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

Client Alert
July 29, 2024

healthcare icons imposed over an image of a healthcare worker

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

Ohio House Bill 537: Proposed Regulations for Midwives and Birthing Centers

January 28, 2026House Bill 537, introduced in the Ohio House of Representatives, proposes a comprehensive regulatory framework for certified nurse-midwives, certified midwives, licensed midwives, and traditional midwives. The legislation would clarify scope of practice, establish licensure standards, and impose new requirements for freestanding birthing centers and home births. Healthcare providers and facilities should be aware of the proposed changes and their potential operational impact.Client Alert

Proposed Health Information Privacy Reform Act Expands Protections Beyond HIPAA

January 26, 2026The Health Information Privacy Reform Act (HIPRA) seeks to extend privacy protections to health data not covered under HIPAA, including data collected by apps and wearables. HIPRA introduces broader definitions of protected health information, strengthens privacy and security requirements, establishes patient notification rights, and sets national de-identification standards. Companies processing health data should monitor developments to ensure compliance.Client Alert

Medicare Updates on Skin Substitutes: LCDs Withdrawn, Payment Changes Take Effect

January 23, 2026Medicare’s planned Final Local Coverage Determinations (LCDs) for skin substitutes were withdrawn in late December 2025, meaning previous coverage rules remain in effect. The 2026 Medicare Physician Fee Schedule introduces a single payment rate of approximately $127.14 for these products. Providers should review implications for diabetic foot and venous leg ulcer treatments.Client Alert

Understanding the Seven Core Elements of an Effective Healthcare Compliance Program

January 22, 2026The Affordable Care Act requires healthcare providers participating in Medicare, Medicaid, and CHIP to maintain an effective compliance program. Guidance from the Department of Health and Human Services and the Office of Inspector General outlines seven core elements that form the foundation of these programs, from written policies and compliance oversight to auditing, training, and corrective action. This alert highlights each element and explains how practices can tailor compliance programs to their size and risk profile while meeting federal expectations.Client Alert

Preventing a Board Investigation

January 21, 2026Healthcare professionals in Ohio are subject to licensing board investigations that can lead to disciplinary action. Staying compliant with regulations, documenting carefully, and operating within your professional scope can help prevent issues. If contacted by a board, working with an attorney is critical to protect your license and rights.
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