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Medicaid fraud, waste and abuse – Ohio Admin. Code 5160-1-29

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The Ohio department of job and family service will have a program to prevent and detect fraud, waste, and abuse in the Medicaid program.  Cases of fraud, waste, and abuse may include the following:

  • A pattern of duplicate billing by a provider to obtain reimbursement to which the provider is not entitled;
  • Misrepresentation as to services provided, quantity provided, date of service, or to whom provided;
  • Billing for services not provided;
  • A pattern of billing, certifying, prescribing, or ordering services that are not medically necessary or reimbursable, not clinically proven and effective, and not consistent with Medicaid program rules and regulations; and
  • Misrepresentation of cost report data so as to maximize reimbursement and/or misrepresent gains or losses.

Current as of June 2015