Ohio Passes Legislation to Push Back Against Medicaid Fraud

COLUMBUS, Ohio—Ohio State Representatives announced the passage of a legislative package aimed at fighting fraud, waste and abuse within Ohio’s Medicaid program.

Lawmakers said the Ohio Medicaid Program Integrity and Fraud Prevention Act  (SB 315) works to strengthen oversight and accountability within the system, ensure transparency, target high-risk providers to provide quality care, boost fraud reporting requirements, implement guardrails around home health services and enhance penalties for Medicaid fraud.

“Today’s passage of this Medicaid reform package sends a clear message: Ohio is serious about protecting the integrity of one of our state’s largest and most important programs,” said Rep. Mike Dovilla. “Medicaid must be preserved for Ohioans who truly need it, and that means verifying eligibility, strengthening oversight, exposing fraud and ensuring taxpayer dollars are not treated like an open checkbook. I appreciate the work of Chairman Stewart, Representative Williams and our colleagues who have helped advance a thoughtful package aimed at restoring accountability and public confidence in this system.”

The bill was amended to include a targeted list of key reforms including:

Preventing Fraud

• Delivers transparency within the provider enrollment process by requiring the Ohio Department of Medicaid (ODM) to conduct in-person inspections before approving any new providers for home and community-based care.
• Triggers an investigation if a provider seeking enrollment utilizes the same address or other similarities as another provider. 
• Requires ODM to establish criteria for classifying high-risk providers, allowing them to impose a temporary payment suspension and conduct an investigation if there is a suspicious increase in claims. 
• Requires that an alternative payer analysis be conducted prior to payment of all Medicaid claims. This will ensure that Medicaid is the payer of last resort in these scenarios. 
• As a condition of entering into or revalidating a Medicaid provider agreement, requires each person or government entity to disclose the identity of each person with at least a 5% direct or indirect ownership interest in the person or entity, which ODM shall verify. 
• Maintains options for at-home caregivers to provide personal care services. 
   

Detecting Fraud

• Enhances the electronic verification of in-home personal care services by requiring the Department of Medicaid (ODM) to maintain a statewide electronic visit verification (EVV) performance dashboard. 
• Requires high-risk providers to utilize fingerprint scanning, facial recognition, vocal recognition, a secure personal identification number or other approved verification method as a condition of receiving payment.
• Enables MCOs to identify waste and abuse, as well as possible fraud, to ODM. 
• Requires ODM to submit likely fraud allegations to the attorney general’s office in a timely manner.
• Requires ODM to submit a report to the general assembly, by March of next year, regarding the creation of a Medicaid encounter data system and a risk matrix that will provide a framework for the state to utilize identity proofing, financial distress among providers and provider ties to foreign entities.
• Creates a new definition of in-home care services, which will be subject to EVV along with on-site clock-in and clock-out requirements in order to receive payment. 
   

Fraud Enforcement & Penalties

• Increases penalties for Medicaid fraud by allowing sentencing all the way up to a first-degree felony relative to the amount of fraud committed.
• Requires ODM to coordinate with the attorney general to create a disclaimer form that explains the penalties under Ohio law for Medicaid fraud.
• Grants the auditor of state and attorney general subpoena power. 
   

Lawmakers said this legislative package of provisions is in addition to the work accomplished through the state operating budget passed in 2025 that implemented a broad range of healthcare transparency and anti-fraud reforms that worked to better protect taxpayer dollars.

SB 315 now goes to Governor Mark DeWine for consideration.