Ohio Medicaid Fraud and Patient Abuse Investigations

You may first become aware that you are under investigation when agents of the Ohio Attorney General’s Office come to ask you questions, or request records, or visit your patients to ask questions. To understand the role of the Ohio Attorney General in health care fraud or abuse investigations is to understand the exact nature and subject matter of the legal problems that you or your practice may face. The following are the basics of the Ohio Attorney General’s designated health care-related investigations, particularly the Medicaid Fraud Control Unit (MFCU).

Criminal or Civil

Make no assumptions about whether the Ohio Attorney General’s Medicaid fraud case is civil or criminal, because it could be either. It could be both. The unique nature of health care crimes, and the authority of the Ohio Attorney General allows for the government to either prosecute or sue health care providers in cases relating to billing false or fraudulent claims for medical services. Prosecutors make that determination based on the nature and quality of the evidence (i.e. whether there is sufficient proof of intent to defraud).

It is also important to know that obstructing, interfering, or providing false statements to investigators, even in a civil investigation, could conceivably result in criminal charges. On one hand, citizens should be cognizant of their Constitutional rights. On the other hand, the Ohio Attorney General can obtain certain records from you without a warrant, especially in Medicaid fraud investigations. This is a tricky area of law, and it is always advisable to consult an attorney if you think you are under investigation.

Ohio Medicaid Fraud Control Unit: Billing Fraud and Patient Abuse & Neglect

The Ohio Attorney General Medicaid Fraud Control Unit (MFCU) handles cases involving:

  1. provider billing fraud involving the Medicaid program;
  2. abuse and neglect of residents within facilities that receive Medicaid payments; and
  3. misappropriation of patient funds by such health care facilities.

The MFCU investigates providers such as doctors, nurses, pharmacies, DME companies, dentists, counselors, hospitals, home health agencies, and others. They do not investigate patients or recipients concerning the receipt of Medicaid benefits. An exception to this arises in circumstances where patients and providers conspire or collaborate to commit Medicaid fraud.

The Ohio Attorney General MFCU is not a part of the Ohio Medicaid program, and Ohio Medicaid has no authority concerning fraud or abuse prosecutions. Although the MFCU and state Medicaid are separate by design, they can work closely to accomplish the common goal of combating fraud and recovering money. Sometimes, the Ohio MFCU investigations and Ohio Medicaid audits will obtain and analyze the same data: billing records and patient charts. However, Ohio Medicaid audits are meant to recover overpayments, or improperly paid claims. If fraud is suspected, Ohio Medicaid auditors must refer the case to the Ohio Attorney General’s MFCU.

Crimes and Penalties involved in Ohio Attorney General MFCU Cases

There are a variety of criminal statutes available to charge in the setting of health care fraud and abuse, but the most relevant are summarized below. Please see my additional FAQ article for an explanation of the Ohio criminal sentencing process.

Medicaid Fraud

The following acts are illegal under R.C. §2913.40:

1. Knowingly making a false or misleading statement or representation in connection with Medicaid reimbursement.

2. With purpose to commit fraud or knowingly facilitate a fraud:

  1. Charge, solicit, accept, or receive money or other consideration over and above the Medicaid reimbursed amount (with the exception of co-pays);
  2. Solicit, offer, or receive any remuneration (other than co-pays), including, but not limited to, a kickback or rebate, in connection with Medicaid services.

3. For a period of 6 years following reimbursement, knowingly alter, falsify, destroy, conceal, or remove any records that are necessary to fully disclose:

  1. The nature of all goods or services paid by Medicaid (e.g. office visit notes, service records);
  2. All income and expenditures upon which rates of reimbursements were based (e.g. cost reports).

Penalties are based on the dollar value of the fraudulent billing:

  • < $1,000 First Degree Misdemeanor
  • $1,000 to < $7,500 Fifth Degree Felony
  • $7,500 to < $150,000 Fourth Degree Felony
  • $150,000 + Third Degree Felony

Patient Abuse or Neglect

R.C. §2903.34 covers owners, operators, administrators, agents and employees of care facilities. The statute makes it illegal to commit neglect, gross neglect, or abuse against a resident or patient.

“Neglect” means recklessly failing to provide a person with any treatment, care, goods, or service that is necessary to maintain the health or safety of the person when the failure results in serious physical harm to the person.

“Gross neglect” means knowingly failing to provide a person with any treatment, care, goods, or service that is necessary to maintain the health or safety of the person when the failure results in physical harm or serious physical harm to the person.

“Abuse” means 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 a physical or chemical restraint, medication, or isolation on the person.

Penalties:

  • For neglect: Second Degree Misdemeanor
  • For gross neglect: First Degree Misdemeanor
  • For abuse: Fourth Degree Felony

Our Attorneys

Chapman Law Group has extensive experience in health care fraud and abuse cases. Attorney Laura Perkovic is a former health care fraud prosecutor with the Idaho Attorney General Medicaid Fraud Control Unit, with additional years of experience involving medical practice management, compliance, and provider billing; in addition to criminal defense. The Chapman Law Group health care fraud team handles cases in many courts throughout the nation. State and Federal investigations and audits involving provider billing can result in career-ending criminal charges or civil liabilities. It is wise to consult with an experienced legal team as soon as government investigators make contact with your business, in order to understand your rights, obligations, and exposure.


Let Us Help You Now
  • Disclaimer