Q: What is Medicaid fraud?
A: Medicaid fraud can be committed in one of three ways: 1) when a person knowingly makes, or causes to be made, a false or misleading statement or representation to obtain reimbursement from the Medicaid program; 2) when a person solicits or accepts payment in exchange for services covered under the Medicaid program with the purpose of facilitating or committing a fraud; and 3) when a person falsifies, alters, or destroys documents necessary for reimbursement from the Medicaid program after submitting billings to Medicaid. Examples include acts such as billing for services or goods that were never provided, submitting false information on Medicaid cost reports, and providing medically unnecessary services. Medicaid fraud schemes may also involve providing kickbacks or rebates for goods or services for which Medicaid reimbursement will be sought; billing for more expensive products or services than were actually delivered; and billing separately for services that should be billed together.
Q: What are the penalties for Medicaid fraud?
A: Medicaid fraud is a crime. If the fraud involves sums greater than $150,000, it is a third-degree felony with maximum penalties of 36 months in prison and $10,000 in fines. Fraud involving sums of more than $7,500 but less than $150,000 is a fourth-degree felony with maximum penalties of 18 months in prison and $5,000 in fines. Fraud involving sums of more than $1,000 but less than $7,500 is a fifth-degree felony with maximum penalties of 12 months in prison and $2,500 in fines. Any fraud involving sums under $1,000 is a misdemeanor of the first degree with a maximum penalty of 180 days in jail and $1,000 in fines.
There are also potential civil consequences to Medicaid fraud. Individuals and entities convicted of Medicaid fraud and/or any related offenses are excluded from participation in all federal health care programs for a period of time determined by the Office of Inspector General, U.S. Department of Health and Human Servivces.
Q: What does the Ohio Attorney General’s Office do about Medicaid fraud?
A: Federal law authorizes Medicaid Fraud Control Units across the country to investigate allegations of fraud and abuse involving the Medicaid program. Forty-nine states and the District of Columbia have such units, and each is subject to annual recertification by the U.S. Department of Health and Human Services. In 1978, the Ohio General Assembly authorized the Attorney General to create and oversee the Ohio Medicaid Fraud Control Unit, and Ohio law grants this unit original criminal jurisdiction to investigate and prosecute Medicaid fraud statewide. The unit’s staff of more than 100 individuals includes special agents, analysts, nurses, paralegals and attorneys.
Q: What can I do if I suspect a health care provider of Medicaid fraud?A:
If you know about any instances of Medicaid fraud, you can contact the Ohio Attorney General’s Office at (614) 466-0722 or (800) 282-0515, send a fax to (877) 636-8334, or visit www.OhioAttorneyGeneral.gov/ReportMedicaidFraud
This “Law You Can Use” column was provided by the Ohio Attorney General’s Office and prepared by the Ohio State Bar Association.