Archive

Archive for September, 2011

Special Investigations Units: SID Regional Claimant Fraud Teams

When claimants commit workers’ compensation system fraud and other crimes against the State Insurance Fund, the respective SID regional claimant fraud team responds to ensure compliance and integrity of the system. A special investigations unit (SIU) dedicated to investigating claimant fraud operates within most of the BWC customer service offices. Multiple SIUs comprise each of the three regional claimant fraud investigative teams. These teams are designated by their geographical location in North, South and West regions of the state.

SID has recently increased its staffing to combat claimant fraud, such as working while receiving disability benefits or “double dipping”, reporting false claims, exaggerating the extent of their injuries and/or misrepresenting the status of their physical recovery and their ability to return to work, forgery, falsifying their eligibility for death benefits, drug deception, drug diversion or doctor shopping.

During the last two years, their investigations have resulted in 289 criminal referrals and 195 convictions. Be sure to read more about the claimant fraud investigative successes in our SID FY 2011 Annual Report.

This concludes our claimant fraud awareness series. Look for our next fraud awareness article that will offer a review of the department’s 18 years of effectively and proactively preventing losses to the workers’ compensation system; and deterring, detecting, investigating, and prosecuting workers’ compensation fraud.

If you suspect that a claimant is committing workers’ compensation fraud, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

Advertisements
Categories: SID Information

Lost Years and Lives: Prescription Drug Abuse

Prescription narcotic drugs

Most of us are reluctant to take medicine, but we do so when such is truly needed to protect our health and, even then, only as directed by a trusted physician. However, others in our society – often our friends, neighbors and family members – are alarmingly, increasingly abusing and misusing narcotics prescribed by a medical provider. These highly addictive drugs are, by law and all good reason, “controlled” substances because they can negatively affect a patient’s quality of life, and may lead to death. Sadly, some individuals, including claimants, are committing crimes to obtain drugs. Some are illegally diverting their drugs to others. The scope of this national concern is quite significant here in Ohio.

Fast Facts — BWC Prescription drug statistics for 2010:

  • Claimants received more than $130 million in prescription drugs;
  • Oxycontin accounted for nearly $20 million of the prescription drug costs; and
  • More than 50,000 claimants received prescription narcotic drugs.

Drug Deception: Claimants criminally deceive their honest medical provider to obtain prescriptions. Claimants exaggerate symptoms or fabricate their conditions to cause their medical provider to prescribe drugs to them. For example, some claimants repeatedly file claims at emergency rooms to obtain narcotics. Claimants alter prescriptions to increase prescribed pill count, dosage or strength. Claimants criminally deceive pharmacists to fill prescriptions. Claimants falsify prescriptions, sometimes making copies of a valid prescription or stealing a blank prescription to complete as they will and forging the signature of a medical provider.

Drug Diversion: Some claimants illegally divert their prescribed narcotics to others. The street value of these narcotics can often be 10 times the cost of such to BWC. These “claimants turned drug dealers” sell their pills out of their homes, on the street, or at our schools. They also barter their pills for services, some of which are also illegal. The frequency and magnitude of this criminal behavior cannot be over-stated. In an article, May 21, 2011, entitled “Kasich signs ‘pill mill’ bill,” the Columbus Dispatch reported the Ohio State Patrol “…confiscated 20,219 pills from Jan. 1 through May 10 [2011]. The agency also made 1,979 drug-related arrests through April, a 6 percent increase from the first four months in 2010.”

Doctor Shopping: Claimants criminally deceive multiple medical providers to obtain multiple, often redundant, prescriptions. Some claimants seek and secure treatment from multiple medical providers. Here, the claimant deceives each medical provider, causing them to believe the claimant is receiving treatments and prescriptions exclusively from them. These claimants shop medical providers until they find those that they can successfully deceive. When an effective medical provider challenges the claimant, he/she simply moves on to another prospective medical provider.

A Case In Point

The SID Intelligence Unit detected a claimant had filled prescriptions written by eight physicians for nine narcotics overlapping during an eleven month period of time. Our investigation found the claimant had deceived physicians in order to obtain the narcotic prescriptions. When furnished proof of the claimant’s actual drug use, the physicians stated in writing the claimant had deceived them by failing to disclose his treatment by other physicians. The physicians documented they would not have prescribed narcotics for the claimant had they known of his doctor shopping.

The subject pled guilty to one count of deception to obtain dangerous drugs, a fifth-degree felony. The court sentenced the subject to serve 12 months of incarceration (suspended) and two years of community control, and suspended his driver’s license for six months. The court ordered the subject to pay court costs.

Effective Strategic Responses: Each month our SID Intelligence Unit reviews data pertaining to all claimants receiving BWC-paid prescriptions and refers claims to field operations for review and determination, including scheduling physicians to review the appropriateness of prescribed drugs to treat a claimant’s allowed conditions. Since March 2008, these reviews have resulted in the termination of drugs in 1,666 cases, generating $39.7 million in savings to the Ohio workers’ compensation system. We are increasingly deploying significant resources to conduct joint investigations with federal, state and local law enforcement agencies to combat prescription fraud. For example, our department is a member of the Ohio Governor’s Opiate Drug Task Force.

We work with the BWC pharmacy department, established in 2009, to address issues related to the BWC drug program. During FY 2011, the pharmacy department enacted several changes. We assisted the pharmacy department with several innovations. For example, we are pursuing a rule change that no longer requires BWC to pay for prescriptions written by decertified or non-enrolled providers. Additionally, the BWC Board of Directors approved BWC’s first ever formulary of medications for the outpatient treatment of claimants. Formularies are an industry standard that improve quality of care by enhancing the effectiveness and safety of the medications prescribed to Ohio’s claimants. Our drug formulary will improve treatment and limit the inappropriate use of medications and reduce prescription costs. We are also seeking a rule change that will allow BWC to designate a single pharmacy and/or a single prescribing physician to a given claimant.

Each of these strategies ensures the agency balances good patient care with fiscal responsibility and effectively responds to the dramatic increase in accidental deaths associated with the use of prescription narcotic drugs.

Be on the Lookout

Red flags that may indicate a claimant may be committing deception to obtain a dangerous drug or diverting their narcotic prescriptions by selling or giving them to others:

  • A claimant brags about being able to secure any drugs they want from a “friendly” physician;
  • A claimant is suspected of receiving treatment and/or prescriptions from multiple physicians;
  • A claimant repeatedly files claims at emergency rooms to obtain narcotic;
  • A claimant is suspected of being addicted to narcotics and/or other drugs; and
  • A claimant is suspected of selling narcotics and/or other drugs.

If you suspect anyone is fraudulently receiving the benefits of a deceased claimant, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

Dishonored Memories: Deceased Claimants with Dishonest Relatives

September 23, 2011 2 comments

Most of us seek to honor the memories of our deceased loved ones. Sadly, however, dishonest relatives may express their grief quite differently than law-abiding citizens. These criminals choose to dishonor the memory of deceased relatives by committing workers’ compensation fraud in the personal, confidential records of a deceased claimant.

Forgery and Uttering: Our workers’ compensation laws demonstrate compassion by granting death benefits to spouses and dependents of claimants whose injuries result in death. We expect that a responsible, surviving relative will report the claimant’s death to us and other pertinent agencies in order to stop lost time benefits. Yet, this does not always occur. Therefore, we proactively compare our claim data with obituary records to identify deceased claimants and cease lost time benefits payments. However, criminals falsely report to us that their deceased relatives continue to live. These criminals pretend to be the claimants themselves, even adopting the voice of an opposite gender’s voice and/or an elderly person in an attempt to deceive us. These charlatans would seek to intercept any check addressed to a deceased claimant, forge their signature, and pretend to be the claimant (aka “uttering”) in order to cash the check to which they know they are not entitled. In situations where lost time benefits are paid electronically, family members inappropriately access and use monies to which they are not entitled, by concealing the claimant’s death. We prosecute these deceptive acts to the fullest extent of the law.

Falsifying Eligibility for Death Benefits: Our workers’ compensation laws ensure the surviving spouses of deceased claimants receive widow benefits – that is until they re-marry. Unfortunately, dishonest surviving spouses falsely report to us that they are single, even after they have re-married. In attempting to deceive us, they may even submit falsified or altered documents.

Lastly, our workers’ compensation laws permit the surviving dependents of deceased claimants to receive benefits for a work-related death when they are dependent children under 18 years of age, or are attending an accredited educational institution full-time and between 18 and 25 years of age. Unfortunately, dishonest surviving dependents falsely report to us that they are attending an accredited educational institution full-time even after they drop classes and attend only part-time or have discontinued their studies and dropped completely out of such programs. Further, some of these criminals submit enrollment applications to accredited programs only to apparently secure the required, preliminary documentation. They may not, in fact, intend to attend a single class. In attempting to deceive us, they too may submit falsified or altered documents.

A Case In Point

We received an allegation that a subject had submitted falsified college enrollment documentation and was not, in fact, eligible to receive benefits from his father’s death claim. Our investigation identified the subject had forged multiple enrollment verification forms to three institutions from 2003 to 2009 as part of a fraud scheme in order to continue receiving death benefits past the age of 18. We found that at the final institution for which he submitted enrollment documentation, the subject had not attended even one class.

The subject pled guilty to one count of workers’ compensation fraud and one count of forgery, both fifth-degree felonies. The court sentenced the subject to serve 12 months of incarceration concurrently on each count (suspended) and five years of community control, and to perform 40 hours of community service. The court ordered the subject to pay BWC $60,500 in restitution and $2,000 investigative costs.

Be on the Lookout

Red flags that may indicate a person forged and cashed checks of a deceased claimant or falsified eligibility for death benefits:

  • A relative of a deceased claimant brags about receiving benefits;
  • The spouse of a deceased claimant attempts to conceal his/her re-marriage;
  • The college-age dependent of a deceased claimant attempts to conceal his/her part-time enrollment, or non-enrolled, status at an accredited institution;
  • A person accesses and uses funds from a deceased claimant’s bank account (into which BWC makes deposits); and
  • A relative of a deceased claimant asks others to participate in a fraudulent scheme against the workers’ compensation system.

If you suspect anyone is fraudulently receiving the benefits of a deceased claimant, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

False is Never True: False Claims and Physical Activities

“The truth, the whole truth, and nothing but the truth” – such is the simple standard we have all known since childhood. Nevertheless, some claimants make the criminal’s choice to commit fraud by reporting false claims, exaggerating the extent of their injuries and/or misrepresenting the status of their physical recovery and their ability to return to work. Unfortunately, these individuals take advantage of our system and fraudulently receive benefits.

False claims include those for which a claimant intentionally files a first report of injury (FROI) form for a non-work related injury. For example, a claimant may falsely report that an injury sustained at home or at play was sustained during the course of his/her employment. A false claim may also be filed by a claimant intentionally misreporting accident details. For example, a claimant may falsely report a pre-existing injury, perhaps one sustained and reported in another state, as new injury just sustained with a current Ohio employer. Lastly, false claims include those filed by claimants who stage accidents, including claimants who intentionally injure themselves.

Physical activity cases include those pertaining to claimants who “malinger” – who prefer not to return to work even when they are able to do so. These claimants exaggerate their injuries, falsely reporting that they cannot return to work. They prefer to receive lost time benefits than to earn an honest living.

Some of these claimants are apparently rather convincing actors when they falsely report during examinations by their healthcare providers that they need continued medical treatment. In fact, they may wear their braces or slings, or use their crutches, only as “props” for medical appointments.

A Case In Point

We received an allegation that a claimant was receiving lost time benefits for a falsified assault and that he routinely engaged in several, strenuous physical activities without any apparent physical restriction. Our investigation revealed the subject had furnished no fewer than 17 versions of how he had sustained his injuries in an attempted robbery reported to, and investigated by, local law enforcement. The evidence we secured included statements from multiple witnesses to whom the subject had admitted he had sustained no injury. Additionally, we secured a security guard’s statement that he observed the claimant put on back and leg braces and a sling in a parking lot prior to attending an Industrial Commission hearing. After viewing our surveillance video, a provider concluded the claimant’s “presentation was not true and it was a conscious and deliberate feigning of an illness or disability.” In fact, our investigation proved that while receiving benefits the claimant had continued to work as a self-employed auto mechanic.

When indicted, the subject fled prosecution. However, our Fugitive Task Force located him in Las Vegas, Nevada and secured his extradition back to Ohio. The subject pled guilty to one fifth-degree felony count of workers’ compensation fraud. The court sentenced the subject to serve five years of probation. The court ordered the subject to pay BWC $33,635 in restitution.

Be on the Lookout

Red flags that may indicate a claimant filed a false claim and/or is engaging in physical activities that are inconsistent with his / her reported physical condition:

  • Accident or injury occurs just prior to strike, layoff, plant closing, job termination or job completion;
  • Claimant is in line for early retirement;
  • Claimant admits to a pre-existing injury;
  • Claimant previously described a related accident or injury;
  • Claimant admits he or she did not sustain the injury in course of employment;
  • Claimant admits he or she gave a different account of the accident to medical providers;
  • Claimant admits he or she has filed for benefits in another state;
  • Injury is not consistent with nature of the claimant’s occupation;
  • Claimant cannot recall the date, time and place of the accident;
  • Claimant cannot recall specific details about the accident, injury or medical treatment;
  • Claimant admits he or she intentionally self-inflicted the injury;
  • Claimant is observed engaging in physical activities that are inconsistent with the reported injury;
  • Claimant is observed behaving differently on days he or she receives medical treatment;
  • Claimant is observed behaving differently on days he or she receives attending a hearing; and
  • Claimant relocates out of state or country shortly after filing claim.

If you suspect that a claimant has filed a false claim or engages in a physical activity, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

Double Dipping: Working While Receiving Disability Benefits

While it goes by many names (compensation, indemnity, lost time, disability, etc) the benefit is the same: an insurance to pay claimants an income while they are unable to return to work due to a work-related injury or illness. Unfortunately, individuals take advantage of our system and fraudulently receive these benefits.

Known to us as “work/comp”, working while receiving compensation is our second most common complaint type. This type of claimant fraud occurs when a claimant covertly returns to work, either with an employer or by engaging in self-employment, while he or she is receiving a benefit that is paying for their lost wages and prohibits any employment. It often involves a scheme that conceals the conflict employment from BWC and the claimant’s physician, who requests benefits for the claimant.

A Case In Point

We received an allegation that a claimant owned and operated a business in Arizona while receiving lost time benefits from BWC. Our investigation revealed the subject owned and operated a home restoration business in Sierra Vista, Arizona. The evidence we secured included reports documenting the subject was found guilty in Arizona on three occasions of operating his business without a contractor’s license. Our evidence also included 149 checks written by customers to the subject. In all, we identified $419,357 in cash and checks the subject received for his active work as a contractor.

The BWC SID Fugitive Task Force coordinated the subject’s arrest at work by the Cochise County (Arizona) Sheriff’s Department. The U.S. Marshalls Service extradited the subject back to the State of Ohio.

On February 28, 2011, the subject pled guilty to one fifth-degree felony count of workers’ compensation fraud. The court sentenced the subject to serve 12 months of incarceration (suspended) and five years of probation. The court ordered the subject to pay BWC $64,273 in restitution and $2,727 investigative costs.

Be on the Lookout

Red flags that may indicate a claimant is working while receiving include:

  • Claimant uses alias names;
  • Claimant has calluses on hands, grease under fingernails;
  • Claimant wears a work uniform;
  • Claimant drives a work vehicle;
  • Claimant leaves homes early in the morning and returns home in the evening; and
  • Claimant relocates out of state or country after filing the claim.

If you suspect that a claimant is working while receiving, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

BWC Investigations Result in Eight Workers’ Comp Fraud Convictions in August

September 19, 2011 2 comments

Ohio Bureau of Workers’ Compensation (BWC) Administrator/CEO Stephen Buehrer today announced eight individuals were convicted of or pleaded guilty to charges related to defrauding Ohio’s workers’ compensation system during the month of August. The court actions are the result of investigations conducted by BWC’s Special Investigations Department (SID), which works to deter, detect, investigate, and prosecute workers’ compensation fraud.

“Eight more convictions during the month of August are the result of close monitoring of suspicious activity by our investigators and detailed follow-up on allegations of fraud,” said Buehrer. “Their diligence helps to protect the State Insurance Fund on behalf of Ohio injured workers and employers.”

Following is a sampling of cases that resulted in a guilty plea or conviction during the month of August.

Cecil Webb (Dayton, Montgomery County) pleaded guilty to eleven felony counts of deception to obtain a dangerous drug and one first degree misdemeanor count of workers’ compensation fraud. The SID originally received an allegation that Webb may have been working while collecting disability benefits. During the investigation, investigators identified numerous instances in which Webb sought narcotics from three different physicians and one nurse practitioner over the same period of time. The investigation also revealed that Webb utilized four different pharmacies in the Dayton area to conceal his deception. Webb was ordered to pay $1,689.39 in restitution and mandated that all his medications be verified and taken as prescribed. The court also ordered Webb to comply with treatment, seek employment or show medical documentation that he cannot work, and comply with a curfew and a child support order.

Robert Black, DBA Mallard Home Services (Westlake, Cuyahoga County) pleaded guilty to workers’ compensation fraud for operating his business without coverage. BWC received an allegation that Black was operating Mallard Home Services although his coverage had been canceled. Surveillance conducted at this business revealed it was fully operational. BWC later received an allegation that an altered certificate of coverage was provided to a Mallard customer. Investigators interviewed the customer and obtained a copy of an altered Mallard workers’ compensation certificate. Agents interviewed Black, who indicated the altered certificate was a clerical error on his part, and then admitted to operating a business while his business’ coverage was in final cancel status and submitting false payroll and other information to BWC. Black pleaded guilty in Cuyahoga County Court of Common Pleas on August 23. Sentencing is scheduled for September 29, 2011.

Dr. John Esarco, DC (Youngstown, Mahoning County) pleaded guilty to workers’ compensation fraud for billing for services not rendered. SID received an allegation that Esarco, a chiropractor, was improperly billing BWC and executed a search warrant to analyze medical records and interview patients. The investigation found Esarco was billing for exercise therapy, a service which he did not perform. Esarco pleaded guilty August 22 and was sentenced to six months in jail, suspended, and ordered to pay restitution. Esarco provided a check for $44,184.80 at the hearing to satisfy the ordered restitution. Esarco also signed a voluntary BWC decertification letter, which decertifies him as a BWC provider.

George Seiber (Brunswick, Medina County) pleaded guilty to working while receiving benefits. SID received an allegation from a BWC employee who suspected Seiber of working, and an investigation found he was employed with Roofer Inc.com while receiving temporary total disability benefits. Seiber owned and operated the company and performed work activities including contacting customers, appraising roofs, preparing proposals, supervising staff, and handling money transactions. Seiber pleaded guilty August 10, 2011 in the Franklin County Common Pleas Court. His sentencing is scheduled for September 22.

Dana Fordenwalt (West Salem, Wayne County) , owner of Twin Peaks Roofing, pleaded guilty to three misdemeanors for failure to comply with the law for underpaying his workers’ compensation and misrepresenting the number of workers employed by his business. BWC investigators determined that over a period of three years Fordenwalt did pay his premium but was knowingly underpaying by submitting false payroll documentation. Sentencing is pending. Fordenwalt is no longer in business.

Claimant Fraud: Think you won’t get caught? Think again.

BWC is here for those hard-working people who are unfortunate enough to get hurt on the job.  BWC ensures injured workers receive entitled benefits and quality care so they can return to work.

Unfortunately, there are individuals who think it is okay to get more than they deserve. These individuals falsify information about the extent of their injuries or hide the fact that they are working while they still receive benefits to which they would no longer be entitled. Don’t be THAT guy/gal.

Committing workers’ compensation fraud may result in a felony conviction and jail time.  BWC Special Investigations has agents throughout Ohio to identify, investigate, and prosecute individuals who commit workers’ compensation fraud.  Think you won’t get caught?  Think again.

Since its inception in 1993, the Special Investigations Department has made almost 3,800 criminal referrals resulting in over 1,900 convictions for workers’ compensation-related crimes in Ohio.  Furthermore, over 55,000 investigations have been completed resulting in $1.4 billion in identified savings.

This article kicks off our Claimant Fraud Awareness series.  Throughout the month of September, we will release a series of articles on some of the types of claimant fraud, including drug-related fraud.  Additionally, we will let you know of some things that are being done to identify possible fraud.  This series follows our Employer Fraud Awareness series that was completed in August.

To report fraud online, please visit: http://bit.ly/reportfraud.
To speak with a fraud hotline agent, please call: 1-800-OHIOBWC.