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The Ohio Department of Medicaid Amends Fraud, Waste, and Abuse Rules

Client Alert
July 29, 2024

healthcare icons imposed over an image of a healthcare worker

Ohio Administrative Code rule 5160-1-29 Medicaid fraud, waste, and abuse provides definitions and examples of fraud, waste, and abuse and describes the Ohio Department of Medicaid's (ODM) program to detect, prevent, and address these issues. OAC 5160-1-29 has been reviewed as part of the five-year rule review process and has been amended to update definitions, language, and citations; add clarifying language; and remove regulatory restrictions in accordance with Ohio Revised Code section 121.95.

As part of its five-year review, ODM has reorganized and clarified the definitions of "Fraud" and "Waste and Abuse":

  • "Fraud" now explicitly refers to the definition in 42 C.F.R. 455.2
  • "Waste and abuse" is now split into two separate definitions:
    • "Waste" is any preventable act leading to unnecessary Medicaid expenditures.
    • "Abuse" is now defined as in 42 C.F.R. 455.2

ODM also adds specificity and clarity to the list of examples, including:

  • Misrepresentation of services, billing for services not provided, and violation of provider agreements.
  • New examples include misrepresenting information on provider applications, ordering excessive quantities of supplies, and non-compliance with service definitions.
    • Provider Fraud – “Non-compliance with the service definitions, activities, coverage, and limitations as listed in the applicable provisions in agency 5160 of the Administrative Code.”
    • Recipient Fraud – “Any action to falsely obtain Medicaid eligibility as described in section 2913.401 of the Revised Code.”

Please contact BMD healthcare attorney Daphne Kackloudis at dlkackloudis@bmdllc.com with questions.

Ohio Department of Medicaid
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