Fraud and Abuse Referral Form

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If you suspect any fraud or abuse of publicly-supplied vaccine please report the activity by submitting the form below. We cannot release information about the status of or findings from an investigation of suspected Fraud or Abuse. Information collected during the investigation may be shared with the Wyoming Department of Health and other government agencies, as allowed by law.

What is Fraud? Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

What is Abuse? Abuse refers to provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program, (and/or including actions that result in an unnecessary cost to the immunization program, a health insurance company, or a patient); or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

Suspected Fraud and Abuse Complaint

Date of Incident/Observation:

YYYY

Name of facility suspected of fraud or abuse:

Name of individual(s) suspected of fraud or abuse:

Department/Service Area(s) involved in the suspected fraud or abuse:

Please select the type of fraud or abuse that are reporting:

Vaccine administered to ineligible patients

Charging more than the established maximum regional charge for administration of a publicly-funded vaccine

Denying eligible children publicly-funded vaccine because of parent's inability to pay the administration fee

Other:

Clear selection

Description of suspected fraud or abuse in as much detail as possible. Include such things as the date alleged activity occurred, whether or not the alleged behavior is still occurring, and if a supervisor or any other personnel, law enforcement or outside agency was notified about this allegation:

What type of documentation are you able to provide in support of this report of fraud and abuse?

(Examples: copies, photos, schedules, statements etc.)

Names of witnesses or others who may have knowledge of this allegation (Please include contact information if possible):

How did you become aware of the incident(s)?

(Examples: witnessed firsthand, heard it from another person, etc.)

Additional Comments:

Person Reporting

I wish to remain (choose one):

Anonymous

Confidential

No Restriction

Clear selection

Name:

Address:

Phone:

Email:

Preferred Method of Contact:

Phone

Do Not Contact

Clear selection

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This form was created inside of State of Wyoming. Report Abuse

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