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Archive for October, 2011

Paying for crime…

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Fraud subjects repaid BWC $8.5 million during fiscal year 2011!

For 18 years we have faithfully fulfilled the mission of our Special Investigations Department. We have effectively and proactively prevented losses to the workers’ compensation system; and deterred, detected, investigated, and prosecuted workers’ compensation fraud. This recovery of money from subjects of investigations protects the BWC State Fund – the fund which is used to collect premiums and pay claim costs. This serves to ensure employers pay their fair share, and those that attempt to get more are punished.

The Special Investigations Department works with the BWC Collections and Legal departments to ensure overpayments and premiums due resulting from our investigations are returned. The following are some of the ways we ensure debts are repaid:

  • Certify accounts to the Office of the Attorney General of Ohio for collection of past due debts;
  • File liens against debtors’ assets;
  • Collect overpayment from future benefit awards;
  • Pursue decertification by BWC for providers that fail to pay back overpayments resulting from fraudulent or inappropriate billing; and
  • Pursue an injunctive relief from courts (i.e., stop work order) against an employer that fails to pay premium.

Restitution also serves to deter prospective criminals from attempting to victimize our BWC State Fund. Criminologists tell us that criminals make a conscious decision to avoid committing crimes against victims whenever there is a high likelihood of being detected, investigated, prosecuted and punished. Accordingly, BWC may administratively order subjects to pay the State Fund more than the actual amount they steal. BWC may impose a financial penalty upon the subjects of closed, founded fraud investigations. For example, BWC may require employers to pay a penalty that is up to ten times of their unpaid premium amount.

Moreover, SID refers its cases to criminal prosecutors at all levels – municipal, county, state and federal. These experienced prosecutors secure appropriate indictments, convictions and sentences. At sentencing, criminal courts often order our convicted fraud subjects to reimburse BWC for the amount of monies stolen and our investigative costs. Therefore, prior to the sentencing of a convicted defendant, SID fraud analysts and special agents submit Victim Impact Statements to the court. In these statements, we ask the court to order the defendant to pay full restitution and our costs to investigate the subject.

Criminal courts often stipulate in their official judgment entries that our convicted defendants must pay BWC restitution according to a monthly payment plan. Indeed, a defendant’s failure to do so could be deemed by the court to constitute a violation of the conditions of probation. The court may then revoke probation and immediately impose upon the sentenced subject a period of incarceration. Thus, to avoid incarceration, our fraud probationers are fairly and appropriately incented are make restitution to BWC.

A Case In Point

During fiscal year 2011, we received, via a U.S. District Court, three restitution checks from a convicted provider subject totaling more than $1.2 million.

In 2006, a jury convicted this provider fraud subject on 56 felony counts, including two counts of wrongful death due to medical malpractice, 21 counts health-care fraud, 8 counts of corrupting another with drugs, 15 counts of mail fraud and 10 counts of wire fraud. After reviewing victim impact statements, the court ordered the provider subject to serve two life sentences, 20 years and 10 years of incarceration. The court ordered the subject to pay $14.3 million in restitution to 15 victims, including $7,275,762 to BWC.

Be on the Lookout

Look for our next fraud awareness article that will discuss the SID digital forensics unit. Meanwhile, be sure to read more about fraud investigations in our SID FY 2011 Annual Report.

If you suspect anyone 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.

In summary: SID Health Care Provider Team (HCPT)

October 27, 2011 1 comment

When providers commit workers’ compensation system fraud and other crimes against the State Insurance Fund, the SID Health Care Provider Team (HCPT) responds to ensure compliance and integrity of the system. The team is comprised of dedicated analysts and agents located statewide. SID has recently increased its staffing to combat provider fraud, such as billing for unnecessary or non-rendered services, practicing without an active license, overprescribing narcotics, operating pill mills, trafficking in drugs, operating injury mills, unbundling and/or upcoding.

In the last article, we explained that SID staff members furnish orientation and training to MCOs in how to meet their contractual obligation to detect and report fraud. These SID staff members, who successfully drafted and finalized “Special Investigations – MCO Fraud Reporting and Referral Requirements,” are professionals assigned to HCPT.

To bring criminal providers to justice, these talented HCPT professionals conduct joint investigations with dozens of other agencies, such as the FBI, IRS – Criminal Investigations, U.S. Department of Justice – Drug Enforcement Administration (DEA), and local law enforcement narcotics units, vice units and drug task forces. During the last two years, HCPT made 36 criminal referrals for prosecution to state, county and local prosecutors. During last year alone, their work resulted in the identification of over $8.2 million in savings to the State Insurance Fund.

Be on the Lookout

This concludes our provider fraud awareness series. Look for our next fraud awareness article that will describe how we collect on the debts owed to the BWC State Insurance Fund by subjects of our investigations. In the meantime, be sure to read more about the BWC Special Investigations Department’s strategies and successes in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Managed care organizations (MCOs): Medically managing claims and combating fraud

BWC contracts with managed care organizations (MCOs) to provide several services to both employers and injured workers. The primary service they provide is case management of the medical services the injured worker needs to get better and return to work at the earliest, safest interval. In providing medical case management services, MCOs are in close contact with injured workers, providers of record, and employers to promote the delivery of treatment and a timely return to work.

To provide effective case management, MCOs furnish core medical services, such as:

  • Ongoing contact with the injured worker to assist in finding a physician to provide treatment, to assess their work status, and to help move treatment forward;
  • Ongoing contact with the provider of record (the injured worker’s lead physician) to determine the best treatment plan or plan of care for the injured worker, the status of treatment, and the injured worker’s work restrictions, if any;
  • Ongoing contact with the employer to determine the injured worker’s work status and the availability of light duty or restricted work; and
  • Constant coordination between the provider of record and employer regarding treatment expectations and facilitation of a safe and efficient return to work.

While performing these services, the MCO is in position to identify potential fraudulent activity. After being in close contact with the provider and having knowledge of a specific claim, often the MCO may be alerted to inconsistencies or red flags. Meticulous reviews of the medical documentation and provider billing data may detect errors and fraud. If fraud is suspected, the MCO should timely report such to BWC for investigation. This obligation of each MCO to combat fraud is specified in a signed MCO agreement with BWC. The obligation includes:

“The MCO agrees to identify and report any suspected fraudulent or deceptive behavior committed by injured workers, employers, providers or any other person or entity…”

This fraud detection and reporting obligation is essential. To support each MCO in meeting its obligation, we furnish clear guidance and direction, as specified in an 8-page appendix to the MCO agreement, entitled “Special Investigations – MCO Fraud Reporting and Referral Requirements.” For example, each MCO is required to establish and maintain an effective fraud detection and corrections program. We furnish orientation and training to MCOs in how to meet this requirement because they can and should detect fraud.

A Case in Point

An MCO employee furnished an allegation to the SID Health Care Provider Team (HCPT) pertaining to a provider. The source detected the provider subject was over-prescribing in claims.

HCPT conducted an investigation in conjunction with the U.S. Department of Justice – Drug Enforcement Administration (DEA) and a local law enforcement vice unit. The multi-agency investigation included an undercover operation, a search warrant, and interviews with patients, employees and former employees. The investigation found the subject billed for services not rendered, upcoded bills, tampered with records, and engaged in drug trafficking. Even while under investigation, the subject voluntarily surrendered his DEA certificate. The State Medical Board of Ohio permanently revoked the subject’s license to practice medicine in the State of Ohio.

The case resulted in the identification of savings to the Ohio workers’ compensation system of more than $685,000. The Office of the United States Attorneys for Ohio’s Northern District is currently reviewing the case for prosecutorial merit.

Be on the Lookout

Look for our next fraud awareness article that will conclude this series pertaining to provider fraud. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Violating the code: Providers who unbundle or upcode when billing BWC

Some providers commit fraud by billing BWC separately for services that BWC requires to be billed together, as a single or “bundled” service. We refer to this fraudulent act as “unbundling.” For example, BWC requires a provider to cleanse the claimant’s skin with an antiseptic prior to giving him or her any injection. BWC requires providers to bill this as one, single service — for the cleansing of the skin and the injection. Providers are prohibited from unbundling this service. However, a criminal provider, motivated by greed, may attempt to circumvent the bundled billing requirement in order to bill BWC for a greater, total amount.

Some providers commit fraud by billing BWC using a more expensive treatment code than the appropriate code for the service actually performed. The costs of some medical services are based upon the length of time the service is provided. Services are often priced in minute increments. For example, BWC will reimburse a provider for some therapies based upon the number of minutes furnished to a claimant. However, a criminal provider may bill BWC for more minutes of therapy — at a greater cost — than they actually furnished the claimant.

A Case In Point

We detected two brothers — both Illinois psychiatrists, and one an owner/provider of an Ohio psychiatric practice — were upcoding bills they submitted to BWC for psychiatric services. Data analysis by our intelligence unit revealed the psychiatrists billed BWC for more than twenty hours of individual psychotherapy on a single day.

During the course of our investigation, we conducted undercover surveillance, a search warrant, record analyses, subject and patient interviews, and grand jury subpoenas. We obtained evidence to substantiate the allegation that the subjects falsified treatment notes and billed BWC for services not being rendered and upcoded bills for services that were provided. We determined the Ohio provider was spending significantly less time with his patients than he billed to BWC in their claims. The investigation uncovered instances in which the Ohio provider spent less than five minutes with the patient, yet he billed BWC for 45 to 50 minutes of individual psychotherapy. We also proved both brothers billed BWC for services when patients were not even present in the office.

The owner/provider of the Ohio practice pleaded no contest to one fifth-degree felony count of workers’ compensation fraud. The court sentenced this subject to serve 5 years of community control and ordered him to pay $78,573 in restitution and investigative costs to BWC. His brother, the Illinois-based provider, pleaded no contest to one first-degree misdemeanor charge of workers’ compensation fraud. The court ordered this subject to pay $27,423 in restitution and investigative costs to BWC. Subsequently, he made payment in full. An employee of the practice pleaded guilty to one first-degree misdemeanor charge of workers’ compensation fraud. The court ordered this subject to pay a $250 fine.

BWC de-certified both providers; they may no longer provide services to BWC claimants. The convicted owner/provider closed the Ohio practice.

Be on the Lookout

Red flags that may indicate a provider is unbundling or upcoding:

  • Provider inexplicably attempts to explain or justify his/her billing practices to a patient;
  • Provider furnishes services to more patients in a period of time than one suspects is feasible; and
  • Provider furnishes a service for a shorter period of time than the patient suspects is needed for effective treatment.

Look for our next fraud provider awareness article that will discuss the role of managed care organizations (MCOs) in the Ohio workers’ compensation system. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Milling about: Providers who operate injury mills

October 20, 2011 1 comment

In the second article of this Provider Fraud Awareness series, we quoted Dr. Louis Lasagna as having taught medical students to meet the following standard of conduct in the modern version of the Hippocratic Oath:

“I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism” [non-treatment].”

In the last article we examined examples of overtreatment when we discussed the scourge of criminal providers who overprescribe narcotic drugs. In this article we discuss criminal providers who engage in overtreatment of their patients by overusing multiple, repetitive, often unnecessary and ineffective, medical services. For example, these criminal providers treat patients by performing many diagnostics tests with little or no advance explanation or follow-up interpretation and often for extended periods of time.

Such a practice – from which providers conspire to furnish unnecessary care in order to overbill BWC and/or other insurers – is commonly known as an “injury mill”. In an article entitled “Insurance fraud: How to spot a personal injury mill,” Stephen Barrett, MD, Charles Bender, DC and Frank P Brennan, Esq., describe injury mills as follows:

‘The key players are (a) providers who hope to profit from their expensive services; (b) attorneys who hope to profit from insurance settlements, which often are a multiple of the health-care expense; and (c) patients who may or may not have full knowledge of the conspiracy. Some mills use “runners” to recruit accident victims, but some mills even fabricate their own accidents.’

Clearly, the intent of an injury mill is not to effectively treat the patient’s unique symptoms, to provide a cure, but rather only to maximize billings per patient per visit. Consequently, these criminal providers furnish patients short, incomplete and/or infrequent medical examinations. Injury mill providers ignore the true medical care needs of our claimants.

Be on the Lookout

Red flags that may indicate a provider is operating an injury mill:

  • Provider furnishes unnecessary treatments and/or services, often for extended periods of time;
  • “One-stop shopping” — the provider practice includes multiple provider types, typically at a single location; e.g., medical doctors, chiropractors, physical therapists, and massage therapists;
  • Physical examinations of patients are infrequent, short and incomplete;
  • Provider routinely maximizes billing per patient per visit, for example by performing many diagnostics tests with little or no advance explanation and follow-up interpretation;
  • Provider has close working relationships with attorneys;
  • Provider bills increasing units of service for massage and physical therapy;
  • Provider uses the same treatment even after the patient reports physical health improvement;
  • Patients have multiple claims and frequently receive treatment from the provider; and
  • Patients file new claims shortly after settling their older claims.

Look for our next fraud provider awareness article that will discuss providers who commit fraud by unbundling and/or upcoding bills. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Danger — Trafficking area ahead!: Providers who overprescribe narcotics, operate pill mills, and/or traffick in drugs

In the opening article in this Provider Fraud Awareness series, we noted some providers, acting with hypocrisy, violate their Hippocratic Oath and/or professional commitment to prescribe regimens for the good of patients according to the provider’s ability and judgment and never do harm to anyone. These providers deceive us and commit crimes. In that October 7th article, entitled “Hypocrisy rather than Hippocrates: Providers who harm patients and society,” we wrote: “They harm claimants, sometimes fatally…prescribing unnecessary drugs, operating pill mills and injury mills, or drug trafficking.”

Well, these words are no overstatement, embellishment or hyperbole. Proof of such exists throughout our beloved state and beyond. That is why, in a February 2011 press release, the FBI affirmed it “remains committed to working additional health care fraud investigations … to address drug diversion, Internet pharmacies, prescription drug abuse, and other health care fraud threats.” At that time the FBI reported its agents were nationally working more than 2,600 pending health care fraud investigations. Indeed, during fiscal year 2010 alone, the FBI’s collaborative efforts with law enforcement partners – including our BWC Special Investigations Department – led to charges against approximately 930 individuals and convictions of almost 750 subjects. The FBI concluded these investigations had “dismantled dozens of criminal enterprises engaged in widespread health care fraud.”

In a May 21, 2011, Columbus Dispatch article, entitled “Kasich signs ‘pill mill’ bill,” Ohio Governor John Kasich offered insight and leadership. He noted: “We really are a main artery for the transport of drugs, not just in Ohio, but through Ohio to other places.” Thus, Governor Kasich concluded: “We have to really engage even more in the war on drugs in this state.” As a member of Ohio Governor’s Opiate Drug Task Force, we take decisive action in the war to protect Ohioans from pill mill operators. To eradicate this scourge of criminal providers we continue to conduct joint investigations with other agencies. In addition to the FBI, these agencies include:  IRS – Criminal Investigations, U.S. Department of Justice – Drug Enforcement Administration (DEA), and local law enforcement narcotics units, vice units and drug task forces.

A Case In Point

We received an allegation that a Cuyahoga County doctor was prescribing significant amounts of narcotic drugs. The SID Health Care Provider Team (HCPT) conducted an investigation — with the DEA, local law enforcement, and a local drug task force — that included undercover operations and a search warrant. Our undercover operations revealed the subject prescribed narcotic medications to undercover agents without providing them with proper medical examinations and then billed BWC improperly for their office visits. Moreover, the subject wrote a prescription for an undercover agent who advised the subject she was not experiencing any pain. The investigation found the provider continued to prescribe narcotics to patients who were known doctor shoppers, even after she received warnings from pharmacies, parents, spouses, social service agencies and police departments. Our investigation proved the subject falsified records to indicate she delivered services that she did not furnish and that she falsely elevated pain levels and fabricated tests to justify her continual overprescribing of pain medication to patients.

The subject pled guilty to one count each of attempted theft, attempted workers’ compensation fraud and telecommunications fraud, all felonies of the fifth degree. The court sentenced her to serve two years of probation. The court ordered the subject to pay $5,067 in restitution to BWC and a $2,500 fine. The court further stipulated the subject may no longer be a provider of services to BWC claimants.

Be on the Lookout

Red flags that may indicate a provider is overprescribing drugs, operating a pill mill, and/or drug trafficking:

  • The provider ignores a patient’s or guardian’s questions about the necessity of a prescription narcotic drug;
  • The provider dismisses a patient’s or guardian’s questions about the necessity of a prescription narcotic drug with the excuse: “It will cost the patient nothing. The Bureau or another insurer will cover the expense;”
  • The provider fails to require a patient to complete urinalysis drug testing to confirm the patient is taking the prescribed narcotic drug;
  • The provider writes a prescription for a cash payment by the patient;
  • The provider prescribes narcotic drugs without examining and/or treating the patient; and
  • The provider’s patients sell and/or barter their prescribed narcotic drugs to others.

Look for our next fraud provider awareness article that will discuss providers who operate injury mills. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Toledo Man Caught on Camera Roofing While on Workers’ Comp

October 18, 2011 1 comment

Daniel Uribes sentenced in fraud case

A Toledo (Lucas County) man has been sentenced in a fraud case after investigators from the Ohio Bureau of Workers’ Compensation (BWC) captured video not only showing him working a roofing job while receiving benefits, but also leaving the worksite to attend a hearing on his workers’ comp case, and later returning to finish the job. The investigation, conducted by BWC’s Special Investigations Department (SID) resulted in a guilty plea by Daniel Uribes, who was sentenced the Toledo Municipal Court last week.

“It is ironic that our investigators were able to catch Uribes on tape taking a break from his illegal work activity to attend a hearing related to his workers’ compensation case,” said BWC Administrator/CEO Stephen Buehrer.  “It is also telling of the lengths some will go when committing fraud, and a reminder to us of the importance of our work to put an end to it.”

Uribes became the subject of an investigation after SID obtained evidence that he engaged in roofing work with his father while receiving Temporary Total Disability benefits for a workplace injury.  A surveillance operation showed Uribes was performing roofing work at a residence in Toledo.  During the surveillance, Uribes left the job site to travel to downtown Toledo and attend his Industrial Commission hearing on a separate issue related to his incarceration while collecting disability.  After the hearing, the investigators followed Uribes back to the work site, where he returned to work on the roof and more video was obtained. 

Uribes originally pleaded not guilty but withdrew and entered a no contest plea to a misdemeanor charge of workers’ compensation fraud.  The judge sentenced Mr. Uribes to ten days in the Corrections Center of Northwest Ohio, with credit for time served.  Mr. Uribes had already paid his full restitution of $3,254.30. 

If you suspect that a subject 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.

https://www.ohiobwc.com/home/current/releases/2011/101811.asp

BWC Investigations Result in 3 Workers’ Comp Fraud Convictions in September

Ohio Bureau of Workers’ Compensation (BWC) Administrator/CEO Stephen Buehrer today announced three individuals were convicted of defrauding Ohio’s workers’ compensation system during the month of September. 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.

“Those convicted in September bilked the system for more than a quarter million dollars, showing  the impact fraud can have on the State Insurance Fund,” said Buehrer.  “While we are pleased that the justice system is ensuring the perpetrators in these cases are on the hook for repayment, fraud of any kind is simply intolerable and unfair to honest employers and injured workers.”

Following are two of the cases that resulted in a conviction during the month of September.

Marvin Pyle (Cleveland, Cuyahoga County) was sentenced September 20 for working while receiving benefits.  BWC’s Intelligence Unit identified Pyle as possibly working while checking records with the Public Utilities Commission of Ohio. Those records showed he was stopped for a safety inspection while driving a truck for BTB Trucking (BTB).  An investigation found Pyle had returned to Hamrick Truck Driving School as a full-time student and was employed as a truck driver for GV Trucking & Excavating Inc. and BTB, despite receiving temporary total disability benefits.  Pyle provided false information to the BWC in order to obtain the benefits.  Pyle pleaded guilty to a felony count of attempted workers’ compensation and was ordered repay more than $10,300.  He was also sentenced to probation and a suspended 10 month prison sentence. 

Obie Martin and Michael Collins (Cleveland, Cuyahoga County) were sentenced for operating their business without valid workers’ compensation insurance coverage.  Investigating an allegation of fraud, SID agents interviewed Obie Martin, owner of Obon, Inc., as well as the company’s payroll officer, Michael Collins.  Agents discovered seven BWC certificates that had been altered and used by the business to obtain work contracts.  Collins admitted to altering one certificate while Martin admitted to altering the other six.  Both originally pleaded not guilty but later withdrew those pleas to plead guilty.  Martin was sentenced October 13 to six months in prison, suspended for five years of probation.  During this period, he is to repay the $236,757.34 in restitution.  Michael Collins was sentenced to one day in jail, which was suspended for time served.

If you suspect that a subject 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.

https://www.ohiobwc.com/home/current/releases/2011/101711.asp

Unlicensed to steal: Providers who practice without an active license

October 13, 2011 1 comment

Dubious doctor

Nearly all adult Ohioans, certainly those over the age of 15 years and 6 months, know that to legally operate a motor vehicle one must have a valid driver’s license or a temporary learner’s permit. They also understand that other eligibility requirements exist and must be met, including vehicle registration and proof of insurance. These citizens, whether they like it or not, recognize the State of Ohio will impose penalties, fines and even imprisonment upon those who illegally operate a motor vehicle – either without the required, valid driver’s license or learner’s permit or with a suspended license. Nearly all Ohio drivers obey these laws, reasoning they serve to protect the public interest for safety, including their own self-interest in health and well-being.

For the same reasons, these citizens certainly expect each of their medical providers to be licensed by the State of Ohio before they practice medicine in Ohio. These citizens also expect not to be treated by a provider while his/her license is suspended or otherwise inactive.

Yet, as reasonable as this expectation may seem to us, it is a false assumption. While most providers are duly licensed when they practice medicine, some providers commit the crime of practicing without a license or with a suspended license. For example, some have had their licenses suspended by the State Medical Board of Ohio following a hearing wherein their peers found them to be unfit due to an addiction to alcohol and/or drugs.

These criminal providers engage in a pattern of intentional treatment and/or billing in spite of being unlicensed. They often attempt to deceive BWC, and/or other insurers, by submitting fabricated medical reports and bills with the false identity and forged signature of a licensed provider. Fortunately, in handing down guilty verdicts in our criminal prosecution cases, juries see these providers for what they truly are – felons who preyed upon unsuspecting patients.

A Case In Point

The BWC Managed Care Organization Audit Unit and SID Intelligence Unit suspected a provider billing BWC for physical therapy treatments was unlicensed to provide physical therapy in the State of Ohio. The SID Health Care Provider Team (HCPT) interviewed licensed providers, claimants and other witnesses, conducted undercover operations, and analyzed medical records. The investigation found the unlicensed subject attempted to evade detection by submitting falsified documents using the billing identities of two BWC enrolled providers. The subject submitted documents to BWC using the identities and forged signatures of an Ohio licensed physical therapist and an Ohio certified medical doctor without their authorization or knowledge.

The subject pled guilty to one count of mail fraud and one count of tax evasion. Before sentencing, the subject’s home was sold at a Sheriff’s auction. The court sentenced him to serve 37 months of federal incarceration and three years of supervised release, and to perform 80 hours of community service. The court ordered the subject to pay $2,103,188 in restitution to BWC and $92,148 in restitution to the IRS.

Be on the Lookout

Red flags that may indicate a provider is unlicensed to render services in the State of Ohio:

  • The provider who examines and/or treats the patient is not the provider who bills for the service;
  • An “explanation of benefits” statement from BWC and/or another insurer lists a provider who did not examine and/or treat the patient; and
  • A search of the State Medical Board of Ohio’s on-line “License Center” suggests the provider’s license is in a credential status that is not “active”.

Look for our next fraud provider awareness article that will discuss providers who overprescribe drugs, operate pill mills, and/or engage in drug trafficking. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Extreme [con] games: Providers billing for unnecessary or non-rendered services.

October 11, 2011 1 comment

Billing document with penMost providers, in faithfulness to their patients and profession, avoid the extremes. Indeed, they accomplish their life’s mission as described in the modern version of the traditional Hippocratic Oath, by Dr. Louis Lasagna, in the profound words:

“I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism” [non-treatment].

Admittedly, even the best providers, through simple, human frailty, will sometimes fail. Occasionally, they over treat one patient and under treat another. As unfortunate as these occurrences are, they are certainly not criminal acts.

Yet, still other providers do, in fact, commit a crime when they over treat or under treat. Here’s how. The criminal provider engages in a pattern of intentional over treatment or non-treatment of patient(s). He or she attempts to deceive BWC, and/or other insurers, by submitting fabricated medical reports to justify falsified bills demanding payment for their unnecessary or non-rendered services. In the latter instance, the criminal provider displays brazen arrogance in submitting any bill for a service that was not provided to a patient. Millions of ‘reasonable people on the street’ have no difficulty deeming such acts as criminal. Thus, jurors appropriately hand down guilty verdicts in our criminal prosecution cases.

A Case In Point

We received an allegation from a managed care organization employee that a provider was billing for durable medical equipment not provided to claimants. The SID Health Care Provider Team (HCPT) interviewed patients and analyzed medical records. The investigation found the provider submitted fraudulent patient progress reports to BWC for reimbursement of medical supplies she did not provide to her claimants.

The subject pled guilty to one fifth-degree felony count of workers’ compensation fraud. The court sentenced her to serve one year of incarceration (suspended) and one year of community control, and to perform 80 hours of community service. The court ordered the subject to pay BWC $11,154: $5,577 in restitution and $5,577 investigative costs.

Be on the Lookout

Red flags that may indicate a provider is engaging in billing for unnecessary or non-rendered services:

  • The provider ignores a patient’s or guardian’s questions about the necessity of a treatment;
  • The provider dismisses a patient’s or guardian’s necessity of a treatment questions with the excuse:  “It will cost the patient nothing; the Bureau or another insurer will cover the expense.
  • An “explanation of benefits” statement from BWC and/or another insurer lists services the patient does not recall receiving from the provider;
  • An “explanation of benefits” statement from BWC and/or another insurer lists dates of services on which the patient was not seen or treated by the provider, perhaps due to a canceled appointment; and
  • An “explanation of benefits” statement from BWC and/or another insurer lists non-feasible dates of service, dates when the provider would not have been available, perhaps on a weekend or holiday.

Look for our next fraud provider awareness article that will discuss providers who practice without a valid license. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject 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.

Hypocrisy rather than Hippocrates: Providers who harm patients and society

Wikipedia explains The Hippocratic Oath is an oath “historically taken by doctors and other healthcare professionals swearing to practice medicine ethically. It is widely believed to have been written by Hippocrates, often regarded as the father of western medicine, or by one of his students.” In the original classic version of the oath, translated into English, the individual established a covenant with patients and society by promising to meet several commitments, including:

“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”

Most providers – whether they are physicians, surgeons, chiropractors, pharmacists, or medical professionals in hospitals or urgent care facilities – honor the oath. Further, even those who do not formally take the oath – such as durable medical equipment vendors, members of third-party administrators or managed care organizations – adopt its precepts and meet its intent.

Sadly, however, other providers violate the oath, acting with hypocrisy. They deceive us and commit crimes. They harm claimants, sometimes fatally. They harm insurers, including the BWC State Fund, by billing for services not rendered, not needed, or furnished by an unlicensed provider, manipulating procedure codes to bill for a more expensive treatment than provided, prescribing unnecessary drugs, operating pill mills and injury mills, or drug trafficking. Subsequently, employers are harmed when they must pay additional premiums to cover undetected fraudulent provider costs and manage an impaired work force. Employees are harmed by reduced wages, job loss and workplaces made unsafe by impaired co-workers. Indeed, all of society suffers.

We recognize the impact of provider fraud upon Ohio. In 1994, our department created the Health Care Provider Team to exclusively investigate this type of fraud. In 2005, we expanded the team with dedicated analysts and agents located statewide. During the last two years, the Health Care Provider Team made 36 criminal referrals for prosecution to state, county and local prosecutors. During last year alone, their work resulted in the identification of over $8.2 million in savings to BWC’s State Fund.

During the month of October, we will discuss several of the above provider fraud schemes, introduce other BWC departments tasked with regulating providers and describe strategies that our department uses to detect provider fraud. Look for our next fraud awareness article that will discuss providers who bill for non-rendered or unnecessary services, two of our more common provider fraud complaints.

Meanwhile, be sure to read more about our fraud investigative performance results in the SID FY 2011 Annual Report.

If you suspect that a subject 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.

SID Comes of Age: A Retrospective Review at 18

In 1984, the National Crime Prevention Council designated October Crime Prevention Month. Every year since then, government agencies, civic groups, schools, businesses, and youth organizations have reached out to educate the public, showcase their accomplishments, and explore new partnerships during this special month. October has become the official month for recognizing and celebrating the practice of crime prevention, while promoting awareness of important crime prevention strategies. The month-long celebration spotlights successful crime prevention efforts on the local, state, and national levels.

In honor of Crime Prevention Month 2011, we offer the following respective review of the BWC Special Investigations Department.

Our department was formed by statute and commenced operation in 1993. For 18 years we have faithfully fulfilled our mission: effectively and proactively preventing losses to the workers’ compensation system; and deterring, detecting, investigating, and prosecuting workers’ compensation fraud.

During that time, we have achieved significant performance milestones, such as:

  • Completed 55,163 investigations;
  • Closed 22,270 founded cases;
  • Identified more than $1.4 billion in savings;
  • Identified $25,906 per closed case;
  • Referred 3,760 subjects for prosecution; and
  • Secured 1,902 criminal convictions.

Strategic Innovation. To generate these notable outcomes, supported by our agency executives we have consistently identified and implemented innovations.  For example, we created and deployed specialized teams each dedicated to combating a type of workers’ compensation fraud subject; claimants, employers, providers, MCOs, etc. We have identified and implemented new technology to detect fraud, analyze data and secure evidence. For example, the SID Digital Forensics Unit utilizes advanced forensic software and equipment to secure electronic evidence from subjects.

A Common Thread: Detection and Intelligence. The Intelligence Unit program uses various technologies and techniques to detect fraudulent activity and refer allegations to each of our specialized investigative teams. This program includes exchanging data with other agencies and organizations to identify claimants receiving total disability benefits who are gainfully employed, incarcerated, or otherwise not entitled to these benefits. Additionally, the Intelligence Unit identifies fraudulent trends by performing data analyses of BWC indemnity (lost time), medical and employer information.

Most recently, SID has recently increased its staffing to even more effectively combat fraud. In June 2011, BWC Administrator/CEO Stephen Buehrer approved us to post and fill critical vacancies, including those with our Intelligence Unit. The selected professionals will generate significant increases in SID performance results.

Be sure to read more about our fraud investigative strategies and successes in the SID FY 2011 Annual Report.

Look for our next fraud awareness article that will commence a series focused upon health care provider fraud. If you suspect that a subject 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.

Brunswick Man Caught Running Roofing Company While on Workers’ Comp

George Seiber sentenced in fraud case, must repay more than $24,000

A Brunswick (Medina County) business owner has been sentenced following a fraud investigation that showed he was operating his business in violation of the law that forbids injured workers from working while receiving benefits from the Ohio Bureau of Workers’ Compensation (BWC). George Seiber was ordered by a Franklin County judge last week to repay more than $24,000 he received while he was working and simultaneously receiving Temporary Total Disability benefits.

“The law is very clear in forbidding employment or running a business while receiving workers’ comp benefits,” said BWC Administrator/CEO Stephen Buehrer. “Unfortunately for many of the perpetrators, BWC’s fraud staff sees these cases over and over again and is very attuned to the red flags that often signal fraudulent activity.”

BWC’s Special Investigations Department (SID) received a fraud allegation from a BWC employee who suspected Seiber of working while receiving Temporary Total Disability benefits. When the employee called Seiber, she received a voice message for a business called Roofer Inc. SID opened an investigation suspecting that Seiber may be working at Roofer Inc. The investigation found 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. On September 27, Seiber was sentenced to 12 months incarceration, suspended, and five years of community control. He was also ordered to pay restitution to in the amount of $24,883.88, including $1,000 for investigative costs.

If you suspect that a subject 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.

https://www.ohiobwc.com/home/current/releases/2011/100411.asp