Recent Medicaid Fraud Initiatives Illustrate How Administrative Law Operates in Ohio 

Ohio Governor Mike DeWine recently issued an executive order directing the Ohio Department of Medicaid to implement additional anti-fraud measures aimed at certain Medicaid providers and Home and Community-Based Services (HCBS) waiver programs. The announcement followed a newly launched federal investigation into alleged fraud, waste, and abuse involving portions of Ohio’s Medicaid system. 

While the headlines have largely focused on allegations of improper billing and provider misconduct, the developments also serve as a useful reminder of how administrative law operates in everyday life. Many people are familiar with statutes passed by the legislature, but far fewer realize how much authority state agencies possess through administrative regulations and executive action. 

Under Ohio law, the Ohio Department of Medicaid derives much of its authority from provisions contained in the Ohio Revised Code, including R.C. Chapter 5164, which governs Medicaid provider participation, screening, and oversight. Those statutes authorize the agency to adopt more detailed administrative rules contained in the Ohio Administrative Code regarding enrollment requirements, credentialing procedures, revalidation standards, audits, and provider compliance obligations. 

In practical terms, this means that many of the rules affecting healthcare providers are not found directly in statutes enacted by the legislature, but instead in administrative regulations created by the agency itself pursuant to delegated authority. Those regulations nevertheless carry the force of law and can significantly affect providers, patients, caregivers, and businesses operating within the Medicaid system. 

The recent executive order appears aimed at increasing oversight in several specific areas. Among other things, it directs Ohio Medicaid to implement more frequent provider revalidation procedures, expand credentialing requirements for certain higher-risk providers, and permit termination of providers who have not billed or rendered services within a specified period of time. The order also references enrollment moratorium procedures tied to federal Medicaid approval requirements. 

Several of these initiatives relate to existing provisions found in Ohio Administrative Code Sections 5160-1-17.4 and 5160-1-17.8, which govern Medicaid provider revalidation and screening procedures. Federal regulations, including 42 C.F.R. Part 455, also play a significant role in establishing provider screening and anti-fraud standards for state Medicaid programs. 

Regardless of one’s views on the policy issues involved, the situation highlights an important legal reality: administrative agencies exercise substantial authority over areas that affect individuals and businesses every day. Understanding the distinction between statutes enacted by the legislature and regulations implemented by administrative agencies is often critical when navigating healthcare, licensing, probate, tax, and other areas of Ohio law. 

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