FAQ > Health Care Fraud FAQs
Frequently Asked Questions
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What is Medicaid Fraud?
The medical assistance program, or Medicaid, is a vital program that provides health care benefits to low income and medically fragile Ohioans of all ages. The program is administered by the Ohio Department of Job and Family Services, which contracts with providers (e.g. doctors, dentists, hospitals, nursing homes, and medical equipment suppliers, etc.) to deliver needed goods and services to eligible Medicaid recipients, and then reimburses the providers for the goods and services they deliver.
When providers knowingly make false or misleading statements in association with claims for reimbursement of goods or services under the Medicaid program, they commit the criminal offense of Medicaid Fraud, codified in Ohio law at Revised Code Section 2913.40. Examples of Medicaid Fraud schemes include: billing for products and services not delivered; billing for a more expensive product or service than was actually delivered; billing separately for services that should be billed together; billing twice for the same product or service; dispensing generic drugs and billing for brand-name drugs; denying services to eligible recipients or not providing the level of service medically necessary/required; and submission of false information on Medicaid cost reports. The statute also prohibits Medicaid providers from charging co-pays and prohibits the payment of kickbacks or rebates in connection with the delivery of goods or services for which Medicaid reimbursement is sought.
We all share the cost of this $23 billion a year program, and provider fraud costs the taxpayers of this state millions of dollars each year, depriving the neediest among us of the care necessary to maintain quality of life. Attorney General Yost is committed to fighting fraud and corruption in state government and the programs for which our elected officials have statutory responsibility. Ohio’s Medicaid Fraud Control Unit is recognized as one of the finest and most effective in the country, and we are working every day to safeguard the tax dollars you have entrusted to our care.
If you suspect Medicaid Fraud, or have specific knowledge of corrupt or deceptive practices by Medicaid providers, you should contact the Ohio Attorney General’s Medicaid Fraud Control Unit at 614-466-0722, or the Attorney General’s Help Center at 800-282-0515.
What is Patient Abuse/Patient Neglect?
When we entrust our loved ones to a long term care facility, we expect them to receive the best care possible. Despite the fact that most facilities take care to ensure the safety of their residents, abuse and neglect occur. Patient abuse and neglect are serious crimes. Our most vulnerable citizens are often completely dependent upon the care and services provided by the facilities in which they reside. It is tragic to think that when abuse occurs, these patients find themselves in the care of the same people that are responsible for the abuse.
Ohio Revised Code Section 2903.34 makes it a crime for any person who owns, operates, administers, is employed by, or is an agent of a care facility to abuse or neglect a resident of that facility. The term “care facility” applies to nursing homes, group homes, residential facilities run by the Department of Mental Health or Mental Retardation and Developmental Disabilities, and long term care units of hospitals.
Ohio Revised Code Section 2903.33 defines “abuse” as “knowingly causing physical harm or recklessly causing serious physical harm to a person by physical contact with the person or by the inappropriate use of physical or chemical restraint, medication, or isolation.” It is a violation of this statute for staff to use a restraint, medication, or isolation as “punishment, for staff convenience, excessively, as a substitute for treatment, or in quantities that preclude habilitation and treatment.” This same statute defines “neglect” as “recklessly failing to provide a person with any treatment, care, goods, or services that is necessary to maintain the health or safety of the person when the failure results in serious physical harm to the person.”
Attorney General Yost has statutory authority to investigate these crimes and he is committed to ensuring the safety of Ohio’s long term care facility residents. If someone you know is a victim of Patient Abuse or Patient Neglect, you should contact the Ohio Attorney General’s Medicaid Fraud Control Unit at 614-466-0722, or the Attorney General’s Help Center at 800-282-0515.
What is Workers’ Compensation Fraud?
Fraud is a hidden cost of Workers’ Compensation Insurance that impacts employers, injured workers, health care providers and the general public. Contrary to what most people believe, workers’ compensation fraud is more than just an injured worker exaggerating his medical condition or working for cash while allegedly disabled. While these things do occur, employers are also committing fraud by underreporting their payroll to receive lower premiums, and health care providers are billing for services they’ve never performed. Workers compensation fraud is costing the industry and citizens of our state millions of dollars each year.
The criminal offense of Workers’ Compensation Fraud, codified in Ohio law at Revised Code Section 2913.48, occurs when someone knowingly makes a false statement or conceals information in order to receive workers’ compensation benefits to which they are not entitled or to prevent someone from receiving benefits to which they might be entitled. As examples, injured workers may commit fraud by exaggerating their symptoms, working while allegedly disabled, failing to report income, claiming job-related injuries that never occurred, or claiming that non-work related injuries are work-related. Employers may commit fraud by underreporting payroll or misclassifying employees for lower insurance premiums, deducting premium dollars from employee’s wages, or knowingly failing to maintain necessary workers’ compensation coverage. Health care providers may commit fraud by billing for goods or services they never provided, by providing medically unnecessary goods or services, or by billing the Bureau of Workers’ Compensation and other third party insurers for the same goods or services.
Attorney General Yost has statutory authority to prosecute these crimes, and he is committed to fighting fraud and corruption in state government and the programs for which our elected officials have statutory responsibility. If you suspect Workers’ Compensation Fraud, or have specific knowledge of corrupt or deceptive practices by claimants, employers, or health care providers, you should contact the Ohio Bureau of Workers’ Compensation at 800-OHIOBWC / www.ohiobwc.com.
To whom should I report a guardian’s failure to provide appropriate/necessary care for their ward?
To whom should I report abuse or neglect of a child?
You should report such allegations to the Department of Children’s Services in the county in which the victim resides. For a county by county directory of departments, please visit:
To whom should I report abuse, neglect, or financial exploitation of an adult?
If the victim resides in an Ohio care facility, you should report such allegations to the Ohio Attorney General’s Medicaid Fraud Control Unit at 614-466-0722, or the Attorney General’s Help Center at 800-282-0515. If the victim resides in a private residence, you should report such allegations to the Adult Protective Services Agency in the county where the victim resides. For a county by county directory of departments, please visit:
To whom should I report allegations of fraud by a Medicare provider?
You should report such allegation to the United States Department of Health and Human Services, Office of the Inspector General at 800-447-8477/
www.oig.hhs.gov.
You should report such allegation to the Ohio Department of Insurance at 800-686-1526 /
www.insurance.ohio.gov.
To whom should I report allegations of misconduct or unethical behavior by an attorney or judge?
To whom should I report an individual that I believe has fraudulently obtained food stamps?
You should report such individuals to the Ohio Department of Job and Family Services at 800-627-8133 /
www.jfs.ohio.gov
To whom should I report complaints about the quality of care provided by a health care professional?
You should contact the following regulatory agencies, as appropriate:
Where can I find information about care facilities in my area?
You can search for care facilities by city, county, state, and zip code by visiting the United States Department of Health and Human Services web site at
www.medicare.gov/NHCompare
Where can I find information about complaints filed against a particular Ohio care facility?
You should contact the Ohio Department of Health’s Public Information Department at 614-466-7217 /
www.odh.ohio.gov
Where can I find information about the rights afforded by Ohio law to care facility residents?
You should contact the Ohio Department of Aging’s Long Term care Ombudsman Program at 800-282-1206 /
www.aging.ohio.gov/home
Where can I get legal assistance in matters regarding the rights of the elderly or disabled?