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Federal and State Program Integrity in Ohio

To ensure the integrity of Ohio’s medical assistance programs, the law provides a number of fraud, waste and abuse provisions governing the Medicaid and Medicare programs.  The Ohio department of job and family services will establish a program to detect and prevent fraud, waste and abuse in the Medicaid program, including submission of false claims.1  Managed health care programs must have procedures to guard against fraud and abuse, and must report all instances of fraud and abuse to the department of job and family services.2  Medicaid fraud will be considered a first-degree misdemeanor, and, depending on the monetary amount of the fraud, can be a fifth, fourth or third degree felony, with all associated penalties available.3  Submission of a false claim to the Medicaid program will subject a provider to a range of penalties, including repayment of an amount equal to three times the amount of excess payment, a monetary penalty of $5,000 to $10,000 for each false claim, payment of interest, other reasonable expenses incurred by the state and termination of the provider agreement.4

 

Footnotes

  • 1. Ohio Admin. Code 5101:3-1-29
  • 2. Ohio Admin. Code 5101:3-26-06
  • 3. Ohio Rev. Code § 2913.40
  • 4. Ohio Rev. Code § 5111.03

 

Federal and State Program Integrity in Ohio

Subtopic Statute/Regulation Description
Fraud and abuse provisions about Medicaid or Medicare: Anti-kickback laws Managed health care programs: program integrity – fraud and abuse, audits, reporting, and record retention – Ohio Admin. Code 5160-26-06 Managed health care programs (MCPs) must have administrative and managed arrangements or procedures, including a mandatory compliance plan, to guard...
Medicaid fraud – Ohio Rev. Code Ann. § 2913.40 “Medicaid fraud”   The following acts will be considered Medicaid fraud: Making a false or misleading statement or...
Medicaid fraud, waste and abuse – Ohio Admin. Code 5160-1-29 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...
Fraud and abuse provisions about Medicaid or Medicare: False claims submitted to Medicaid or Medicare Managed health care programs: program integrity – fraud and abuse, audits, reporting, and record retention – Ohio Admin. Code 5160-26-06 Managed health care programs (MCPs) must have administrative and managed arrangements or procedures, including a mandatory compliance plan, to guard...
Medicaid fraud – Ohio Rev. Code Ann. § 2913.40 “Medicaid fraud”   The following acts will be considered Medicaid fraud: Making a false or misleading statement or...
Medicaid fraud, waste and abuse – Ohio Admin. Code 5160-1-29 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...
Fraud and abuse provisions about Medicaid or Medicare: Laws prohibiting self-referrals Managed health care programs: program integrity – fraud and abuse, audits, reporting, and record retention – Ohio Admin. Code 5160-26-06 Managed health care programs (MCPs) must have administrative and managed arrangements or procedures, including a mandatory compliance plan, to guard...
Medicaid fraud – Ohio Rev. Code Ann. § 2913.40 “Medicaid fraud”   The following acts will be considered Medicaid fraud: Making a false or misleading statement or...
Medicaid fraud, waste and abuse – Ohio Admin. Code 5160-1-29 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...
False claims submitted to Medicaid Provider offenses – Ohio Rev. Code Ann. § 5164.35 Obtaining or attempting to obtain payments from the Medicaid program to which a provider is not entitled will subject the provider to the following...
Penalties for false claims Provider offenses – Ohio Rev. Code Ann. § 5164.35 Obtaining or attempting to obtain payments from the Medicaid program to which a provider is not entitled will subject the provider to the following...