(a) As used in this section:
(1) “Provider” means any person who has signed a provider agreement with the Ohio Department of Medicaid to provide goods or services pursuant to the Medicaid program or any person who has signed an agreement with a party to such a provider agreement under which the person agrees to provide goods or services that are reimbursable under the Medicaid program.
(2) “Provider agreement” has the same meaning as in R.C. § 5164.01.
(3) “Recipient” means any individual who receives goods or services from a provider under the Medicaid program.
(4) “Records” means any medical, professional, financial or business records relating to the treatment or care of any recipient, to goods or services provided to any recipient, or to rates paid for goods or services provided to any recipient, and any records that are required by the rules of the Medicaid Director to be kept for the Medicaid program.
(5) “Statement or representation” means any oral, written, electronic, electronic impulse or magnetic communication that is used to identify an item of goods or a service for which reimbursement may be made under the Medicaid program or that states income and expense and is or may be used to determine a rate of reimbursement under the Medicaid program.
(b) No person shall knowingly make or cause to be made a false or misleading statement or representation for use in obtaining reimbursement from the Medicaid program.
(c) No person, with purpose to commit fraud or knowing that the person is facilitating a fraud, shall do either of the following:
(1) Contrary to the terms of the person’s provider agreement, charge, solicit, accept or receive for goods or services that the person provides under the Medicaid program any property, money or other consideration in addition to the amount of reimbursement under the Medicaid program and the person’s provider agreement for the goods or services and any cost-sharing expenses authorized by R.C. § 5162.20 or rules adopted by the Medicaid Director regarding the Medicaid program.
(2) Solicit, offer or receive any remuneration, other than any cost-sharing expenses authorized by R.C. § 5162.20 or rules adopted by the Medicaid Director regarding the Medicaid program, in cash or in kind, including but not limited to a kickback or rebate, in connection with the furnishing of goods or services for which whole or partial reimbursement is or may be made under the Medicaid program.
(d) No person, having submitted a claim for or provided goods or services under the Medicaid program, shall do either of the following for a period of at least six years after a reimbursement pursuant to that claim, or a reimbursement for those goods or services, is received under the Medicaid program:
(1) Knowingly alter, falsify, destroy, conceal or remove any records that are necessary to fully disclose the nature of all goods or services for which the claim was submitted, or for which reimbursement was received, by the person; or
(2) Knowingly alter, falsify, destroy, conceal or remove any records that are necessary to disclose fully all income and expenditures upon which rates of reimbursements were based for the person.
(e) Whoever violates this section is guilty of medicaid fraud. Except as otherwise provided in this division, medicaid fraud is a misdemeanor of the first degree. If the value of the property, services or funds obtained in violation of this section is one thousand dollars ($1,000) or more, medicaid fraud is a felony to be prosecuted under appropriate State law.
(f) Upon application of the governmental agency, office or other entity that conducted the investigation and prosecution in a case under this section, the court shall order any person who is convicted of a violation of this section for receiving any reimbursement for furnishing goods or services under the Medicaid program to which the person is not entitled to pay to the applicant its cost of investigating and prosecuting the case. The costs of investigation and prosecution that a defendant is ordered to pay pursuant to this division shall be in addition to any other penalties for the receipt of that reimbursement that are provided in this section, Ohio R.C. 2913.40 or 5164.35, or any other provision of law.
(g) The provisions of this section are not intended to be exclusive remedies and do not preclude the use of any other criminal or civil remedy for any act that is in violation of this section.
(ORC 2913.40)
(h) Medicaid Eligibility Fraud.
(1) No person shall knowingly do any of the following in an application for enrollment in the Medicaid program or in a document that requires a disclosure of assets for the purpose of determining eligibility for the Medicaid program:
A. Make or cause to be made a false or misleading statement;
B. Conceal an interest in property;
C. 1. Except as provided in division (h)(1)C.2. of this section, fail to disclose a transfer of property that occurred during the period beginning 36 months before submission of the application or document and ending on the date the application or document was submitted;
2. Fail to disclose a transfer of property that occurred during the period beginning 60 months before submission of the application or document and ending on the date the application or document was submitted and that was made to an irrevocable trust a portion of which is not distributable to the applicant for or recipient of Medicaid or to a revocable trust.
(2) A. Whoever violates this division (h) is guilty of Medicaid eligibility fraud. Except as otherwise provided in this division, a violation of this division (h) is a misdemeanor of the first degree. If the value of the Medicaid services paid as a result of the violation is one thousand dollars ($1,000) or more, a violation of this division (h) is a felony to be prosecuted under appropriate State law.
B. In addition to imposing a sentence under division (h)(2)A. of this section, the court shall order that a person who is guilty of Medicaid eligibility fraud make restitution in the full amount of any Medicaid services paid on behalf of an applicant for or recipient of Medicaid for which the applicant or recipient was not eligible, plus interest at the rate applicable to judgments on unreimbursed amounts from the date on which the Medicaid services were paid to the date on which restitution is made.
C. The remedies and penalties provided in this division (h) are not exclusive and do not preclude the use of any other criminal or civil remedy for any act that is in violation of this division (h).
(3) This division (h) does not apply to a person who fully disclosed in an application for Medicaid or in a document that requires a disclosure of assets for the purpose of determining eligibility for Medicaid all of the interests in property of the applicant for or recipient of medicaid benefits, all transfers of property by the applicant for or recipient of Medicaid, and the circumstances of all those transfers.
(4) Any amounts of Medicaid services recovered as restitution under this division (h) and any interest on those amounts shall be credited to the general revenue fund, and any applicable Federal share shall be returned to the appropriate agency or department of the United States.
(5) For the purpose of this division (h), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
A. “Medicaid services” has the same meaning as in R.C. § 5164.01.
B. “Property” means any real or personal property or other asset in which a person has any legal title or interest.
(ORC 2913.401)
B. “Property” means any real or personal property or other asset in which a person has any legal title or interest.
(ORC 2913.401)