Current through all regulations passed and filed through September 16, 2024
(A) For purposes of this rule, the following
definitions apply:
(1)
"Abuse" has the same meaning as in
42 C.F.R.
455.2 (as in effect on October 1,
2023).
(2)
"Fraud" has the same meaning as in
42 C.F.R.
455.2 (as in effect on October 1,
2023).
(3)
"Waste" means any preventable act such as inappropriate
utilization of services or misuse of resources that results in unnecessary
expenditures to the medicaid program.
(B) The Ohio department of medicaid (ODM)
will
have in effect a program to prevent and detect fraud, waste, and abuse in the
medicaid program. Where cases of suspected fraud to obtain payment from the
medicaid program are detected, providers will be subject to a review by ODM and
the case will be referred to the attorney general's medicaid fraud control unit
or the
appropriate enforcement officials. If waste and abuse are suspected or
apparent, ODM,
the office of the attorney general, or both will take action to gain compliance and
recoup inappropriate or excess payments in accordance with rule
5160-1-27 or
5160-26-06 of the Administrative
Code.
(C) Cases of provider fraud,
waste, and abuse may include, but are not limited to, the following:
(1) A pattern of duplicate billing by a
provider to obtain reimbursement to which the provider is not
entitled.
(2) Misrepresentation as
to services provided, quantity provided, date of service, who performed the
service or to whom services were provided.
(3) Billing for services not
provided.
(4) A pattern of billing,
certifying, prescribing, or ordering services that are not medically necessary
or reimbursable in accordance with rule
5160-1-01 of the Administrative
Code, not clinically proven and effective, and not consistent with medicaid
program rules and regulations.
(5)
Differing charges for the same services to medicaid versus non-medicaid
recipients. For inpatient hospital services billed by
hospitals reimbursed on a prospective payment basis, ODM will not pay, in the
aggregate, more than the provider's customary and prevailing charges for
comparable services.
(6) Violation
of a provider agreement by requesting or obtaining additional payment for
covered medicaid services from the
recipient or the
recipient's family, other than medicaid co-payments as
designated in rule
5160-1-09 of the Administrative
Code, or from other providers.
(7) Collusive activities involving the
medicaid program between a medicaid provider and any person or business
entity.
(8) Misrepresentation of
cost report data so as to maximize reimbursement or misrepresent
gains or losses.
(9) Billing for
services that are outside the current license limitations, scope of practice,
or specific practice parameters of the person supplying the service.
(10) Misrepresenting by commission or
omission any information on the provider enrollment and revalidation
application, provider agreement, or any documentation supplied by the provider
to ODM.
(11) Ordering excessive
quantities of medical supplies, drugs and biologicals, or other
services.
(12) Any action which
would constitute a violation of the False Claims Act (October 1,
2023), 31 U.S.C.
3729-3733.
(13)
Non-compliance
with the service definitions, activities, coverage, and limitations as listed
in the applicable provisions in agency 5160 of the Administrative
Code.
(D) ODM will
not pay for services prescribed, ordered, or rendered by a provider, when those
services were prescribed, ordered, or rendered by that provider after the date
the provider was terminated under the medicaid program in accordance with rule
5160-1-17.6 of the
Administrative Code.
(E) In
instances when a provider suspects that there may be fraud, waste, or abuse by
a recipient, the provider should contact the local
county department of job and family services (CDJFS). Cases of
recipient fraud, waste, and abuse may include, but are
not limited to:
(1) Alteration, sale, or
lending of the medicaid card to others for securing medical services, or other
related criminal activities.
(2)
Receiving excessive medical visits and services.
(3) Obtaining services not personally needed
and used by the recipient.
(4)
Any action to
falsely obtain medicaid eligibility as described in section
2913.401 of the Revised
Code.
(F)
Providers will assume responsibility for the business practices of employees.
In accordance with rule
5160-1-17.2 of the
Administrative Code, the Ohio medicaid provider agreement states that each
provider will comply with the terms of the provider agreement, Revised Code,
Administrative Code, and federal statutes and rules. Providers will take the
necessary time to thoroughly acquaint themselves and their employees with all
rules relative to their participation in the medicaid program. Ignorance of
medicaid program rules will not be an acceptable justification for violation of
the provider agreement, relevant statutes, or rules.
