(A) For purposes of this rule, the following
definitions apply:
(1) "Fraud" is defined as
an intentional deception, false statement, or misrepresentation made by a
person with the knowledge that the deception, false statement, or
misrepresentation could result in some unauthorized benefit to oneself or
another person. It includes any act that constitutes fraud under applicable
federal or state law. If fraud is suspected or
apparent, referral of the case to the attorney general's medicaid fraud control
unit and/or the appropriate enforcement officials will be made by the Ohio
department of job and family services (ODJFS)
(2) "Waste and abuse" are defined as
practices that are inconsistent with professional standards of care; medical
necessity; or sound fiscal, business, or medical practices; and that constitute
an overutilization of medicaid covered services and result in an unnecessary
cost to the medicaid program.
(B)
ODJFS
The Ohio department of
medicaid (ODM) shall have in effect a program to prevent and detect
fraud, waste, and abuse in the medicaid program. Where cases of suspected fraud
to obtain payment from the medicaid program are detected, providers will be
subject to a review
or an audit by
ODJFS
ODM and the
case will be referred to the attorney general's medicaid fraud control unit
and/or the appropriate enforcement officials. If waste and abuse are
suspected or apparent,
ODJFS
ODM and/or the office of the attorney general will
take action to gain compliance and recoup inappropriate
or excess payments
through
audit and review in accordance with rule
5101:3-1-27
5160-1-27
or
5101:3-26-06
5160-26-06 of the Administrative Code.
In all instances of fraud, waste,
and abuse, any payment amount in excess of that legitimately due to the
provider will be recouped by ODJFS through the office of fiscal and monitoring
services, the state auditor, or the office of the attorney
general.
(C) Cases
of provider fraud, waste, and abuse may include, but are not limited to, the
following:
(1) A pattern of duplicate billing
by a provider to obtain reimbursement to which the provider is not
entitled.
(2) Misrepresentation as
to services provided, quantity provided, date of service,
who performed the service or to whom
services were provided.
(3) Billing for services not
provided.
(4) A pattern of billing,
certifying, prescribing, or ordering services that are not medically necessary
or reimbursable in accordance with rule
5101:3-1-01
5160-1-01
of the Administrative Code, not clinically proven and effective, and not
consistent with medicaid program rules and regulations.
(5) Differing charges for the same services
to medicaid
and
versus non-medicaid consumers. For inpatient hospital
services billed by hospitals reimbursed on a prospective payment basis,
ODJFS
ODM will
not pay, in the aggregate, more than the provider's customary and prevailing
charges for comparable services.
(6) Violation of a provider agreement by
requesting or obtaining additional payment for covered medicaid services from
either the consumer or consumer's family, other than medicaid co-payments as
designated in rule
5101:3-1-09
5160-1-09 of the Administrative Code.
(7) Collusive activities,
involving the medicaid program, between a
medicaid provider and any person or business entity.
(8) Misrepresentation of cost report data so
as to maximize reimbursement and/or misrepresent gains or losses.
(9) Billing for services that are outside the
current license limitations
, scope of practice,
or specific practice parameters of the person supplying the service.
(10) Misrepresenting by commission or
omission any information on the provider enrollment
and
revalidation application,
form or included in
the provider
enrollment packet
agreement, or any documentation supplied by the provider to
ODM.
(11) Ordering excessive
quantities of medical supplies, drugs and biologicals, or other
services.
(12)
Any action which would constitute a violation of the
False Claims Act (March 23, 2010),
31
U.S.C. 3729-
3733.
(D)
ODJFS
ODM will not pay
for services prescribed, ordered, or rendered by a provider, when those
services were prescribed, ordered, or rendered by that provider after the date
the provider was terminated under the medicaid program in accordance with rule
5101:3-1- 17.6
5160-1- 17.6 of the Administrative Code.
(E) In instances when a provider suspects
that there may be fraud, waste, or abuse by a consumer, the provider should
contact the local county department of job and family services
(CDJFS). Cases of consumer fraud, waste, and
abuse may include, but are not limited to:
(1)
Alteration, sale, or lending of the medicaid card to others for securing
medical services, or other related criminal activities.
(2) Receiving excessive medical visits and
services.
(3) Obtaining services
outside of those
not personally needed and used by the
consumer.
(F) Providers
must assume responsibility for the business practices of employees.
In accordance with rule 5160-1-17.2 of the
Administrative Code, the Ohio medicaid provider agreement requires each
provider to comply with the terms of the provider agreement, Revised Code,
Administrative Code, and federal statutes and rules.
ODJFS presumes that providers will
Providers shall take the necessary time to
thoroughly acquaint themselves and their employees with all rules relative to
their participation in the medicaid program. Ignorance of medicaid program
rules will not be an acceptable justification for violation of department
rules.
Notes
Ohio Admin. Code
5160-1-29
Effective:
7/1/2016
Five Year Review (FYR) Dates:
02/10/2016 and
07/01/2021
Promulgated
Under: 119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5164.02
Prior
Effective Dates: 4/7/77, 7/1/00, 10/1/84, 10/1/87, 8/1/96, 5/30/02, 1/1/04,
12/30/05 (Emer), 3/27/06, 10/08/2009