Ch. 16, § 12. Adverse Actions for Providers

(a) The Department may impose adverse actions against a provider for: (i) Suspected or substantiated fraud, waste, 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) Civil Remedies imposed by Centers for Medicare and Medicaid Services (CMS); (vi) Failure to render requested documentation; (vii) Situations that pose a threat to the health, safety, or welfare of the clients or general public; (viii) Suspension, termination, or expiration of state licensure or any certification required to provide services; (ix) Lack of or repeated failure to provide documentation of Medicaid services; (x) Provider's inability to repay overpayments; (xi) Failure to maintain current contact information; (xii) Exclusion by the Office of Inspector General; (xiii) Termination/exclusion under Medicare, Children's Health Insurance Program (CHIP) or another State's Medicaid program; (xiv) Failure to maintain records; (xv) Refusal to grant access to records; (xvi) Refusing to complete education; (xvii) Pending the completion of an on-going investigation conducted by the MFCU or another law enforcement agency; (xviii) Failure to notify the Department of the completion of a self-audit within sixty (60) days; (xix) Prosecution by the MFCU or another law enforcement agency and found guilty of healthcare fraud; (xx) Failure to submit any paid claims for over one (1) year; (xxi) Failure to submit an acceptable corrective action/quality improvement plan, or has failed to implement the corrective action/quality improvement plan approved by the Department; (xxii) The chronic failure to provide services pursuant to the individual plan of care; (xxiii) Providing services that fail to meet the applicable standard of care for the profession/service involved; (xxiv) There is a continuing condition creating serious detriment to the health, safety, or welfare of recipients of home and community-based waiver services; or (xxv) Violation of Medicaid, Department, or other State or Federal statute, rule, or law relating to provisions of services. (b) When making a decision to impose adverse actions, the State Medicaid Agent, or the Agent's 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) The Department may take any of the following adverse actions against a provider: (i) Educational intervention; (ii) Recovery of overpayments; (iii) Suspension of payments; (iv) Suspension of provider agreement; (v) Termination of provider agreement; (vi) Place conditions on the provider; (vii) Impose a monitor; (viii) Impose civil monetary penalties; (ix) Impose an immediate suspension; or (x) Impose an additional appropriate adverse action. (d) The Department shall send written notice of the adverse action, to the provider, via certified mail, return receipt requested. The notice shall include: (i) A statement of the intended action; (ii) The effective date of the intended action; (iii) The reason(s) for the intended action; (iv) The specific regulations that support, or the change in federal or state law that requires the action; (v) The provider's right to request reconsideration of the adverse action; (vi) The right to representation by a lawyer admitted to practice in Wyoming; and (vii) A statement that the failure to request reconsideration shall preclude any further appeal of the adverse actions. (e) If a provider agreement has been terminated, and all appeal periods have been exhausted, the Department shall send written notice of the adverse action 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 adverse action, the findings of fact which led to the adverse action and the results of any appeals pursuant to 42 CFR 1001.2005 and 2006 and 42 CFR 1002.212. (f) Effective date of adverse action. (i) Adverse actions shall be effective on the date specified in the notice of adverse actions. (ii) Suspension or termination of a provider shall be effective immediately in the following instances: (A) When the Department determines there is an imminent threat to the health, safety, or welfare of clients the general public; or (B) When the Department receives notice that a provider's state license, any certification required to provide services has been suspended or revoked, or when the provided has been terminated from another State Medicaid agency.