Health Care Fraud
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Health Care Fraud

The Attorney General's Office investigates and prosecutes fraud in the health care industry through the Medicaid Fraud Control Unit and the Workers' Compensation Fraud Unit.  The Units also prosecute claimant and employer workers' compensation fraud, and investigate patient abuse and neglect in Ohio's care facilities.

The Health Care Fraud Section

The Attorney General's Office battles fraud in the health care industry through the Medicaid Fraud Control Unit and the Workers' Compensation Fraud Unit. The Medicaid Fraud Control Unit is responsible for the investigation and prosecution of health care providers accused of defrauding the state's Medicaid program. In addition, this Unit enforces Ohio's Patient Abuse and Neglect Law, which protects the mentally and physically disabled and the elderly from neglect and abuse in Ohio's long-term care facilities. The Workers' Compensation Fraud Unit is responsible for prosecuting claimants, employers and health care providers who defraud the Ohio Workers' Compensation Program.

In the last five (5) years (2015 – 2019), the Section has handled 5,681 complaints; posted 1,146 indictments; 1,074 convictions; 101 civil settlements; and recovered more than $226 million in restitution and penalties.

The Medicaid Fraud Control Unit

Title XIX of the Social Security Act created the Medicaid program. Medicaid is a governmentally funded (federal and state matching) health insurance program for the low-income, disabled and elderly. In 1977, the Medicare/Medicaid Anti-Fraud and Abuse Amendment was adopted, which created a nationwide system of Medicaid Fraud Control Units (MFCUs). Ohio Revised Code (ORC) 109.85 , passed in 1978, authorized the Attorney General to create the Ohio MFCU. In addition, ORC 109.86 authorizes the Attorney General to investigate and prosecute neglect and abuse of patients in health care facilities.

The MFCU has state-wide criminal jurisdiction over Medicaid provider fraud investigations and prosecutions. The Unit empanels a special Grand Jury in Franklin County to hear the majority of its Medicaid fraud cases. Patient abuse and neglect cases are most often prosecuted in the county where the incident occurred. They are typically prosecuted by the local county prosecutor, with the assistance of MFCU personnel.

In 2019, the MFCU received 971 allegations of fraud and abuse, posted 215 indictments, 172 criminal convictions, 19 civil settlements, and recovered more than $76 million in restitution and penalties. All individuals or companies convicted of Medicaid fraud or patient abuse or neglect are “mandatorally” excluded from participation in the Medicare/Medicaid program for at least five years.

The Columbus based Unit is responsible for conducting Medicaid provider investigations throughout the entire state of Ohio. The Ohio Department of Medicaid and local law enforcement investigates allegations of recipient fraud.

The Workers’ Compensation Fraud Unit

The Workers' Compensation Fraud Unit (WCFU) was created to allow the Attorney General to discharge the responsibilities described by Ohio Revised Code 109.84. This statute gives the Attorney General the responsibility of investigating criminal or civil violations of the law related to Workers' Compensation. The Unit receives and evaluates allegations of claimant, medical provider and employer fraud referred by the Bureau of Workers' Compensation special investigation units statewide. When appropriate, the matter may be presented to either a regular grand jury or a special grand jury empanelled in Franklin County. Some cases are referred to local prosecutors where venue is appropriate outside Franklin County. The Unit assists local prosecutors on an as needed basis.

In 2019, the WCFU received 112 cases from the Ohio Bureau of Workers' Compensation, posted 49 indictments, 39 convictions, and recovered nearly $856,000 in restitution for the Ohio Bureau of Workers’ Compensation.