Q:       What, exactly, is Medicaid fraud?

A:        Medicaid fraud involves making false or misleading statements, or causing such statements to be made, in order to get Medicaid reimbursement. Medicaid fraud may include such acts as billing for, but not providing, services or goods, and providing medically unnecessary services. Medicaid fraud schemes also may involve billing for a more expensive product or service than was actually delivered, billing separately for services that should be billed together, and billing twice for the same product or service. It is also illegal to: dispense generic medications while billing for more expensive brand-name drugs; submit false information on Medicaid cost reports; charge co-pays; and provide kickbacks or rebates for goods or services for which Medicaid reimbursement will be sought. Managed care organizations cannot deny service to eligible Medicaid recipients or fail to provide the level of service medically necessary or required.

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. Fraud involving sums of more than $7,500 but less than $150,000 is a fourth-degree felony. Fraud involving sums of more than $1,000 but less than $7,500 is a fifth-degree felony. Penalties may include fines, community control sanctions and, in some cases, prison. Individuals and entities convicted of Medicaid fraud and related crimes are required to be excluded from participation in all federal health care programs.

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 60 includes special agents, ana­lysts, nurses 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 614-644-9973, 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. Articles appearing in this column are intended to provide broad, general information about the law. Before applying this information to a specific legal problem, readers are urged to seek advice from an attorney.