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Health Care Fraud Enforcement Is Intensifying
What Ohio Providers Need to Know
The Growing Focus on Health Care Fraud Enforcement
Federal and state authorities have intensified efforts to combat health care fraud. The Trump administration has signaled it expects states to take a more aggressive role in identifying and prosecuting fraud, including threatening to withhold federal funding from states whose Medicaid Fraud Control Units fail to produce meaningful enforcement results. That sends a particularly powerful message to the states.
In March 2026, President Trump issued an Executive Order creating the Task Force to Eliminate Fraud, chaired by Vice President J.D. Vance. Federal agencies followed with the Centers for Medicare and Medicaid Services (CMS) directing every state Medicaid program to revalidate providers identified as presenting a higher risk of fraud, waste, or abuse. CMS also announced the Department of Health and Human Services Office of Inspector General (OIG) would review each state’s Medicaid Fraud Control Unit before its annual recertification.
Where Ohio Stands
From 2019 to 2025, Ohio routinely fell into the top five states for number of investigations. Data from OIG Medicaid Fraud Control Unit annual reports show that each year more than 1,000 investigations occurred. (In contrast Michigan typically has around 500 cases.) Some recent examples of investigations include one in June 2026, federal authorities announced indictments against 14 individuals accused of participating in Medicaid fraud schemes involving home health care and autism services. Investigators seized bank accounts and luxury vehicles allegedly purchased with proceeds from those schemes. In a separate prosecution, an Ohio physician received a sentence for participating in a conspiracy involving medically unnecessary genetic testing and durable medical equipment, resulting in more than $1.8 million in Medicare billings.
A recent interim report from the Ohio Auditor regarding Ohio Department of Medicaid’s program for the Aged, Blind and Disabled did identify errors in Medicaid payments. Sampling a small portion of those receiving benefits, the Auditor discovered 3% were ineligible while reviewing all recipients found less than 1% who received ABD benefits had died. How long benefits were paid was not discussed.
Actions Taken by the State of Ohio
The increased federal focus has prompted Ohio to strengthen its own oversight efforts. Lawmakers and public officials have called for stronger oversight, more frequent inspections and additional safeguards for publicly funded health care programs. Governor Mike DeWine has defended Ohio’s existing Medicaid oversight system, noting many investigations remain confidential until criminal charges become public. However, with the heightened federal enforcement and increased public scrutiny, Governor DeWine announced several initiatives designed to strengthen Medicaid oversight and improve fraud detection. These include:
- Six-month Moratorium on New Home Health Care and Hospice Providers. Ohio may seek approval from CMS to temporarily pause enrollment of new home health care and hospice providers into the Medicaid program. During the moratorium, state officials plan to review existing providers, identify those presenting a higher risk of fraud and remove providers who fail to meet program requirements.
- Immediate Payment Suspensions for High-Risk Providers. Providers whose billing patterns exhibit significant warning signs of potential fraud may face immediate payment suspensions while the state conducts additional review.
- More Frequent Provider Revalidation. Through emergency rule making, higher risk Medicaid providers could undergo more frequent revalidation to confirm continued eligibility for participation in the program.
- GPS Verification for Electronic Visit Verification. Ohio plans to require GPS location verification for providers using Electronic Visit Verification during home health care visits.
- Electronic Visit Verification for Live-In Caregivers. Live-in caregivers, who previously were exempt from Electronic Visit Verification requirements, could become subject to the same documentation standards as other home health care providers.
Schemes Receiving Increased Enforcement Attention
In Ohio, where more than three million residents receive health coverage through Medicaid, providers, billing companies and businesses participating in government health care programs may expect increased scrutiny as federal and state officials devote additional resources to health care fraud investigations. Recent enforcement actions illustrate several recurring schemes agencies continue to prioritize.
- Billing for Services Not Provided or Not Medically Necessary. One of the most common forms of Medicare fraud involves billing for services never performed or for treatment not medically necessary. These cases often allege providers created patient records, exaggerated treatment or submitted claims for care patients never received.
Just recently, four Ohio Defendants were charged in connection with an alleged $30 million behavioral health fraud scheme. Investigators allege they conspired to submit false claims for medically unnecessary services that were either not provided or not provided as represented.
- Durable Medical Equipment Fraud. Durable Medical Equipment, Prosthetics, Orthotics and Supplies, commonly referred to as DMEPOS, remains one of Medicare’s highest-risk areas. This category encompasses products such as glucose monitors, orthopedic braces, surgical dressings and airway pressure devices. Fraud schemes involving medical equipment often include billing for products never delivered, prescribing equipment patients do not need or submitting claims unsupported by adequate medical documentation
- Phantom Billing. Phantom billing occurs when a provider submits claims for appointments, procedures, tests or medical equipment never provided. In these schemes, Medicaid pays for services existing only on paper. False patient records or fabricated documentation often accompany these claims to make nonexistent services appear legitimate.
- Upcoding & Unbundling. Upcoding happens when a provider performs a lower-cost service but bills for a more complex or expensive procedure. For example a brief office visit may be billed as a lengthy, comprehensive examination to obtain higher reimbursement. Unbundling involves separating services ordinarily billed under a single reimbursement code into multiple individual claims. Billing each component separately increases reimbursement beyond what Medicaid would otherwise pay for the complete procedure.
Key Takeaways
Ohio health care providers should expect increased scrutiny from both federal and state enforcement authorities, particularly in areas involving Medicaid billing. While not every billing error reflects fraud, enforcement agencies are likely to view inadequate documentation, inconsistent billing practices and weak compliance controls as warning signs deserving closer review.
Providers should take proactive steps now to assess their risk and strengthen their compliance programs. In particular, providers should:
- Review billing and documentation practices to confirm that claims are supported by complete, accurate and timely records.
- Evaluate procedures to ensure readiness for Ohio’s announced oversight initiatives and any new CMS or state Medicaid requirements.
If potential compliance concerns are identified, providers should consider addressing them promptly and, where appropriate, seeking legal guidance before responding to investigative inquiries.
Should you have any questions regarding Medicaid enforcement, please contact Mr. Jackson or Mr. Schneider, members of the White Collar and Investigations Practice Group. Attorneys in this group, including Mr. Schneider, have tried federal and state health care fraud cases to verdict, including phantom billing, phantom billing for services not rendered and unnecessary and medical services.
The authors gratefully acknowledge Maddie F. Stiegler’s contributions to this article. Ms. Stiegler is a summer associate with Eastman & Smith who is entering her third year of law school at the University of Toledo.
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Disclaimer: This alert has been prepared by Eastman & Smith Ltd. for informational purposes only and should not be considered legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney/client relationship.
