The Ohio Department of Medicaid (ODM) is the single state agency charged with administering Ohio’s Medicaid
program, and is responsible for minimizing fraud, waste and abuse in the Medicaid program. The State is required
to report fraud and abuse to the U.S. Department of Health and Human Services (HHS) and must also have a method
to verify whether services reimbursed by Medicaid were actually provided to beneficiaries.
The Ohio Department of Medicaid is continually adapting and improving its efforts to combat fraud, waste, and abuse in the Ohio Medicaid program through a complex and comprehensive collaboration of federal, state, local, and private entities in the health care industry. Cooperative, multi-faceted actions in prevention, detection, and recovery are critical to maintaining essential services in a cost effective and efficient program.
If waste and abuse are suspected or apparent, ODM takes action to ensure compliance and recoup inappropriate payments through audits and reviews in accordance with rule 5160:1- 27 or 5160:26-06 of the Ohio Administrative Code. Where fraud is suspected, ODM refers the case to the Ohio AG’s MFCU for further investigation.
The Ohio Department of Medicaid is continually adapting and improving its efforts to combat fraud, waste, and abuse in the Ohio Medicaid program through a complex and comprehensive collaboration of federal, state, local, and private entities in the health care industry. Cooperative, multi-faceted actions in prevention, detection, and recovery are critical to maintaining essential services in a cost effective and efficient program.
If waste and abuse are suspected or apparent, ODM takes action to ensure compliance and recoup inappropriate payments through audits and reviews in accordance with rule 5160:1- 27 or 5160:26-06 of the Ohio Administrative Code. Where fraud is suspected, ODM refers the case to the Ohio AG’s MFCU for further investigation.
What is Medicaid fraud?
Medicaid fraud occurs when a Medicaid provider knowingly makes, or causes to be made, a false or misleading statement or representation for use in obtaining reimbursement from the medical assistance program. This would include, but is not limited to, billing for services not provided, charging Medicaid more than the reasonable value of the services and providing services that were medically unnecessary.
Medicaid fraud occurs when a Medicaid provider knowingly makes, or causes to be made, a false or misleading statement or representation for use in obtaining reimbursement from the medical assistance program. This would include, but is not limited to, billing for services not provided, charging Medicaid more than the reasonable value of the services and providing services that were medically unnecessary.
Medicaid Fraud Control Unit:
Office of the Ohio Attorney General
The Ohio Medicaid Fraud Control Unit (MFCU) ranked first in criminal indictments and second
in criminal convictions among all units nationwide. The unit processed several complaints, posting indictments, convictions, and civil
settlements.
Office of the Ohio Attorney General
Program Integrity Group
The Ohio Medicaid Program Integrity Group (PIG) brings together representatives from ODM, the Auditor of State’s Office, and the Office of the Ohio Attorney General to craft data mining algorithms designed to identify fraudulent Medicaid providers and plan a coordinated response to these findings.
The Ohio Medicaid Program Integrity Group (PIG) brings together representatives from ODM, the Auditor of State’s Office, and the Office of the Ohio Attorney General to craft data mining algorithms designed to identify fraudulent Medicaid providers and plan a coordinated response to these findings.