Medicaid Fraud 101 Healthcare Financial Management Association Ohio Chapter – Spring Conference March 19, 2015 Lloyd Early - Special Agent-In-Charge Ohio Attorney General’s Office Medicaid Fraud Control Unit

MFCU Title XIX of the Social Security Act 1977 Anti-Fraud and Abuse Amendment 42 U.S.C. 1396 Ticket to Work and Work Incentive Improvement Act of 1999 R.C. 109.85

$ 450,000,000,000 $ 580,000,000,000 $ 1,800,000,000,000 $ 2,800,000,000,000 $ 70,000,000,000

“Slick” Willie Sutton

What is fraud? It is a theft… …by deception It is an intentional (or at least knowing) misrepresentation It is, by design, difficult to detect

R.C. 2913.40 Medicaid Fraud “No person shall knowingly make or cause to be made a false or misleading statement or representation for use in obtaining reimbursement from the medical assistance program.”

Provider Fraud Schemes Billing for services not rendered Billing for “phantom patients” Double billing Up-coding Unbundling Billing for medically unnecessary services Billing for non-covered goods/services Kickbacks

Emerging Fraud Trends Prescription drug diversion Pill mills Long term care facility diversion Falsification of criminal background checks Ambulette (wheelchair van) services Home Health Services

MFCU Secrets Collaboration and cooperation Peer comparisons and data mining algorithms Bank/credit card records Covert physical surveillance Covert video surveillance Handwriting analysis Forensic chemistry

Ohio Attorney General Mike DeWine Health Care Fraud Section Medicaid Fraud Control Unit 150 E. Gay Street, 17th Fl. Columbus, OH 43215 (614) 466-0722 Lloyd Early, Special Agent-In-Charge: (614) 466-0786 Lloyd.Early@OhioAttorneyGeneral.gov On-line fraud reporting form: http://ohioattorneygeneral.gov/files/Forms/Forms-for-Seniors/Report-Medicaid-Fraud.aspx On-line abuse/neglect reporting form: http://www.ohioattorneygeneral.gov/About-AG/Service-Divisions/Health-Care-Fraud/Report-Patient-Abuse-or-Neglect Ohio Attorney General’s Help Center: (800) 282-0515