1. 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

2. 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

3. $ 450,000,000,000
$ 580,000,000,000
$ 1,800,000,000,000
$ 2,800,000,000,000
$ 70,000,000,000

4. “Slick” Willie Sutton

5. 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

6. R.C 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.”

7. 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

8. 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

10. 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

11. Ohio Attorney General Mike DeWine
Health Care Fraud Section
Medicaid Fraud Control Unit
150 E. Gay Street, 17th Fl.
Columbus, OH
(614)
Lloyd Early, Special Agent-In-Charge: (614)
On-line fraud reporting form:
On-line abuse/neglect reporting form:
Ohio Attorney General’s Help Center: (800)