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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

The Ohio Board of Pharmacy’s Latest Batch of Rules: What Providers Should Know

January 15, 2024The Ohio Board of Pharmacy released several new rules and proposed amendments to existing rules over the past month that will significantly impact pharmacy operations. Topics range from updates to the Terminal Distributor of Dangerous Drugs license to mobile clinics to mandatory rest breaks for pharmacists of outpatient pharmacies. A summary of the proposed changes is below, along with instructions for commenting on the rules. Your BMD healthcare attorney can help write comment letters and submit the comments on your behalf as well.Client Alert

Employee or Independent Contractor? New Guidance Issued by the Department of Labor

January 10, 2024On January 9, 2024, the U.S. Department of Labor (DOL) issued its long-awaited final rule — effective March 11, 2024 — revising its prior interpretation of worker classifications under the federal Fair Labor Standards Act (FLSA). The new final rule rescinds the standard previously established in 2021, in turn, shifting the analysis of whether a worker is an employee (versus an independent contractor) of a business from a more streamlined “economic reality” test to a more complex “totality of the circumstances” standard.Client Alert

Increased Medicaid Rates to Take Effect This Month for Ohio Providers

January 5, 2024As required by House Bill 33, Ohio’s 2024-2025 operating budget bill, reimbursement rates paid by the Ohio Department of Medicaid will increase for a wide range of providers starting on January 1, 2024.Client Alert

Corporate Transparency Act Update

December 27, 2023The Corporate Transparency Act (“CTA”), with an effective date of January 1, 2024, is set to impose strict reporting guidelines on business owners throughout the country. The following provides a brief update on two aspects of the CTA ahead of its effectiveness next week.Client Alert

The Second Wave of UnitedHealthcare's Prior Authorization Cuts Started in November

December 11, 2023In August 2023, UnitedHealthcare released its plan to eliminate roughly one-fifth of its then-current prior authorization requirements. The first round of prior authorization cuts took effect on September 1, 2023. In that round, UnitedHealthcare eliminated the necessity for some prior authorizations for UnitedHealthcare Medicare Advantage, UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Individual Exchange plan members. The second and final round of prior authorization cuts began on November 1, 2023. The November 2023 Prior Authorization Cuts apply to the same plans as well as community plans (i.e., Medicaid managed care plans).
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