Home > Fraud Awareness, SID Information > Unlicensed to steal: Providers who practice without an active license

Unlicensed to steal: Providers who practice without an active license

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.

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  1. October 11, 2013 at 11:03 am

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