Rep. Craig Supports Medicaid Program Integrity & Fraud Prevention Act

COLUMBUS, OH - State Representative Meredith Craig (R-Smithville) this week voted in support of a comprehensive legislative package aimed at fighting fraud, waste and abuse within Ohio's Medicaid program with the goal of protecting taxpayer dollars.

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

"As a member of the House Medicaid Committee, I appreciated the opportunity to work through this complex issue and help advance meaningful reforms that address fraud, waste, and abuse within our Medicaid system," said Craig. "My goal was to strengthen oversight of taxpayer dollars without disrupting care for Ohioans who depend on Medicaid services."

Senate Bill 315 was amended to include an extensive, targeted list of key reforms that work to prevent fraud, detect fraud and increase penalties for committing fraud within Medicaid.

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 investigate 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 payor 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 home caregivers to provide personal care services.

Detecting Fraud

• Enhances the electronic verification of in-home personal care services by requiring 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 AG'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.
• Clarifies what in-home care services will be subject to EVV along with on-site clock-in and clock-out requirements to receive payment.

Increasing Penalties for Fraud

• 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.

"This final product reflects countless hours of collaboration and around-the-clock work with providers, advocates, and my colleagues to get the policy right," said Craig. "This legislation addresses fraud and improves oversight without disrupting services for Ohio's disabled population and other vulnerable individuals."

This legislative package 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 - championed by Ohio House Republicans - that worked to better protect taxpayer dollars.

Senate Bill 315 now goes to the Governor for consideration.