led to the sanction and the results of any appeals pursuant to 42 CFR 1001.2005 and 2006 and 42 CFR 1002.212.
(f) Effective date of sanction. - (i) The following sanctions shall be effective upon the receipt of notice:
- (A) Suspension or termination for issues involving situations that pose a threat to the health, safety, and welfare of clients and/or the general public; and
- (B) Suspension or termination of state license or any certification required to provide services pursuant to these rules.
- (ii) The following sanctions shall be effective on the date specified in the notice of sanction sent pursuant to subsection (c):
- (A) Recovery of overpayments;
- (B) Postpayment review of all claims submitted by the provider;
- (C) Prepayment of claims submitted by the provider;
- (D) Referral to the appropriate State regulatory agency, licensing agency, or MFCU;
- (E) Conditional future participation; and
- (F) Withholding of future payments and suspension of the provider's certification.
048-16 Wyo. Code R. § 16-9