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

Client Alert

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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.


CMS Rescinds EMTALA Guidance for Emergency Abortions

On June 3, 2025, CMS withdrew its 2022 guidance on emergency abortion care under EMTALA, eliminating federal protection for providers in states with abortion restrictions. This policy change could significantly impact how hospitals handle emergency care involving pregnancy complications.

Supreme Court Eliminates Higher Burden for Majority-Group Plaintiffs in Title VII Claims

In Ames v. Ohio Department of Youth Services, the U.S. Supreme Court unanimously ruled that all Title VII plaintiffs, whether from majority or minority groups, must meet the same evidentiary standard. The decision eliminates the “background circumstances rule” and reinforces equal treatment in workplace discrimination claims.

Understanding Reasonable Fear vs. Credible Fear Interviews: A Critical Guide for Immigrants Facing Removal

In his latest article, Immigration Attorney and former Immigration Judge Rob Ratliff offers a clear breakdown of Reasonable Fear vs. Credible Fear Interviews—key procedures for noncitizens seeking protection from persecution or torture. Citing Judge Brian Murphy’s recent ruling on unlawful deportations to South Sudan, Ratliff connects these critical legal standards to current judicial developments. Read the full article at www.removal-defense.com.

House Republicans Propose Cuts to Medicaid to Finance Savings

House Republicans have introduced legislative language that proposes substantial cuts to the Medicaid entitlement program, aiming to achieve significant budget savings through policy changes. The proposed measures include stricter eligibility verification, work requirements for certain adults, and federal funding cuts to states providing coverage to undocumented residents. The Congressional Budget Office (CBO) estimates that the proposed healthcare provisions would reduce spending by $715 billion and could result in 8.6 million fewer people having health insurance by 2034.

Protecting Your Image in the Age of AI-Generated “Deepfakes”

The rapid evolution of artificial intelligence (AI) has transformed how we create and consume digital content, but it also poses significant risks. Among the most troubling developments in AI is the proliferation of AI-generated fraudulent content, often called “deepfakes”.