A direct care worker helps a patient in his home.
The Ohio Department of Medicaid has suspended payments to eight newly identified high-risk providers, the department stated in a press release.
Each of those providers were connected to at least one of the 49 providers suspended earlier this month following Gov. Mike DeWine’s antifraud executive order.
“These actions reflect ODM’s continued focus on stopping coordinated or entity-related fraud schemes within Medicaid’s home health, hospice, and waiver service spaces,” according to Ohio Medicaid.
“This next round of suspensions shows that we are actively following the data where it leads,” said Ohio Medicaid Director Scott Partika. “When patterns point to connected entities or coordinated behavior, we act quickly. Our commitment is to safeguard Medicaid dollars and protect the Ohioans who rely on these services.”
State continues initiatives to address Medicaid fraud
Ohio Medicaid can suspend entities related to those already suspended due to DeWine’s executive order. These eight providers are under review, and their payments have been temporarily suspended while investigations continue.
This enforcement action builds on strategies to combat Medicaid fraud, including:
A six-month moratorium on new provider enrollments in high-risk categories
More frequent revalidation of providers identified as higher-risk
Accelerated implementation of GPS-based electronic visit verification for in-home services
The state is utilizing enhanced analytics, provider screenings, and close coordination with state and federal oversight partners, Ohio Medicaid’s press release stated. The department will continue monitoring high-risk providers, issuing suspensions when warranted, and pursuing other ways to combat fraud.
Ohio Medicaid is working to be responsive and transparent about the fraud prevention initiatives, the department stated. This is being done through the department’s Strengthening Medicaid Program Integrity webpage, which is being continually updated with news, information, and resources for providers and Medicaid members. Visit medicaid.ohio.gov/home/odm-moratorium for more information.
Criticism coming from multiple sides
From accusations of a lack of oversight to a lack of providers, Ohio Medicaid has faced a range of scrutiny over home- and community-based care waivers.
The waivers are part of Ohio Medicaid’s fee-for-service program, not managed care, and are used to help people avoid having to live in a nursing care facility in order to function in their day-to-day lives.
Disability advocates have criticized DeWine’s moratorium on new provider enrollments due to the difficulty of finding home healthcare providers.
“All of us find our providers by opening up a state database and cold-calling dozens of numbers a day. In just the past few months, I’ve called hundreds. Only three of them called me back. Only one stayed longer than two weeks,” Justin Martin, a disability advocate based in Columbus, said during previous testimony before the Ohio House Medicaid Committee on a bill regarding regulations for certain Medicaid providers.
Pay for home healthcare providers is low and some lack benefits, Martin said, which leads to frequent turnover.
“There’s a dire shortage of providers. The only fix is getting new people into the field. And now, our government has frozen that lifeline for the next six months while they figure out how to save money on it,” said Tim McCabe, another disability advocate who testified during the same hearing as Martin.
At the same time, the state has faced criticism from the conservative media outlet The Daily Wire and the national think tank the Paragon Health Institute, which say the state is not doing enough to protect against misuse.
A policy analyst from the Paragon Health Institute said the waiver programs lack oversight or proper checks, making the programs vulnerable to potential fraud or misuse.
“There’s no verification against the enrollee’s care plan that requires the department to make sure that if the individual was prescribed one hour of home community- based services that they actually only received one hour of home community-based services,” Niklas Kleinworth, a policy analyst at the Paragon Health Institute, said before the Ohio House Medicaid Committee in May.