Ohio House Medicaid Committee - 5-27-2026

Committee to order, please rise for the Pledge of Allegiance.

Good morning, everyone. Will the clerk please call the roll?

Vice Chair BarHorst? Here.

Representative Craig? Here.

Aye! Representative Lampton?

Here. Representative Mullins?

Um, here. Representative Soumani? Here. Representative Stevens?

Here. Representative DaVilla?

Here. Representative Sweeney.

We have a quorum, and we will operate as a full committee. If you'll indulge me just a few seconds, I want to thank our new members that are here today. You heard them called in the roll. We now have 18 members on the House Medicaid Committee. I just want to thank everyone for stepping up and being here today. Thank you for all of you in attendance. Let's start a little bit with a brief history of Medicaid. Medicaid was signed into law on July 30, 1965 by President Lyndon B. Johnson as part of his Great Society programs alongside Medicare. It created a joint federal-state health insurance program for low-income Americans replacing earlier, smaller, welfare-linked medical aid programs. Originally focused on families on welfare, the disabled and pregnant women and children, it has expanded over the decades. States run their own programs with federal matching funds, usually 50 to 78 percent. Major growth came in the 1980s and 90s with broader child coverage, and especially in 2010 with the Affordable Care Act, which allowed states to expand eligibility to more adults, now covering over 80 million people. Today, it is America's largest public health insurer, serving low-income families, seniors in nursing homes, and people with disabilities. So in that vein, we are here today to save some of these programs. Ohio has a problem. And so today, we want you to know that we are taking this extremely seriously. We are not the only state that has these problems. These patterns are seen state after state after state. And as Chair of Medicaid, I want you to know that we cannot look back. We cannot look back at all the programs we did before, the people who made decisions before, because today, as a nurse and a nurse practitioner, some of our programs are in a systole. And what that means is they're bleeding out. And if we do not save the patient who is bleeding out, they will die. And if we do not do some things to protect the elderly, the children, which we will do in compassion, because Ohioans have compassionate hearts. They give to the infirm. They give to the weakest among us, and that is the heart of those that we serve on the Ohio Medicaid program However to the thieves and those that want to fraud and waste our hard taxpayer dollars today we say it stops Today in the Ohio House and the 136th General Assembly we begin, and we hope this lofty goal will accomplish what I call Phase 1 of stopping the bleed. This will not be an end-all, be-all fix to every Medicaid problem. That is absolutely impossible. We shall look for the good and not the perfect, and we will do our best not to harm the good actors in our system who are working so hard to take care of our people. And on that note, I would ask, like to call House Bill 795 for its second hearing. The chair recognizes Representative Davila for a motion.

Representative DeVilla, will you please explain this sub-bill?

Yes, thank you, Chairwoman.

Thank you, Representative Davila. Are there any objections to the sub-bill? All right. Hearing no objections, the substitute bill becomes part of House Bill 795. All right. I would like to call on invited testimony today on a House Bill, sub-House Bill 795. Our first witness will be Attorney General Yost. All right. I would like to call invited testimony and call on Ben Karash. Is that you, Ben? All right. Thank you so much. A representative from the Ohio Attorney General's Office. and sir the stage is yours We look forward to what you have to say today Thank you Chairwoman Gross Good morning Chairwoman Gross Vice Chair Barhorst Ranking Member Baker and members of the Ohio House Medicaid Committee

Thank you so much, Mr. Karish. Your recommendations are very well thought out, and we appreciate the AG and yourself being here. with your expertise and recommending to this committee. Vice Chair Barhorst.

Absolutely. I would make the argument we are already, if not the best, in the team picture for best in class. I think what's been going on a lot lately underscores the importance of working with your state and federal partners, and this is something the Ohio Mofuku has been doing for years. We work with the Auditor of State. We work with several other state and federal agencies to go through cases. If we're seeing something, other agencies are typically seeing that, and it helps to deconflict and throw the right resources and the right amount of resources at these cases.

I think there's absolutely a place for that. We work with the Department of Medicaid. We work with HHS OIG on getting access to data, sharing data in real time. One of the big things we have been doing in the last year, the MFUKU, is working with the Department of Medicaid to mine Medicaid claims data. As we sat down and worked on this process, General Rios was very excited about this process. The theme for all of us was billions of lines of Medicaid claims data. So having more smart people looking at this has been a very effective tool for us, and we've already bared fruit in terms of indictments on some of this data initiative here.

Follow-up? Representative Williams.

Thank you, Chair.

Thank you, Representative.

Follow-up, Representative.

I would never say no to more. But with that being said, we have 110, 115 people at any given time broken down by attorneys, analysts, investigators, nurse analysts, supervisors, data analysts, you name it, we have it. We are very well funded, but with this being as important as it is right now in the spotlight, I would never say no to more resources to help move things quicker.

My follow-up, yeah, is does the AG's office have a stance on Ohio participating in the Medicaid False Claims Act where the state can recoup 10% more of fraud?

Have not used it effectively?

Thank you.

Representative Romer. Thank you so much, Chair. Maybe a two-part question. And again, we've seen a lot of work around the bad actors relative to the providers and having hundreds of these registered in one building and those types of things. But before that happens, there has to be certification from PAs, from APRNs, and physicians. Do you, in some manner, or does the AG maintain a database that tells us that this specific physician authorized this 472 times, and another person might have done it twice. If you could expand a little bit, please, on the amount of work that's done relative to the physicians and those that are authorized, if you could, please.

It does. And one follow-up, Chair, if I could, please. Does your office track situations? You talked about this. It was a perfect lead-in. where there is no improvement in the situation, where it goes on for a long period of time? Is there any analysis of the efficacy of what we are doing relative to home health care and then taking that back to those physicians that authorized it?

Excellent. Thank you, Chair.

No. Not now. Representative Lett. Thank you so much, Chairwoman. Thanks so much for being here today and providing testimony. I'm curious about a couple of things. One in particular is, you know, what does the AG's office think of expanding subpoena authority to also the state auditor as the sub bill does? And the language that seems to take away prosecutorial discretion to enforce subpoenas if the auditor's office says so. I just am curious what your thoughts are on those provisions in the sub bill. and subsequently what evidence is there to support the suggestion that fraud is happening as a conspiracy among providers working in concert, as was stated in your testimony?

First part, no, it's fine.

Yes, ma'am. Yes, and could you expound on what some of those tools are to kind of differentiate between those good actors and bad actors or administrative mistakes, billing errors, and those working in concert to purposely defraud the Medicaid system?

Representative Hall. Thank you, Chair. Appreciate it. So through the chair to the witness, first off, thank you for being here. Appreciate all the good work you all are doing over there. I have a follow-on question to the ranking member. And I was going to ask it a bit differently. I was going to ask, do we have enough mousetraps? Because if mice are a fraud and I have 1,000 mice out there, I can have three mousetraps. It can be very efficient and effective, but I'm never going to make a dent in it. And so I appreciate your answer to her. I guess my question to you is, if I talk to the MCOs, because they're all required to have a mandatory compliance plan, they're required to be engaged in activities to detect fraud, waste, and abuse, and monitoring the processes that gets referred to ODM, which then gets turned over to you all, right? You know, and FUCU, which I can't pronounce correctly, you know, and then eventually to the health care fraud section. I'm wondering, because obviously the MCOs, they don't want fraud to exist either, right? Because they're capitated, cuts in their bottom line too, right? So nobody likes this, nobody wants this. My question is, if I were to ask the MCOs, are we doing enough around this, what would they say? Would they say, listen, we're detecting 1,000 – I'm making up numbers here – but we're detecting 1,000 cases in a finite period of time. We're sending over these to the ODM and to the AG's office, but we're just not making a dent. They don't have enough people, right? So what are your thoughts on that?

Roger, that follow-up here? Yes. So follow-up. First off, thank you for that answer. Appreciate it. And again, I want to make sure that none of what I'm saying is taken critically because it's not. I appreciate that work that you guys are all doing over there. But you mentioned that you had, for example, like 900 sort of cases that are open right now, right? Are there more than that that are sitting, that are waiting for you all to take a peek into? Are there another 1,000 or 2,000 or 3,000 that are kind of just sitting there waiting for there to be space? And, again, I'm not trying to trap you or trick you into saying anything, but just trying to get at. I mean, because if we're really serious about fraud, I mean, if we're really serious about fraud, then let's be serious about fraud, right? Let's make sure that we're dedicating every resource that we possibly can to rooting it out. And so I appreciate it. So, again, not trying to trap you with the question, but just really trying to flesh that part out.

Thank you, Representative. Representative Williams. Thank you, Chair. Again, thank you for being here. I just want to talk again. I don't want to build a new mousetrap. But our MCOs currently have investigative authority. They have internal teams that do investigate for fraud. But I've met with MCOs, and they're told that they need prior approval from ODM to investigate, to audit, to ask for medical records, which could prove the actual billing cycle. That's one of their requests that we address here is giving them the authority without asking ODM permission. to look into one of their providers. But in Ohio, we don't just have MCOs. We have these agencies, independent providers. We have self-directed providers. Most of them don't fall under the MCO network where MCOs are providing oversight. Can you talk to that a little bit? Because some of the reporting that we had was a lot of the providers that are being suspected for this type of fraud, especially in the home personal service space, are not under MCO. They're independent or they're self-directed providers and they don't have that MCO kind of in the middle, looking over their shoulder, making sure they're doing everything right. Is that what you're seeing on your end?

Yes. I just wanted to clarify that not all 100% of them were under an actual MCO that's letting this slip through, that there are other providers that are directly billing to Medicaid directly.

Representative?

Representative Davila. Thank you, Madam Chair. Thanks to the witness for being here. The substitute bill includes provisions from House Bill 683, which is a bill that I've introduced to Representative Odioso to grant law enforcement authority to the Inspector General and the Deputy Inspector General. I'm curious whether that type of law enforcement authority would also be helpful for the members of your unit at the AG's office.

A lot of our cases require issuing search warrants to access data, and you need to be a law enforcement or peace officer designation to do that. So cellular providers, we're using cell records to help establish some of these cases. Email and cloud service providers, all the way down to your apps and your social medias, like DoorDash, Uber, Cash App, Zelle, all of these things require a search warrant to be done. And you can't serve that search warrant unless you're a law enforcement officer or a peace officer. So it takes an additional step for our investigators to just load this into a portal. We have to call over to a peace officer or law enforcement, and I think that takes resources away from the agencies that are helping us to do that. We've made a lot of good cases over the years, but to get these cases moved a lot quicker, I think that would be very helpful. Thank you. Follow-up? Yes, follow-up. Just a quick follow-up. Do other states have that type of authority within their units? Yes. Thank you. Thank you. Representative Stewart.

Sort of. Our office is 75% federally funded through HHSOIG. The remaining 25% comes out of the general fund. There are instances where we get involved in civil recoveries and under 109-11, since the AG's office is doing that work, we're able to keep some of the money in-house, but that goes back into the general fund overall. Because at the end of the day, this money comes from the federal government through CMS, through HHSOIG. So these are Medicaid dollars. They need to be paid back to the Department of Medicaid and the federal government. So any dollar we would recover, we would have that offsetting our federal grant, and that creates large math issues.

I don't think I could put a number on it, but it happens often.

Thank you, Representative. Representative Sweeney.

Every case is reviewed by someone at our office who has experience in this, someone who knows what they're looking at and knows what they're doing. the things we're going to be looking at is is this within our jurisdiction is this fraud is this something that could be substantiated through interviews and claims data sometimes we get a lot of crazy wacky calls that are not fraud they're not within our Medicaid jurisdiction and we really I hate to be the government person who doesn't get someone where they should be where they need to be there's a lot of state agencies here who are able to help people and very often I've seen instances throughout my career where, yeah, sorry, that's not what we do. I don't know what to tell you. We don't do that in my office. We need to get people where they need to go. We have partnerships with a lot of these state agencies where we're helping each other out. So if someone needs to go to a different state agency or a different federal agency for something, we get them there. But to answer your question, I strongly disagree with this. If someone hands us a smoking gun, we're going to have an – if it actually is a smoking gun, we'll have an indictment in rather quick time. We've demonstrated that over the years. We're indicting more cases than anybody over the years at the Ohio Medicaid Fraud Control Unit. Very rarely are we handed a smoking gun but in cases where we are handed what is being called a smoking gun we get those We do our very best to get those moved I hope that answers your question A follow Chair Yes ma Thank you Yes it does

Sure. So for the longest time, the Ohio Medicaid Fraud Control Unit has been a national leader in criminal indictments, criminal convictions. If we're not number one, we're two or three in a state with bigger resources has maybe passed us just because they're shooting fish in a bigger barrel, so to say. Where we've lacked and where I think there's room for improvement to build a better mousetrap, if this is the term we're using today here, is civil authority. Because sometimes you get to the end of a case, and to prove criminal intent, you have to prove beyond a reasonable doubt that someone knowingly submitted a false claim or someone knowingly committed theft. So sometimes we get to the end of the day and there will be an overpayment and there is something very suspicious and suspect going on, but the criminal intent's not there. The who did it's not there, but there's an overpayment. Someone needs to be accountable for this bad act. That's where civil cases come in. And if we're going to investigate something through a civil demand, that sort of thing, we don't have the tools to do that. So we can either send a civil demand letter, we can try to file a civil suit, but to gather the evidence necessary to do that and to hold folks civilly accountable, like some other states do who have these civil tools, is where Ohio can really take the next step, I believe, to be fully operational here.

So Medicaid has always been a pay-and-chase system. We get these cases a lot of times after the money's already out the door. One of the nice things is the data mining initiative that I've been discussing has allowed us to start to chase a little bit earlier when we see some of these anomalies before a whole bunch of money goes out the door. But as noted before, Prior testimony through both myself and Attorney General Yost, prior authorization requirements could throw up a large roadblock to prevent a lot of these dollars going out the door. If we can get prior authorization on some of these services that Representative Stewart has declared wasteful, I think that would really go a long way to cutting off the bleeding on the front end. That's where I'm seeing a lot of the gaps.

Thank you, Mr. Karish. I'm going to ask a question. I have many. I met with a whistleblower last week who wrote the AG's office for two years anonymously. A physician has family members who are physicians. They're seeing it all. They are afraid they will be killed. There is a criminal network that looks like gang. It looks like gangs. So that particular physician has all of the emails that he sent to the AG's office. So how, when something like that happens, he has to send anonymously, but none of his questions were ever returned. He has all of the email receipts for that. How can we protect whistleblowers? And also, what would you see as the fallout for that particular case? I don't know the particular case that you're talking about. We've had a lot of cases in the past where we've made cases on anonymous, just a quick tip in the wind to go off of. But having the access to the data, knowing where to ask the right questions is something we've done a good job on. I don't know the details of the specific case that you're talking about. It's something I'd be happy to look into. I could probably provide a more clear picture, especially if the volume you're describing is what it is. but a lot of times those cases are made, you have to nibble around the edges. You have to set it up without going through the initial complaint, and we've made cases like that in the past. Great. Thank you. And just to clarify, if we fail to recognize fraud and it's pointed out by the federal government, then it is true that the federal government can withhold payment to the state, correct? I understand it with the current messaging that's out there. That's how I understand it. There was a letter that came out from the inspector general from HHS recently that discussed that. I would argue that Ohio is one of the good stewards of federal taxpayer dollars that he also mentions in that letter. Thank you. Thank you very much.

Yes, absolutely. Every case is different. All 5,000 of those cases, no two of them are going to be the same. They're going to have different fact patterns. They're going to have different evidentiary concerns. They're going to have different evidentiary strengths. Are we going to be able to pursue this criminally, civilly, refer it out to the appropriate agency to do it, but they're all going to have different nuances to them. We get a lot of stuff that comes through the door. And as I've testified today, everything gets eyes put on it. I don't want something falling through the cracks. So a lot of the times though, it's just not there. You can't make the fraudulent case. So sometimes it is just waste. Sometimes it is, but sometimes we just don't have the evidence to prove that it is fraud. Sometimes we don't even have the evidence to prove that it's waste. But when there is evidence, I can assure you that Haimafuku is hammering home on it.

about what types of cases and complaints are sort of coming through? No, I appreciate you asking that. I had the honor last year of being the president of the National Association of Medicaid Fraud Control Units. So every state plus D.C., Puerto Rico, and the Virgin Islands has a Medicaid Fraud Control Unit. But the old saying is if you've seen one Medicaid Fraud Control Unit, you've seen one Medicaid Fraud Control Unit. We're all built differently in size, budget, population, Medicaid budget, and we all have different enforcement tools. I worked at the D.C. Mifuku for several years, and every case had to be referred up through the U.S. Attorney's office. So that could be frustrating. Every state has different subpoena authorities. Some states need to be sent out to the local prosecutor. Some states can be prosecuted in-house. But at the end of the day, a lot of times we're seeing a lot of the same cases here. I mean, I'd be lying if I didn't say I was in a group chat with several other directors where we talk about these. I was in the last week, I've been on the phone with several other directors in similarly situated States, talking about the challenges. We meet several times a year, both formally and informally, and the topic always goes to what are you seeing at work. I have the direct cell phone number of the Mafuku director in almost every border state here. So if something is happening, since you used the Michigan example, if something's going on in Toledo, there's a good chance it's going on in Michigan, and I can call the Michigan director. I consider him a friend, and we're able to deconflict on that. The same thing for Indiana, Kentucky, Pennsylvania, West Virginia. A lot of times when we start looking at our investigations, we will see things happening in different jurisdictions. We'll look at our bank records reviews, a very standard investigative tool we use, and we will see something happening in a different state. And one of the best parts of this job, I would argue, is being able to work with people across the country and make those connections on a very similar mission.

So as part of our federal grant, we're under 12 different performance standards, somewhat under 13, but there's 12 solid ones. And one of the performance standards is we make recommendations to the single state agency, the Department of Medicaid here, where if we investigate these cases, we're getting in them and we see gaps, we send a letter over to them. So we started to see a gap in these cases, like a big gap, actually, where a lot of money was going out the door. And just to tighten things up a little bit. But to answer your question, I would say a lot of times they're in responses to just gaps we're seeing in the program, just through our investigative and prosecutorial experiences.

Yes. Turning the spigot off is something we're very cognizant of because you want the bleeding to stop, but you also sometimes need to see if the billing is being done in real time. So we take that very seriously, and, hey, this might still be going on. We need to get in a hurry here. We need to get this shut off, but we need to also gather evidence to present a criminal conviction. This is something we talk with our partners at the Department of Medicaid and with the managed care organizations on a regular basis. But with the data, we're starting to see it quicker. We're starting to see it more in real time, and we have more smart people looking at it both in our office and at the Department of Medicaid, so we're able to identify these things a lot quicker. I don't have an actual timeline on these I need because every case is different. Sometimes you can shut them off immediately. Sometimes one of the tools in managed care organizations uses prepay review. So if something suspicious is going on, it's like, hey, show your work. Let's see this. And a lot of times they don't make it through that, so they don't get paid.

So any other members with questions? Ah, Representative Samani.

I just want to make sure before I. Currently today or proposed? Or is, I guess it'll be in the sub bill. So is there something currently in terms of what happens to those dollars?

So any criminal restitution will go back to the Medicaid program or to the managed care organizations, because they were ultimately who this money was taken from. And I'm not an accountant, but I understand that since the federal government is administering the Medicaid program to a certain extent. A lot of that money gets kicked back up to the federal government because if you paying to administer the Medicaid program any fraudulent dollars that should be used for legitimate service a percentage of it needs to be taken back up So any Medicaid funding I think you would probably run into some issues out of a restitution standpoint you would run into some issues of that money needed to be directed to the appropriate place I can say a lot of times, every time when a criminal restitution is ordered, the Department of Medicaid is the victim on that, and they need to be made whole.

Thank you, Mr. Karish. Any other questions? Representative Barhorst.

Yeah, we have, in our fraud cases, we have original criminal jurisdiction to investigate and prosecute Medicaid fraud here. So that includes setting up a special grand jury. It's impaneled through Franklin County. This is the garden variety. It's impaneled through Franklin County. We get juries from Franklin County because since the Department of Medicaid is housed in Franklin County, that gives us jurisdiction in Franklin County. We have grand jurors that come through every nine to 12 months, and then we get a fresh batch of grand jurors. We meet over at the state office tower, and every month we have a grand jury date. We have our attorneys and our paralegals coordinate that, and we present cases to the grand jury. So anything you see coming out in a press release from our office is typically through that grand jury. However, in certain circumstances, we have taken that show on the road before.

Generally, and we've had large cases in Franklin County as well. We try to make sure the venue is absolutely appropriate, both legally and for the case. If you look back a couple years, It was a multi-million dollar case, and we took it up to Richland County, and we had a very good outcome on that case. Thank you. Thank you, Vice Chair. Thank you again, Mr. Karish. Any other?

That is something we see on a very regular basis. I would have to see the exact language of the bill. And as I've testified before here today, I think every case is a little different. We do a great job of communicating with our state Medicaid program to just, hey, if we're starting to see someone, we want to shut them off here, a lot of times they'll check to make sure that's not interfering with criminal investigation, and the lines of communication have been great with our state agency to that extent. But to answer your question, I think we would need to see the language in the

Representatives, are there any other questions? All right. You got me. A couple more questions. You had asked in your recommendations, Mr. Karish, for a codified agreement, data sharing agreement between ODM and the AG. Do you see any benefit adding the SOS who develops and allows LLCs to be formed? Because I'm aware of a person with a federal tax lien who had an LLC that racked up $600,000 and then started another LLC under his very own same name, and then did it again a third time under Ohio Medicaid. Do you see a benefit to ODM, the AG, the SOS and ODM AG auditor and the SOS having a joint codified data sharing agreement, or do you believe that's too many cooks in the kitchen? I think we have a lot of cooks in the kitchen right now. We're working together pretty well. Again, more smart people looking at this stuff never hurts anything. This is ultimately the Department of Medicaid's data, so there's probably some nuances to work out there, But more smart people looking at billions of lines of claims data, it's never a bad thing. I completely agree. And on that note, the last one, do you see a benefit to AI? I'm aware, and I'm going to pick on John Smith. If we had 50 John Smiths, AI can pick out the trends of John Smith, SOS John Smith, ODM John Smith, AG John Smith, and Auditor John Smith. Pick out the patterns. It is not sentient. pick out the patterns and then further utilize your resources to a point where AI, and it has this capability to be able to pull the worst infractions in our system out. Where, if any, place do you see AI functioning to help your department? I know the AG had mentioned that in our testimony in March. Absolutely. AI could play a great role if used appropriately in our, just looking at claims data, compressing. I mean, I had a meeting with my assistant section chief yesterday where it was one of those things I was kind of dreading because I knew it was going to take us a while, and we were able to use AI to compress it into an hour and a half and get a nice product on the back end of it. There's a lot of good things you can do with AI, but at the end of the day, in the three-hour meeting that I ended up being an hour and a half meeting, I still had to go through on the back end and correct it because ultimately I'm responsible as the section chief of the healthcare fraud section, as an attorney, and I would expect my investigators to have the same level of responsibilities. This still needs a human eye on it. AI is not perfect yet, and I hope that gets us. I don't know if I want it to be. I still think it would be irresponsible to not put a human eye on a lot of this stuff. Absolutely. I completely agree with you. But if it could funnel in, take your resources, you have 900 cases, but it funnels into 300 so that you can pinpoint those resources, get more bang for your buck, could AI make you more efficient? I think AI can make anybody more efficient. That doesn't mean, I hate to see it fall off, I'd like to see it eliminated on the front end, so if we are investigating less, that means it's not going out the door. But I'd hate to cut off good cases because AI shut it off. I still think you need human eyes to look at some of these cases Having talked to several different people across the country who are really much smarter than me in terms of AI talking about here how AI can help you assess risks Here are risky behaviors you should be looking at. If you combine these risk factors with the Medicaid claims data, yes, that's the future of where this is heading. And Attorney General Yost has been a pioneer on this, of driving us forward with it and working with the Department of Medicaid. These are conversations we have been having. Fantastic. It is my belief that we could take ODM data, AG data, auditor data, SOS data, AI, can mix that together, look for, and obviously we never get rid of the human who needs to be the eyes on that. Thank you so much for your time today, and have a great afternoon. Thank you, Sherwin. Thank you, committee. All right. Just a reminder to the witnesses, please address the chair through to the committee like you're in court. Address the chair to the members. And I would like to now call on Auditor Faber, former Representative Faber.

Chairman Gross, are you ready? We are, sir. Go for it. All right.

Thank you so much, Auditor Faber. We appreciate your time today and all of your hard work, warning us and warning us. I remember as a freshman, I remember looking at your first audit six years ago and wondering what do we do. So thank you so much, and we appreciate your time today.

Great question. Thank you. We have been struggling with that since I became auditor. Every report we issue in one of these areas goes to the legislative leadership, it goes to the chairman of the committee, and it generally goes to the members of the committees and is on our website and out to members. I just remember from my time in the legislature, and this is a reality all of you know firsthand, you get so much information that crosses your desk. And what you know and what you're working on today may not be the thing that you pull your time out, something that may be a big deal for you tomorrow. And so your staff are really empowered with vetting that information. And I can just tell you that that report went out. It went widespread. I testified in front of the former oversight committee, and we have done those kind of things every time we've had those issues. The problem is that, again, when we put that stuff out, we have been flagging it. We've been identifying it. The new attention and this structure between the two committees getting bigger and getting – I mean, look, it's almost half of what you spend everything in state government on is a big priority. And so this new attention I think makes that type of issue and this easier But one of the things in the Mufuku director testified but I will make a very very forceful argument over the next six 12 18 months that maybe we need to take the M off of Mufuku not because the acronym gets cooler it doesn't. But the reality is that same organization needs to look at all public benefit fraud. They have jurisdiction over Medicaid, but who's looking at food stamps? Who's looking at housing? Who's looking at all of the other issues? I can tell you in talking to my federal partners and leaders around the country, this is the trend going on and this is the new push. And so in lighting all this public benefit waste, fraud, and abuse that's going on probably needs a broader spectrum. But as you heard him testify very, very, I thought, cogently, a lot of what they see and what they can criminally prosecute somebody, and that's what everybody's claiming for, let's prosecute them, prosecute them, prosecute them, is interesting. And certainly we want to do that. But here's the problem. Prosecution is after the fact. The chances of clawing back a lot of that money is very small. You're better off stopping it on the front end by taking controls in place to do that verification. Let me just give you a real one when it comes to home health care. I would, you know, is it expensive? Yeah. I think we need to have a database of providers. Every provider, when you get qualified, ought to be on the top. They probably have the billing numbers, and we could probably use AI to try and sort that out. But the reality is we need to look to see whether we've got doctor mills just like we had pill mills before that are providing some of these home health care waivers. And that data needs to be collected and outed. But maybe we need to ask a second question. Shouldn't Medicaid on some of these high-risk home health care programs do an independent verification by sending them to a Medicaid-approved doctor? Or having somebody internally to be making those determinations that's consistent to say, look, just because this doctor thinks you need home health care, you need home health care, you need home health care, when we're talking about limited state resources, that maybe that's not the determination we make, kind of like we do in workers' comp. A different analysis for you guys to make. That's a public policy concern. But I go back to a bunch of different things that are in the bill and from the discussion. But back to your original question, when we come out with this stuff, we send it out to everybody. We ring the bell. The problem is that, I hate to say it this way, for many legislators in particular, you guys have so many bells ringing all the time, you can get lost in the music. And I don't want to say that's what happened, but that's why this new format of paying attention and having us come back is, I think, an improvement.

Madam Chair, Representative, look, we have been, and you know this because you and I have had a number of status updates, we've been trying to push that through as quickly as we can. That's been a data application. access and frankly a data reliability issue. We were getting unreliable data from Medicaid, unreliable data from the vendors, unreliable data from an intermediary, such that finally we asked one of the vendors and they redid the data for us at no cost. And that was unusual. And I do want to, look, I will be the first one to call out criticism of Medicaid, back to your prior question about some of these reports we've done. We actually stood in front of a committee where one of the Medicaid directors on our report, we were not the first time, I think we issued it two or three times talking about multiple state beneficiary programs. The feds had said the same thing, and the former Medicaid director stood in front of all of you and almost mocked our report, saying, I mean, really? Okay, the world has changed. You've got a new Medicaid director who is taking this stuff seriously. And the cooperation and partnership from their office is good. Okay, look, I always want it better. Good is good. A lot better than it was. But we're heading in the right direction. So much of the things that we identify, we don't do them to embarrass Medicaid. We don't do them to embarrass people. We do them to fix things. To keep Bob and Betty Buckeye's money in their pockets. And in that regard, having a director who is willing to do this has been really refreshing. And I will give the governor cred. his steps of actually responding recently to try and address some of these issues I think comes from having a director that's in his ear saying some of these things are real. It's not just a big government program who's designed to throw benefits on the table and get them out the door. I think that's a change in attitude and that change in attitude can make a real difference. On the ABD audit, look, if I had good data that I could trust and have confidence in and put my seal of approval on, I'd give it to you tomorrow. We're in the process of running through that. You know I've got a very dedicated team that's working almost nonstop on that. Once we get our initial data set, we have run our own data where we have run our own examinations, and we have relatively strong confidence in that data. We may be comfortable giving that data out as an interim report while we follow up the total analysis that the legislature asks us to do. That total analysis means we have to hire a vendor, do RFPs, get out and do that stuff. We have our own sample set of the data that has shown problems, and the one recommendation that I'm willing to throw out here today as we have this conversation, it's preliminary, is that we have grave concerns over the waiver about using Social Security eligibility classification data into the program. I think if we're going to find holes in assets, it's going to come from that program. And you're aware of this, I know. But if I were going to make a quick recommendation for you guys going into the next budget cycle, I would be get rid of that waiver. Let's go back to individual eligibility inside of Ohio and not use that blanket federal waiver because I'm not sure what they're doing. If we're going to have holes, I think that's where we're going to find them. Did I answer your question?

Thank you, Auditor.

And I agree as well. Representative Williams.

to make it where these providers have to have clear ownership interests outlined to the department of who actually has any ownership interest in the entities providing care in the state of Ohio? Look, there was a federal law not long ago that required basically ownership interest of LLCs and the like to be federally filed with the Department of Taxation. That ultimately was gone the back road because I thought it was overbearing and uncalled for. But in the end, I will tell you in this circumstances, you're asking for taxpayer dollars. I don't think it's inappropriate for the taxpayers and Medicaid who are approving people to know the real and legitimized holders of interest of entities that are filing for a Medicaid number. And I think that it needs to be not just the official, but the real actual control entities. I mean, we heard stories where you've got somebody who files the organization under their wife or their daughter or one of their kids' names, but the person who's running it has been convicted of fraud and is convicted of theft and what you and I as lawyers would call theft and dishonesty cases. Those kind of things ought to be disclosed. And somebody who was licensed and lost their licensing as a nurse then opens a home health care organization, but I'm not providing medical care. Well, that brings up the question of why Medicaid is paying for non-medical care anyway, but that's a different waiver question. All of that, I think, would be helpful if that transparency were part of their Medicaid licensing filings. Follow-up? Follow-up. Thank you. Going down that same line of thinking, there's something that we don't use a lot. So, one, the current penalty for Medicaid fraud is maxed out of the F3, which makes the civil fines for that very minimal. So traditionally in racketeering cases, we always have the ability to do civil asset forfeiture. If you were able to buy a house, a car based off of drug trafficking, we can seize that. But then we had the Thames decision where the court said the potential fine was $10,000 for drug trafficking. You couldn't take his $80,000 Range Rover. That was an excessive fine. So thinking about that today, right now while we're on committee, we increased the penalties in this bill for potential prison time. Do you think we should also increase the actual fines? So even if you are not able to claw back the actual funds, you may be able to go after the assets that were purchased with those funds, the homes, the cars, the buildings, the things that were purchased with them. Because if we increase the fines, then you could go after civil asset forfeiture. Chairman, Representative, sure anything that gives us extra tools to try and make the taxpayers whole on four but my guess is that some of that already exists if you can show the track of the the ill gains funding the asset you can use that on the seizing and going back after the money now But I don't really dislike the idea of saying that fines are related not necessarily to the criminal level of the offense. They're leveled to also the amount that was stolen. So if you steal a million dollars and I'm tapped at a fine for an F2, because I think it does elevate this to higher levels now. I don't have a problem saying it's some multiple of the amount that was ill-gotten gains to put the owners in. And obviously the other thing I always say, look, we usually can get in criminal cases our audit expenses back. We can't get the prosecution expenses. That generally is a different question under criminal law. But look, we're talking about this, and there is one thing that I wanted to throw in here. There is a provision that we ask for to be in this bill and you guys put in the bill that to me will do more towards identifying the fraud, waste, and abuse than a lot of other things we've talked about. And that's the 10%. Look, most of our stuff is coming from tips, guys. It is. Okay? The chance data analytics may help that. AI may help that. But if you call in and give us a real tip that leads to somebody who has actually stolen money. Representative Hindle has a bill that's similar to what we were working on, too. And so we call that out. We think the language that's going to come to you guys as an amendment is going to be stronger. But this concept is that if you give real, actionable evidence, actionable evidence, not, look, I think everybody on this street's a Medicaid fraud. That really doesn't help as much. But if you think that Joe Smith is engaged in Medicaid fraud and the doctor is facilitating it, and here's the evidence and that leads... I don't think a bounty is too much to ask. I akin that to the reward sign that you used to put out on, you know, wanted, here's the reward. Let's reimburse that. And if the state's 10% is determined by the AG's office, it can be a real good deterrent encouraging people not to lie, steal, and cheat. And so I just throw that out there. We ask for that to be in the bill. I'm glad it is. So with that, sorry, Representative. No, thank you, Auditor. Representative Barhorst. Thank you, Chair. Thank you, Auditor Faber. Kind of following up with legitimizing providers on the front end, I've got a question. As to non-MCO providers being registered, certified, and accredited with Ohio Medicaid, do you believe requiring proof of business insurance for agencies and or auto insurance for providers to prove legitimacy on the front end would be valuable? Basically, letting the insurance industry validate a business provider is real before we ever give them a payment. Yeah. Representative, chairman, chairman, representative, I haven't thought about it enough. Could it be helpful? Yeah. I mean, generally, if you're going to be in business, you're going to have insurance. You're going to be a legitimate business. If you've got people on the road going to serve people, look, I think you ought to be responsible for that. It wasn't long ago that this legislature passed, I think, an appropriate good start to all the Uber and all the other people that are going to operate. If you're Uber and you're operating in this state, you ought to have to insure your drivers who you're making money off of. By the way, there's still a huge loophole on all the people who are doing home deliveries. Your law doesn't apply to them. I'm just giving you a hint. Maybe you need to look at that. Might be a good Scott Olslager amendment sometime. But the fact of the matter is that the same thing applies to anybody who's engaged in business. I require my lawyers when they driving to and from court to have insurance Okay it kind of an important thing Yeah briefly I don think we doing that I think some of them are falling through the cracks with these shell companies And I just feel like if we're going to get ahead of that issue and get right down to the legitimate provider and who owns it, I think we could leverage the insurance industry's ability to underwrite and validate real risk as a potential variable to close that on the front end of some of these cases. Chairman and Representative, perfectly fine idea. I don't have anything against it. I can tell you I think what Representative Williams was talking about in the licensing would go further from a data analytics to stop the hopping. If you can actually avoid people from refiling under a fictitious or a derivative or a family member's name, that would do a lot more towards verifying that this is somebody who you do business with. But again, I think one of the other things is the Department of Medicaid, when you file brand new startup organizations, ought to give them elevated scrutiny for a period of time to make sure they're actually doing what they say they're doing. Let's trust but verify. Thank you, Auditor, and thank you, Vice Chair Barr Horstam. We don't want to leave any holes anywhere, so I appreciate that. Representative Stewart. Thank you, Madam Chair, and thank you, Audra Faber, for your work. Your office does incredible work in this issue, including many others, and I know we all appreciate it. I will admit, though, I think I'm in kind of the same bucket as a lot of Ohioans in the sense that when we see the headline and we see the audit come out and we see the warning signs that you found, we kind of assume somebody somewhere took your report and did something about it. And I know that we want to be forward-looking, but there's the famous quote about forgetting history and being doomed to repeat it. And so if we don't kind of identify where some things went wrong, where people dropped the ball, I don't know that we can adequately close the gap. So I'm looking at your testimony. In 2022, your office found 42,807 Medicaid recipients who were dual enrolled in other states. And you told that to the state, you told that to the legislature, you're told that at the Department of Medicaid. And then two years later in 2024 you run the same exact audit and you find that after having sounded the alarm the number of dual enrolled residents had tripled in two years to 124,000 individuals who are now dual enrolled. So my question is basically what came of that report? You're not the enforcement arm, you don't run the Medicaid department. I know they have new leadership, but I think we need to be specific about this. Did Medicaid department do anything about this? If you don't want to go there specifically, can you at least just kind of speak to the importance of executive branch agencies taking your findings seriously and addressing those warning signs when you present them? Yeah, I'll hit that last part. Look, I will tell you a little bit, I'm going to temper the 2024 report a little bit. Remember, COVID came in. They had Medicaid freeze when you got the enhanced, I don't, FMAP, I always get these terms wrong. But they couldn't kick people off the program. So even though they knew about some of these, we argued that the dual enrollees could have been kicked off because that was a condition that we thought you could remove. But again, they weren't doing that kind of verification because, frankly, the feds didn't allow them to do some of that. So part of that, I will give them a little bit of grace. because I still think they can do some of that. But the reality is we flagged it, and they knew it, and the director came in here and said, and poo-pooed it in front of your testimony. But the funny thing about that, it wasn't just us. We did it a couple of times. The feds did it too. And so this is a problem. I know they're on top of that. At least they're trying to get on top of that because this is a big problem nationally. But back to the issue. We had a concern when I first became state auditor that performance audits, when we go into a state agency and figure out recommendations for ways to do things better, faster, cheaper, were being ignored. okay we do an audit and we look at audits and in every audit when we go back in the next year particularly of state agencies we will look and say hey we found this last year did you fix it and in our audit reports there's always a commentary on did you fix it okay and and i added to that list when i became auditor a commentary portion to check in on performance audits because what i was concerned with is exactly what you're saying. The legislature asks us to go in or we go in with our own authority and do a performance audit to figure out how to make government work better, faster, cheaper. We issue the report. It becomes a very expensive paperweight on somebody's shelf that the department looks at. They go through and they say, yeah, we're going to do all of this, but the inertia in government agencies beats we're going to do something about this and nothing happens or it gets slow walked or it gets changed. And so part of that is a statutory requirement that if the agency doesn't implement our recommendations, they and or the governor has to tell you why not. And so we are going back in now when we do those audits and saying, what say you about the performance audits that we did? Are you doing these things and have you done the reports? Now, some of them will take more than a couple of days to implement. Some of these are big recommendations. The problem is, is when we send those as budget chairman, if you remember a number of years ago, I suggested this really crazy concept that I encouraged somebody to take back up. Let's sunset state agencies, unless they're reauthorized by you, every five years. What it does is shift the power back to you as the legislature. Now, look, everybody's going to get reauthorized. You're not going to kill the EPA. You're not going to kill Medicaid. But what it does is it requires you guys to come back in and do these holistic reviews of internal agency operations. And are they being responsive? How are they being managed? Maybe five years isn't the right time period. But when you do budgets, here's the reality. You know this is finance chair. Scott, you were finance chair. The House gets what? Six weeks to do how much is the all funds budget now? darn near $200 billion over a biennial. The Senate gets four weeks. Conference committee gets two, three weeks. And to do all of that work, you've got one budget person in the House, one budget person in the Senate, maybe an assistant budget person, and you're running against OBM that has 100 people. I'd say you're overstaffed, but I know the quality of your staff. That's the reality of your ability to do meaningful oversight during the budget process. So the rest of it comes to these kind of committees having these kind of hearings. Now, as auditor, our job is to give you tools to help do that. And so the one message I will tell you is we will keep sending you reports. Please tell your staff those go to the head of the list. Anything that comes from the auditor's office, I want sitting on my chair for me to read. But the fact of the matter is I know with the volume of things you doing we will try Look I try and keep our reports pithy and short because I know your time frame But we will continue to ring the bell and we will try and get a bigger bell That's all I can tell you on how to handle that. Representative, follow up? Quick follow up? Yes, thank you, Madam Chair. Auditor, you raised a point that I think is vastly under discussed when we talk about this issue, which is that it is far easier to prevent dollars from being misspent or stolen in the first place than to claw them back after the cows are out of the barn. I know you and I are in the same other profession. I tell my legal clients, a lot of times you win the big case, you get the judgment on paper, and then you say, all right, now the hard work begins. It's time to go collect. It's hard to get blood from a rock. The people who defraud the taxpayers, don't leave money in a Huntington Bank account waiting for us to go pick it up. They spend it, they hide it, they ship it overseas. So again, I think a lot of Ohioans see the report and they see the finding for recovery in the newspaper and they kind of assume that we got the money back. I think you do amazing work getting these findings for recovery, but can you speak to the fact that it's just a practical reality that we're not going to be able to collect every dollar that's been stolen. And so it makes it even more important on the front end to kind of tamp down on the spigot here. Absolutely, Chairman, Representative. That's why I talk about controls on the front end all the time. It's much easier to keep a dollar from being wasted or abused or stolen than it is to ever get the money back. However, there is one provision in this bill. we basically try and author, you guys would authorize Medicaid and Mufuku and us to go after unclaimed funds in somebody's name. What we did was found that one of the people that the department found a judgment, I think it was like $30 or $40 million on daycare food, actually has money sitting in unclaimed funds. I'm going, why are they having the ability to get that? Let the state seize that. Frankly, You know, that should be, I don't know why we couldn't do that to begin with. Let's just make it clear. We issue findings of recovery all the time. When I issue a finding of recovery and we certify it over to the AG or the prosecutor, let's let them treat that like a tax lien and go after unclaimed funds in that person's name if they have it. I just look and said, you know, the equitable right to set off probably should allow us to do that anyway. But it's one of those things our people spotted, and I said, I'll certainly throw that to the list of the legislature. It's in this bill. Thank you. Representative, follow-up. Representative Simani. Thank you, through the chair. I was just curious with the EVVs. I know there's a lot of difficulty in using those. Is that something that your office could improve on? How could we improve on that so that we could have a good paper trail? Thank you, Chairman, Doctor, Representative. You're really now getting beyond the auditor's bandwidth about how the program works. That's going to be for the Medicaid and for the vendors and the EVV. They need to work. If they don't work well, they need to fix the glitches in them. My understanding is EVV technology isn't novel. Other states, frankly, the federal government is mandating it. So there's got to be a system that works well. And so if there's a glitch in the system not working, let's fix it. And that's a Medicaid call to fix it. This isn't novel technology. It's largely GPS tracking. And if the current system, I always say, if the current system isn't working, let's find something that does. Representative follow Follow And then since it based on GPS tracking I know we heard that that hard to do in rural areas where oftentimes the home health services are being utilized So how, I guess it's not your office, but how would we, like, how do we implement that or how do we work on that? Representative, Chairman, Representative, again, you're beyond my knowledge base. The only thing I can tell you is I live in a rural area. I represented a rural area. most of my career, I almost always have GPS, particularly map tracking throughout Ohio. Maybe in some of the Appalachian rural areas, there are some places to where the map doesn't work. My guess is there are alternatives that can be employed, whether it's satellite-based data or another method, because I'm sure there's a backup if the EVV system doesn't work. You can do it with signatures. You can do it with other things. Thank you, Auditor. Representative Stevens. Thank you, Chair. Thank you for being here. Thank you for your testimony. Since we got a little shout out in your testimony, I wanted to talk a little bit about the rehab homes. One of the things that's happening in our local DJFS is they're being overwhelmed. As these folks come out of the home, they don't go back to where they're from. What happens is, is their entire family moves to Ironton. And so, you know, and all of those folks are on some sort of assistance somewhere, and our local DJFS is just overwhelmed, as you can see the comparison to a very urban situation. I'm not sure if you're prepared to have any recommendations for that today, but I'm hopeful that this committee can do something. I know my colleague and good friend, Representative Pizzouli, has really been working on this issue. So I appreciate you pointing that out. Thank you, Chairman and Representative. Again, I follow the numbers, and the numbers are striking. The cost per bed in your area is 5, 6, 7, 10x, the cost of treatment for similar treatment. And so we're taking a look to see why that is, what's being done. Our audit indicated some of the reasons. I mean, when you're paying people to play cornhole in treating that as therapy, probably explains why these cost numbers are so high. but certainly there is abuse in these programs, and the question is, is it fraud? It's a bigger question that we're trying to get to the bottom of. Follow-up for presenters. And if I can follow up as well, I wanted to bring out the fact that if a family member goes into one of these homes, their children will come, and now all of a sudden the children are in the schools, and they're from who knows where. And so it is causing a real issue, and if it is something that is being precipitated because of fraud, waste, or abuse, it's certainly worth looking at. So I really appreciate you pointing that out. Thank you. Yeah, and Representative and Chairman, there's a question is what is the attraction? How are these people getting the cap rates? You've heard the stories nationally where people are putting people in programs out of state because of the high reimbursement rates, and then the success rates of those programs are in the single digits. and then people are trapped when the program stops paying for them and they get stranded someplace. That's happening in your community. And so that's part of the discussion that we need to be looking at. Are they doing illegal incentives? Are they doing kickbacks? Are they doing, you know, there's an anti-linkage federal statute that says you can't offer housing entry. I mean, all of these are things that we need to take a look at. And again part of this is going to I think be our federal friends and our friends at Mufuku but again in the auditor office we noticed data anomalies and we started noticing this when we did some spot provider audits And so we're using my term from before, ringing the bell. Thank you, Representative and Auditor. I'm aware of people going door to door saying, don't you think you need Ohio Medicaid? We'll help you enroll. So thank you for that. Follow up. Representative Romer. Thank you so much for coming in, Auditor. This is very powerful testimony. I really appreciate it. One of the things, we've talked about recovery a little bit, recovery of funds, and it's obviously hard to recover from somebody that doesn't have a lot of money. But in the 2022 audit, you talked about $14.5 million in duplicate payments, $3.4 million for deceased folks, and $101 million for folks that are incarcerated. And those, I believe, were capitation payments. All those are. Do you know if there were any recoveries made against the MCOs whatsoever for that $120 million plus? Chairman, Representative, I don't. I recall a side comment that was, again, told to me by staff who heard the director's comments and said, no, no, we know about those things. We included a rate adjustment. My response would have been, if I had heard that directly, can you show me the actuarial study that justified that rate modification? The reality is, as a former insurance guy, if you're going to charge and you're going to take a discount in the billion-dollar range, I probably want to see how you accounted for that on the actuarial tables in your adjustments. But the question is, I don't know. That's a question for Medicaid. And again, those are, as I said at the time, those are payments that did not go to Bob or Betty Buckeye and their kids. Those are payments that went to managed care organizations. Because nobody was getting benefits on those numbers for Medicaid in Indiana and Kentucky and Ohio. They were getting their health insurance for their children paid once when they took their kid to the emergency room. That was paid once. It wasn't paid by multiple states. And so the people who were benefiting in that program were largely the managed care organizations. Exactly. Follow-up, Chair. Absolutely. Okay. And thank you for that, because that would flow directly to the bottom line with zero cost associated with it. In House Bill 33, last General Assembly, the operating budget, we put in some important provisions. managed care annual audits, enhanced eligibility reviews, and you had talked also about the auditor of state integration between ODM and the auditor of state, the data that apparently I just found out today required a subpoena, even though we had included it. Not Medicaid, not Medicaid, another state agency. Okay. Can you talk about, give Scott another credit, he's been good about getting me data, although I think we have a couple of things we're waiting on, Scott. I assume I'm going to have those later today. Okay. Okay. Can you talk about the efficacy of what was done in HB 33, including those provisions? Because as many folks have said here, this issue didn't just come up two weeks ago or three weeks ago. This was known in 2019 and 2021 and 2023. Can you talk about what happened in that HB 33, please? I can just generally talk about the concept of data access. Can I do that? Please, Chairman and Representative. Look, here's the issue. If we don't have access to the data, are You have to go on a fishing expedition to get the data. It makes our work so much more complicated. One of the things we're finding in the ABD audit, okay, you allocated $5 million. We would have burned through all of that $5 million just trying to hunt down data. And that's the problem of how expensive it is to get data. As we get into more AI and more data analytic tools, this concept of having separate universes of data within one government starts to become crazy. because if you can pool data and you can run comparisons, you start to be able to find anomalies. You start to be able to see real clear indicators of something's going on. And the ability to match and run that data, and let me give you a real-life example. If somebody is committing fraud in food stamps or SNAP benefits, they're probably enrolled in a whole bunch of other programs across the line. Without having those data in one searchable universe or the ability to cross-compare data, it becomes very difficult to see those trends. And so when you have the ability to pool your data and search across it, you can then spot things real quickly. We're running an analysis right now, and I will just tell you to compare some of this data based on vehicle registrations. If you have a newly registered vehicle, and you're in an income-eligible program, it is difficult to start explaining why you're driving a brand new Mercedes. I'm not saying that's happening. It may be zero in Ohio. But hypothetically, having access to state data across multiple places will allow you to ask those questions and see those cues. And it may be that you won the Mercedes, and then you got unemployed, and your Mercedes is all paid for, but now you're eligible for SNAP benefits. All of that may be legal and legitimate, but there are certainly red flags that you look at when you do these kind of analysis. Having access to that data is very important. The other thing, it is against the law, federally, for anybody to be on a federal benefit if you're here illegally. If you don't have access to the data source, how are you running against the saved database to find out whether or not those people are ineligible beneficiaries? All of these things are things that having data access is so important. And so the other thing you can look for is somebody, I think Representative Williams said it. What you have is actors that are participating in multiple streams of activity. They may be engaged in this role and that role. One of the things that we saw in one of the discussions on the home health, I'm sorry, on the daycare issue, was that people were taking food that was supposed to be for school children and then selling it in their restaurant. Okay? That's an allegation. Again, I'm just telling you what I've heard. Fact? Fiction? I don't know. The reality is having access to multiple data streams will allow you to see whether or not some of those things are out there. And that's why our data requests, when we go in and do it, if we were doing that investigation, we would want to pool their purchasing records from their food vendors. If you're selling $100,000 a month in food and you're only buying $5,000 a month from Cisco, maybe something doesn't add up. And that's why we use subpoenas. And that's how we do investigations. Look, I'll tell you just one story. Sir, we are getting... I'm sorry. We do have seven more representatives or questions and we have another witness and we have caucus too at 2 o So if you could, yes. Thank you, sir, very much. Representative, follow-up? Two-second follow-up. I really appreciate your mission, the hard work that you guys are doing. Please keep it up. We need it. Thank you. Thank you. Thank you, Representative. Representative Craig. If we could also, representatives, keep it to one question now. I apologize, but we're short on time.

Representative, the short answer is our office can look into just about anything if we have the bandwidth. I will be candid. Two-thirds of my staff do the fiscal compliance audits, which you want them doing your local governments every single day, and they spend a lot of time with. We have a group that do performance audits. Where you've asked us to do something, we try and rededicate resources and hit that. Right now, I have a very aggressive fraud tiger team that's out there digging into this benefit fraud stuff. And we put a group together across the organization to dig into some of this stuff that normally goes beyond where we would normally go because, candidly, we're curious if there's something out there that we're all missing. There are a provision in this bill, and I believe it got into the bill. I'm looking for my summary, but I believe it's in the bill and we support it, that the recommendation was that you guys get regular waiver reports from Medicaid on programs, particularly new programs and the uptick in programs, so that you guys can spot anomalies in the data yourself. And let me give you a real-life example. if you guys were for example to see a huge uptick in the hospice utilization rates or the autism utilization rates in some of these programs and Medicaid would report this to you annually or biannually you're going to see that in your budget program, your projection and then you can start asking the questions what going on here That information giving you guys the tools is to me crucial in this analysis because that is something that I think is in this bill If not, it's one of the things we recommended to put in this bill so that you're getting regular reports on the waiver programs. I would tell you, frankly, a lot of these waivers, we need to go back and ask what we're doing. We absolutely, and I said this publicly, the original purpose of a lot of these home health care waivers were to keep people in home health care in their house where people are happier and they have longer and better recoveries. The theory was we're going to do that cheaper, people are going to be more satisfied, it's going to keep them out of a nursing home. All of that's a great concept. We all are for that. The question is, did we expand the authorization to people who would have never ended up in a nursing home anyway? Did we supplement what used to be families taking care of family members with government paying people to take care of family members? What is the unintended consequences of those decisions? And that's a policy decision that falls squarely on you guys. There's my answer. Thank you. Committee, we do have a hard stop at 1.30. Representative Timms.

Chairman, Representative, the short answer is yes. We have conversations with other organizations. What's interesting is that each state auditor's office has different jurisdiction and different methodologies. For example, there are two people in Indiana that do kind of what my office does. Not all of us have elected state auditors who have the authority and the discretion and the tools that I have. Michigan does not. We have a tough time figuring out who's on first, but yes, we talk together. We share information. There are national groups that do this as well. All right. Thank you, Representative. Thank you.

Thank you. Chairman, Representative, the short answer is we tried to balance that with the $10,000 cap. I think it requires actionable information, not, like I said, I think everybody that's in home health care is engaged in fraud. That's real nice, but it doesn't do anything for me. And so we have to get something that's actionable. And so the only people that would be eligible under the AGs, and I think we put it in the AGs office to award this, based on actual savings and an actual, I think the proposal, an actual savings and an actual actionable prosecution or recovery. Thank you, Anki Member Baker.

Chairman, Representative, on the first part of the question, what we did, that came from our state audit, and so we go in and do the single-state audit. And what we found was when we did testing of eligible individuals, we do a random sample, and we found 15.6% ineligible recipients. people who did not meet an eligibility tick when they did the audit. So that's an extrapolation, and that's why you've got a range between $800 and $4.4 billion, depending on what programs you're in and which programs those happen. Now, the reality is, is because it is, I mean, I can't say that that's fraud. I can certainly say that that's waste or abuse in the system, not disallowing people who should not be allowed to have benefits getting benefits. And so that's part of that whole equation. And so that's why we don't necessarily call that fraud. You might notice I've been very careful on what I call fraud. To me, fraud is something I'm going to prosecute you and put you in jail for. Waste, fraud, or abuse is a different term because when you talk about waste or abuse, that may be you're completely within the angle of the law, but the law is stupid. I mean, the law is allowing people to get benefits that everybody around Ohio would go, why are you getting paid or why are you getting that benefit? And that's really a policy issue, and that's why we think this bill is important to require you guys to take a look at some of those waivers. Great. Thank you, Representative.

so I'll let whoever authored that talk about that. We had some concerns about some of the provisions of that language, and if that's going to go forward, we may have some suggestions to modify it. But that is not one that I can give you the bottom line on. We're happy to do whatever you ask us to do. We just want to make sure it doesn't cause us an independence problem with other things that we do. Thank you.

a deterrent to doing your job today? Chairman, simple answer, yes and yes. Great. There's a benefit, and it is a deterrent. That's all I wanted to hear. And then one more

I think that there's a chance we can get them to do it at very little or no cost as a pilot program to give us access to do some of this cross-platform analysis because I think it is absolutely – it's the future. and candidly, it's the future that the private sector is doing better than the public sector right now.

Chairman, here is a copy of that auditor-supported subsection. We can get you all copies, but we can get you all copies. Thank you so much. Thank you so much. All right. I would like to call Director Partika, the Director of Medicaid, Director Scott Partika, to come and testify. And, sir, we are at 1256. So I just ask, sir, that everything you have to say is important, and we will do our best to not only hear your testimony, which is vital to this piece of legislation, but also be succinct in answering questions at the end. Absolutely, Chair.

that medical care and that daily assistance directly into their home to keep them safe, independent, and out of our higher-cost environments, such as nursing homes and hospitals. To be eligible to receive the service, the individual must meet various requirements and depending on the waiver, and all of those requirements for a waiver are approved by CMS. Speaking of CMS and our waivers, we recently completed an audit with CMS of our waiver programs, and the audit did find no structural deficiencies or lack of compliance with the federal law and rules around the program. However, there were several areas that were made as recommendations to the program to look at around tracking our data and using that to make informed decisions. And I'm glad to provide a copy of that audit to you all as well. Again, it's an audit finding of not of is not meant to say the federal government is saying there's no fraud in our program and there's no waste and there's no abuse. That is not what it was meant to do. But it was highlighting the fact that we were following all of the federal standards in terms of the setting of our program. So we have multiple waivers. and administered by not only the Department of Medicaid, but in partnership with the Department of Aging and the Department of Developmental Disabilities. Enrollment numbers by HCBS are available online and provided for context from the most recent wage report here in this testimony. In the Department of Medicaid, we have MyCare waiver. We have the Ohio Home Care Waiver, the Ohio RISE waiver, which is eligible for a subset of individuals who qualify for Ohio RISE. The assisted living waiver is administered at the Department of Developmental Disabilities, as well as passport community waiver, which would be about your most traditional waiver you would hear from and administered locally by the AAAs in your communities. Then at the Department of Development of Disabilities, we have the Individual Option Waiver, a Level 1 waiver, and a Self-Empowered Life Funding waiver, which has a small subset of enrollment. So individual eligibility. To be eligible to receive care under the HCBS waiver, the individual must meet all the Medicaid eligibility requirements, and concluding compliance with income limits as set in state and federal law, have a completed certificate of medical necessity from a qualifying treating physician, which is what I was referring to earlier around tracking that work, then also have a completed level of care assessment by a licensed clinical professional to determine the appropriate level of care needs, depending on the waiver that might be a different individual in each program, whether with the AAA as a managed care plan or a local board of developmental disabilities. Once those requirements are met, the individual service plan is developed by another individual to set the appropriate authorizations for services based on individual need. All of these tools are meant to be another layer. There's not a silver bullet we've found to fighting fraud. I don't think you could create one perfect program that could solve every single fraudulent activity out there, but what you can do is add layers and layers of accountability into the system. In each step of the way, these are layers, and there are layers and opportunities for review in terms of best practice and insurance compliance, of course, is being met. But I do believe having these layers of authorization are something of value. Provider eligibility. Moving to providers, to be eligible to provide home health services in Ohio, every provider must ensure compliance, of course, with federal and state laws, including minimum participant requirements, intensive background checks, and screening for each individual that is providing services This includes FBI background checks national and state sex offender registries abuse and neglect databases and of course our national Medicaid and Medicare exclusion list They must also ensure that all health and safety standards are met, clinical documentation is maintained, and reliable communication systems are in place to ensure continuity of care. And this is an area where oftentimes in some of the audits you'll hear Auditor Faber talk about are the investigations of the MFUCA unit, where they will come in and they will find failure to meet some of these standards, and it will be cause for either a finding or termination from the program. The waiver service providers must, of course, meet the relevant screening and enrollment requirements to become a Medicaid program. I provided the links to those in our testimony, but again, we could follow up with more details in conversation, or feel free to ask questions as appropriate. The next section here, I'll breeze through it just to show, it provides an overview of when we hear home health care and we hear waiver services, there's a lot of different types of services that fall under that. So we tried to break out what are the homemaker services, what are personal care aides, what is a waiver nursing service, and also a private duty nursing service. I think the easiest way to think about this chart is the highest level acuity needs at the bottom where the lowest is at the tops in terms of the intensity of that service. Everything from cleaning soil sheets and ensuring that individual has a meal to keep them in their home to providing intensive hands-on private duty nursing, which oftentimes could be quite intimate and intensive type of service that really mirrors darn near a hospital level of care. Family caregiver and HCBS waivers. A common topic lately that the family caregivers we find play an integral role in ensuring access to care and satisfying desires of patients and families. Been a long standing part of the Medicaid program. Various forms over the years and different rules that have applied but have been in place for quite some time. Within waivers, various programs exist that may allow for additional structure around the caregiver and patient relationships. For instance, structured family caregiving is a specific arrangement through MyCare, the Ohio Home Care and Passport Waiver, where it was structured to pay a per diem instead of an hourly service and have additional supports and requirements for the providers to meet who are providing that and allowing a family caregiver to provide that that puts an extra layer of oversight between the individual giving care in the end of the state uh then following up expenditure data we pulled this from our latest report and we will get you additional updated ones as we have more recent numbers than from state fiscal year 2023 but this was the last published full report of all the waivers together and we will provide those to the committee as well but they do give a very good context of the level of spending in the different waivers, so we wanted to include them here today. Moving down to recent allegations around fraud, waste, and abuse in particular in the home and community-based space. Last week, the governor made an announcement of multiple new administrative measures to address program integrity concerns, specifically in the home and community-based space. These will include a six statewide moratorium related to home health HCBS providers in conjunction with the national effort by CMS This effort not only reflective of what we saw as a growing trend in provider capacity across the state at a very high rate but also in conjunction with our effort to revalidate all of our providers as swiftly as possible to comply with the mandate from CMS to support that. Authorizing the immediate payment suspensions of high-risk providers. This is one that we've been working on as we talked about the data tools, and this is a data tool that we've built over the last few months and has reached a point of fidelity that we can determine who are massive outliers. So when I heard Ben talk about on behalf of Mafuku, the challenge is sometimes when something smells like fraud but you can't quite prosecute it as fraud, well, we have a duty to protect the best interest of the Medicaid program. And there are times where we see something that is such an egregious outlier that it warrants enough evidence to terminate a provider from the program, and that is something we will be using going forward. Additionally, the executive order allowed us to implement the emergency rules that will support the validation of all providers and also directed us to urgently pursue the additional requirement of GPS as a mandatory and not an optional service within our EVV program. So along with that, various other work has been happening. I know when I came in here, I previewed some of it over time. I talked a little bit about the ventilators policy in nursing home space. This is something that would fall in more of the policy disagreement or potential waste in certain cases as well around what is our clinical expectation for someone who's receiving that intensive level of service. And so those revisions were made to that program. Private room compliance as well as rulemaking around private duty nursing are additional examples of that as well. UM updates are one in particular that always draw a lot of attention. Prior authorizations, as most commonly referred to, and I think you heard the Attorney General talk about recommendations they made in the behavioral health space. We are moving forward with those. Those are going into effect on July 1st. So we've been working with managed care plans and behavioral health providers to, one, show what I would say is our level of concern with some of the activity we have seen and build for across the state with everyone involved and collectively working as a group to come up with thresholds that would be most appropriate for the state to come in and ensure there's documentation that verifies we meet the medical necessity of these services. And I'll say another reason why this is critically important is the federal government is paying more and more attention to this issue, as been evident by much conversation recently, but their audit of our books every quarter is becoming more and more scrutinized, and a lot of the questions they are asking are directly tied to, do you have the proper documentation to have been delivering these services, and are those a risk to your program? With that said, I can see we're moving on to time, so I'll just finish in full admittance to not have a chance to fully process the sub-bill, although I'll say, based on somewhat of a quick review and the comments I heard from representatives, especially representative Davila walking through there. I will say largely the department is either doing work similar to that, um already or finds value in legislative efforts to um mandate many of those policies I will commit to devils in the details and we want to make sure we can operationalize that and understand the impact of all of them. But I could at least say broadly from our discussion so far that I think we are in the right ballpark in terms of things that, one, would strengthen the integrity of the program in law, but also help assist us use the tools we have to hold bad providers accountable in this space. So I'll just close with that. We had some recommendations. I think they've largely been touched on today in some way, shape, or form around ownership risk in prohibiting new Medicaid providers. These are an area that we believe any ability to strengthen this oversight and this ability for the department would be absolutely welcomed, as well as potential probationary periods for anyone deemed high risk. So in closing, we're committed to continuing to be partners on this. Please feel free to reach out to me, my staff, or anyone as we go through not only these next couple of weeks, but as we go through, of course, the summer and the end of the governor's term. I know how serious he is taking this issue, and we are committed to doing the same. So thank you for the opportunity to testify today. I'm happy to answer any questions. Thank you. I know it's a lot of information to rush through in 20 minutes. Representative Lett.

Through the chair to the representative, thank you for the question. And I think, you know, that highlights, and I apologize, I have not time to digest all the language to ensure in terms of implementing EVV to its highest fidelity. The IT challenges are certainly something that the entire healthcare system struggles with, and I think we have a great appreciation for it at the department. We are very happy with the EVV launch to date over the last year to ensure that payment is being captured on the front end. And the auditor made that a call out in his 2024 audit. And so I think that's a critical, critical step. But to your point, I cannot speak to that specific instance in terms of that gap there. I could absolutely be committed to take it back to my team and say, how does this impact providers? And let's understand what our policy says. But I think the biggest thing with EVV, and I talked to a few members about this already around EVV, is it's absolutely not a silver bullet to protect fraud. If someone still wants to defraud our system, they can use even GPS verification and they could claim to be where they are and not providing services. That is still a risk. But EVV is a tool is it is a very useful back end fraud tool in terms of when we do get to the point where there is an investigation to be able to look at the data and say, does this line up? And so I understand the attorney general's request to add the GPS requirement for that purpose. I certainly think that is sound and makes sense. And we are we are supportive and we are moving in that direction. there are instances where a manual fix to the EVV claim are allowed to happen. I think what we need to do, and I know there was a reference to a provider EVV dashboard that was made, I'll certainly take a look at, but I've heard that from a couple of other states. I think someone was telling me about Georgia uses one, and they use it from an accountability perspective to say, hey, we get it every so often there is going to be an anomaly and you're not going to capture this. So maybe it's not 100% of the time you were right, but were you 99%, 98%, 97%? Or what were the discrepancies that we could see as the fraud claim? If I have a provider that's flagged and they are just one or two minutes off of their claim, once we open up to do an investigation, right, it's kind of the human in the loop concept with AI. It's the same thing. This is data that's informing our decisions that we still need a human to look at the case and say, okay, does this make sense or does this need to be referred for other action? So I certainly think there's an opportunity and we'll certainly commit to providing feedback to the committee on the specific EVP question. Thank you, Director. Thank you, Representative. Representative Romer.

Through the chair to the representative, thank you for that question and your reference to to Indiana. And there's someone I've talked to before compared notes with its border state, but also very aligned from a program integrity standpoint. I think the answer is yes. And also, I think if I'll refer back to the auditor state made comments around past findings of our audit findings. And as we looked at some of those audit findings, some of those were directly addressed in the big, beautiful bill passed last summer. So concurrent enrollment, dual state enrollment was one to which the federal government has already advanced that effort ahead of building a national system. They've advanced the data sharing capability that we've actually been able to use and begin disenrolling members immediately. So they started sharing that with us late last November and not only sharing with us, but giving us cause for removing people from the roles if they were listed on that. And that's just an efficiency of the system instead of individually working these case files through the county system to be able to go through and make. And so we've been able to say we assume approximately $30 million in this year alone. It's one time savings, most likely, as we are cleaning up our roles. But it but it more it builds more integrity into the roles going forward. Absolutely. As well. That's one. The six month eligibility check is another one where we'll every six months moving forward. We are going to begin checking eligibility, not to mention the work requirements that were added at the federal level. that all 50 states will have to be implementing. So there certainly are a lot of true ups on that side. And coming out of COVID, where the federal government was not allowing us to disenroll folks or do the redeterminations, there was definitely a bit of catch-up that folks were playing across the country. And I think we are well positioned in seeing the roles decline back to pre-pandemic levels. Excellent. Thank you.

Thank you, Representative. Thank you, Director.

Through the chair to the representative, I would say, broadly, there are very few areas where I could see any concern from a transparent standpoint that the department would not want to comply with. Look, I think data helps us make decisions. We assume that there might be underutilization of a service. We assume there might be over-utilization of a service until we actually can dive in and understand that data. So our commitment would be working with you all. If there are things that you guys would like to see specific claims reporting out on a certain service, we certainly will do whatever we can to comply with that and provide the information we have so that you have the same information to make those decisions. So from a veto perspective, I know there was a number of them over the years. I can't speculate on each individual one and what might have been the merits or cause of each. But I know going forward when it comes to sharing where our dollars are going, we certainly are open to – I know I heard a reference to an encounter dashboard. I know we have some public-facing dashboards that maybe aren't as detailed as folks would think is helpful. We're very open to feedback on how to make those more useful for you guys and make them actionable. Thank you. Thank you, Representative. I have a question about, Director, about the positioning of our home care waivers and the expenses that you put in here. is, to your knowledge, was it proposed and positioned to the people of Ohio paying the bill that in order to keep people in their homes, regardless of their diagnosis, that it would be less expensive to the state than putting them in long-term care? And do you believe that in most, if not all cases, that it is less expensive to apply all of these waivers? because I'm looking at the one that's $103,000 a year, is that less than a long-term care facility? Because it would seem to me that in any case, if it costs more to keep people at home with home care waivers, financially to the taxpayer paying the bill, that if in that case it's not equal or less to stay home, then we need to suggest that more people go into long-term care. To the Chair. A completely fair question and certainly appreciate it. I do think by and large and believe we know by and large that the waivers are a lower cost of care as an alternative to an institution. I understand your question around, though, the eligibility and the acuity needs of those individuals. And I'm not going to say that the program roles are 100% perfect, and I think we certainly have found instances where they're not, and we've actually prosecuted for fraud in that space. So there certainly are areas for improvement. But I will say across these waivers in particular, one thing I know, and I'm not a subject matter expert but it is keeping in mind the acuity levels vary depending on the waiver type So the individual needs of the individuals on might not be the same as on the other services So your needs for someone on an individual option waiver are much more severe than someone on a level one And the same could be said for passport and my care as you look at across the board. So certainly open to talking through what eligibility criteria might be and walk through that. But I do think and know we found across the board it is a savings versus institutional care. Thank you very much. Representative Romer.

Representative Sweeney. Thank you, Chair, and thank you, Director, for being here. As we look at expanding within the sub-bill automated enforcement authority, which obviously see the draw to that, and it seems like the department has started doing that. It's in the sub bill. Could you speak to how we can do this in a way that gets at further fraud protection, but also maintains what I believe we all care about is maintaining access to care for our most vulnerable citizens. Some of the concerns of, you know, just looking at the bill this morning of, you know, we don't clearly define what high risk is. And so as we see, there's discrepancies between what the auditor finds and what you guys claim is fraud. there is nothing that says specifically that a human would have to make that determination if AI was mandated. And to me, there's no appeals process. So if you could just speak to how you guys are doing this automated payment stop in a way that you think is protecting that we don't just stop payment for 10 days for providers because of an administrative error.

Representative Lett. Thank you very much, Chairwoman. I had one more question that I wanted to make sure I got in. that we would be implementing the prior auth for all behavioral health services starting July 1st. Are you expecting there that timeframe of when you receive that prior auth and a determination is made to lengthen if we have a significant volume of prior auths coming in to the Medicaid system? And I ask that simply because we already have long wait lists for some of these services. And these are our kiddos and adults that are hanging on the very fringe, desperate for services and prior offs could potentially lengthen that time. If you could comment on that, that would be very helpful and thank you.

I'm just again through the chair to the witness. Can you can you talk about the HCBS waiver programs? There's been a lot of comments in the last Medicaid committee about fraud from in-home care. And I was just curious, are there specific programs or a focus that you are looking at or you're just looking at all of them in general?

Thank you.