(A) Insurance fraud.
(1) For the purpose of this division (A), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
DATA. Has the same meaning as in R.C. § 2913.01 and additionally includes any other representation of information, knowledge, facts, concepts, or instructions that are being or have been prepared in a formalized manner.
DECEPTIVE. Means that a statement, in whole or in part, would cause another to be deceived because it contains a misleading representation, withholds information, prevents the acquisition of information, or by any other conduct, act, or omission creates, confirms, or perpetuates a false impression, including, but not limited to, a false impression as to law, value, state of mind, or other objective or subjective fact.
INSURER. Means any person that is authorized to engage in the business of insurance in this state under R.C. Title 39, the Ohio Fair Plan Underwriting Association created under R.C. § 3929.43, any health insuring corporation, and any legal entity that is self-insured and provides benefits to its employees or members.
POLICY. Means a policy, certificate, contract, or plan that is issued by an insurer.
STATEMENT. Includes but is not limited to any notice, letter, or memorandum; proof of loss; bill of lading; receipt for payment; invoice, account, or other financial statement; estimate of property damage; bill for services; diagnosis or prognosis; prescription; hospital, medical, or dental chart or other record; x- ray, photograph, videotape, or movie film; test result; other evidence of loss, injury, or expense; computer-generated document; and data in any form.
(2) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall do either of the following:
(a) Present to, or cause to be presented to, an insurer any written or oral statement that is part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive;
(b) Assist, aid, abet, solicit, procure, or conspire with another to prepare or make any written or oral statement that is intended to be presented to an insurer as part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive.
(3) Whoever violates this division (A) is guilty of insurance fraud. Except as otherwise provided in this division, insurance fraud is a misdemeanor of the first degree. If the amount of the claim that is false or deceptive is $1,000 or more, insurance fraud is a felony to be prosecuted under appropriate state law.
(4) This division (A) shall not be construed to abrogate, waive, or modify R.C. § 2317.02(A).
(R.C. § 2913.47)
(B) Workers' compensation fraud.
(1) No person, with purpose to defraud or knowing that the person is facilitating a fraud shall do any of the following:
(a) Receive workers' compensation benefits to which the person is not entitled;
(b) Make or present or cause to be made or presented a false or misleading statement with the purpose to secure payment for goods or services rendered under R.C. Chapter 4121, 4123, 4127, or 4131 or to secure workers' compensation benefits;
(c) Alter, falsify, destroy, conceal, or remove any record or document that is necessary to fully establish the validity of any claim filed with, or necessary to establish the nature and validity of all goods and services for which reimbursement or payment was received or is requested from the Bureau of Workers' Compensation, or a self-insuring employer under R.C. Chapter 4121, 4123, 4127, or 4131;
(d) Enter into an agreement or conspiracy to defraud the Bureau or Workers' Compensation or a self-insuring employer by making or presenting or causing to be made or presented a false claim for workers' compensation benefits;
(e) Make or present or cause to be made or presented a false statement concerning manual codes, classification or employees, payroll, paid compensation, or number of personnel, when information of that nature is necessary to determine the actual workers’ compensation premium or assessment owed to the Bureau by an employer;
(f) Alter, forge, or create a workers’ compensation certificate or falsely show current or correct workers’ compensation coverage;
(g) Fail to secure or maintain workers’ compensation coverage as required by R.C. Chapter 4123 with the intent to defraud the Bureau of Workers’ Compensation.
(2) Whoever violates this division (B) is guilty of workers' compensation fraud. Except as otherwise provided in this division, workers' compensation fraud is a misdemeanor of the first degree. If the value of premiums and assessments unpaid pursuant to actions described in divisions (B)(1)(e), (B)(1)(f), or (B)(1)(g) of this section, or goods, services, property, or money stolen is $1,000 or more, workers' compensation fraud is a felony to be prosecuted under appropriate state law.
(3) Upon application of the governmental body that conducted the investigation and prosecution of a violation of this division (B), the court shall order the person who is convicted of the violation to pay the governmental body its costs of investigating and prosecuting the case. These costs are in addition to any other costs or penalty provided under federal, state or local law.
(4) The remedies and penalties provided in this division (B) are not exclusive remedies and penalties and do not preclude the use of any other criminal or civil remedy or penalty for any act that is in violation of this division (B).
(5) For the purpose of this division (B), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
CLAIM. Means any attempt to cause the Bureau of Workers' Compensation, an independent third party with whom the administrator or an employer contracts under R.C. § 4121.44, or a self-insuring employer to make payment or reimbursement for workers' compensation benefits.
EMPLOYER, EMPLOYEE, and SELF- INSURING EMPLOYER. Have the same meanings as in R.C. § 4123.01.
EMPLOYMENT. Means participating in any trade, occupation, business, service, or profession for substantial gainful remuneration.
FALSE. Means wholly or partially untrue or deceptive.
GOODS. Includes but is not limited to medical supplies, appliances, rehabilitative equipment, and any other apparatus or furnishing provided or used in the care, treatment, or rehabilitation of a claimant for workers' compensation benefits.
RECORDS. Means any medical, professional, financial, or business record relating to the treatment or care of any person, to goods or services provided to any person, or to rates paid for goods or services provided to any person, or any record that the administrator of workers' compensation requires pursuant to rule.
REMUNERATION. Includes but is not limited to wages, commissions, rebates, and any other reward or consideration.
SERVICES. Includes but is not limited to any service provided by any health care provider to a claimant for workers' compensation benefits and any and all services provided by the Bureau as part of workers’ compensation insurance coverage.
STATEMENT. Includes but is not limited to any oral, written, electronic, electronic impulse, or magnetic communication notice, letter, memorandum, receipt for payment, invoice, account, financial statement or bill for services; a diagnosis, prognosis, prescription, hospital, medical, or dental chart or other record; and a computer generated document.
WORKERS' COMPENSATION BENEFITS. Means any compensation or benefits payable under R.C. Chapter 4121, 4123, 4127, or 4131.
(R.C. § 2913.48)
(C) Medicaid fraud.
(1) 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.
(2) No person, with purpose to commit fraud or knowing that the person is facilitating a fraud, shall do either of the following:
(a) 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.
(b) 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.
(3) 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:
(a) 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
(b) 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.
(4) Whoever violates this division (C) 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 $1,000 or more, Medicaid fraud is a felony to be prosecuted under appropriate State law.
(5) 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, R.C. § 2913.40 or 5164.35, or any other provision of law.
(6) 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.
(7) For the purpose of this division (C), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
PROVIDER. Means any person who has signed a provider agreement with the 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.
PROVIDER AGREEMENT. Has the same meaning as in R.C. § 5164.01.
RECIPIENT. Means any individual who receives goods or services from a provider under the Medicaid program.
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.
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.
(R.C. § 2913.40)
(D) 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 (D)(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 (D) is guilty of Medicaid eligibility fraud. Except as otherwise provided in this division, a violation of this division (D) is a misdemeanor of the first degree. If the value of the Medicaid services paid as a result of the violation is $1,000 or more, a violation of this division (D) is a felony to be prosecuted under appropriate state law.
(b) In addition to imposing a sentence under division (D)(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 (D) 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 (D).
(3) This division (D) 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, 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 (D) 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 (D), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
MEDICAID SERVICES. Has the same meaning as in R.C. § 5164.01.
PROPERTY. Means any real or personal property or other asset in which a person has any legal title or interest.
(R.C. § 2913.401)