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

Client Alert
July 29, 2024

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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.

Ohio Department of Medicaid
Client Alert

Enhancing Privacy Protections for Substance Use Disorder Patient Records

February 16, 2024On February 8, 2024, the U.S. Department of Health and Human Services (“HHS”) finalized updated rules to 42 CFR Part 2 (“Part 2”) for the protection of Substance Use Disorder (“SUD”) patient records. The updated rules reflect the requirement that the Part 2 rules be more closely aligned with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) privacy, breach notification, and enforcement rules as mandated by the Coronavirus Aid, Relief, and Economic Security Act of 2020.Client Alert

Columbus, Ohio Ordinance Prohibits Employers from Inquiries into an Applicant’s Salary History

January 30, 2024Effective March 1, 2024, Columbus employers are prohibited from inquiring into an applicant’s salary history. Specifically, the ordinance provides that it is an unlawful discriminatory practice to:Client Alert

The Ohio Chemical Dependency Professionals Board’s Latest Batch of Rules: What Providers Should Know

January 26, 2024The Ohio Chemical Dependency Professionals Board has introduced new rules and amendments, covering various aspects such as CDCA certificate requirements, expanded services for LCDCs and CDCAs, remote supervision, and reciprocity application requirements. Notable changes include revised criteria for obtaining a CDCA certification, expanded services for LCDCs and CDCAs, and updated ethical obligations for licensees and certificate holders, including non-discrimination, confidentiality, and anti-sexual harassment measures.Client Alert

Governor Mike DeWine and The Ohio State University Introduce the SOAR Study on Ohio Mental Illness

January 22, 2024On January 19, Ohio Gov. Mike DeWine and The Ohio State University announced a new research initiative, the State of Ohio Adversity and Resilience (“SOAR”) study, which will investigate all factors influencing Ohio’s mental illness and addiction epidemic.Client Alert

CHANGING TIDES: Summary and Effects of Burnett et. al. v. National Ass’n of Realtors, et. al.

January 17, 2024In April 2019, a class-action Complaint was filed in federal court for the Western District Court for Missouri arguing that the traditional payment agreements employed by many across the United States amounted to conspiracy resulting in the artificial increase in brokerage commissions. Plaintiffs, a class-action group comprised of sellers, argued that they paid excessive brokerage commissions upon the sale of their home as a result of the customary payment structure where Sellers agree to pay the full commission on the sale of their property, with Seller’s agent notating the portion of commission they are willing to pay to a Buyer’s agent at closing on the MLS or other similar system.
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