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Happy Anniversary to our Fraud Hotline system!

International Fraud Awareness Week 2020

By Jeff Baker, Program Administrator, Central Operations, BWC Special Investigations Department

Our Special Investigations Department (SID) is celebrating the third anniversary of our Fraud Hotline system this month.

We launched this system on Nov. 14, 2017, during Fraud Awareness Week, and what a successful launch and three years it has been! We’ve received more than 3,900 calls since then from sources suspecting workers’ compensation fraud by injured workers, businesses, and health care providers. That’s an average of more than five each workday.

“Clearly, this important tool is working and we’re glad to have it,” said SID Director Jim Wernecke. “Fraud raises the cost of workers’ compensation for all of us, so the sooner we can stop it, the better.”

If you suspect workers’ compensation fraud in Ohio, give us a call at 1-800-644-6292 or complete a simplified online fraud referral form on our website, We will conduct an investigation and determine the facts.

Together, we are successfully combatting workers’ compensation fraud in Ohio.

Today, and always, we thank you for your support!

Former police officer convicted for workers’ comp fraud

North Canton man owes BWC $89,000

A retired police officer for the city of Canton pleaded guilty to workers’ compensation fraud Thursday after the Ohio Bureau of Workers’ Compensation (BWC) discovered him working two jobs while claiming to be permanently disabled.

James H. Blaine of North Canton must pay BWC $66,481 in restitution and $23,000 in investigative costs after pleading guilty to the fourth-degree felony charge through a bill of information hearing in the Stark County Court of Common Pleas. A judge also ordered Blaine to serve three years of probation, obtain a full-time job, and provide 100 hours of community service.

“If you’re working two jobs, you’re clearly not permanently disabled,” said BWC Administrator/CEO Stephanie McCloud. “Kudos to our investigators for detecting this fraud and putting a stop to it.”

BWC’s Special Investigations Department discovered Blaine working as a security guard for a private company in late 2017 and operating his own landscaping business while collecting permanent total disability benefits for an injury he suffered while working for a salt company. His fraudulent activity is unrelated to his former job as a police officer in Canton, where he retired in 1997, according to city records.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Video surveillance exposes Sidney couple’s scheme to defraud BWC

Agency closes 11 cases in June, July   

The Ohio Bureau of Workers’ Compensation (BWC) closed 11 cases involving workers’ compensation fraud and related charges in June and July, bringing total convictions for BWC to 47 for calendar year 2020.

“Workers’ compensation fraud can happen anywhere in Ohio,” said BWC Administrator/CEO Stephanie McCloud. “That’s why we have dedicated investigators in every corner of the state to uncover folks — whether they’re employers, injured workers or medical providers — who try to cheat the system.”

Among the June cases is a Sidney, Ohio, couple sentenced on felony charges related to workers’ compensation fraud after a BWC investigation found the husband mowing lawns, using a snow blower, and chopping wood while claiming to be permanently and totally disabled from work.

A Shelby County judge sentenced David Juillerat on June 8 to five years of probation in lieu of jail time and a fine of $1,000 for his conviction on a reduced charge of attempted tampering with records, a fourth-degree felony. Juillerat’s wife, Wendy Juillerat, was sentenced three days earlier on a similar charge, attempted complicity to tampering with records, also a fourth-degree felony. A judge sentenced her to five years of probation in lieu of jail time and to pay court costs.

David Juillerat applied to BWC in 2018 for permanent total disability benefits, claiming a work injury left him unable to drive a car or walk without the assistance of a walker. Acting on a tip that he might be faking his injury, agents with BWC’s Special Investigations Department surveilled David for several weeks in 2019. They filmed him on multiple occasions entering and leaving medical offices with a walker. Away from a medical office, however, agents filmed him walking, shopping, working on his car, chopping wood, and other activities, all without the use of a cane or walker.

As for Wendy Juillerat, agents say she admitted to helping her husband complete his application for permanent total disability and accompanied him to numerous doctor’s appointments in which she would exaggerate his physical limitations in order for the disability to be granted.

Based on BWC’s investigation, David Juillerat’s application for disability benefits was denied in late 2019, saving BWC an estimated $233,668 in benefits over the projected life of the claim.

 

Other cases in June and July include:

 

Joseph Ferguson of Toledo

Ferguson pleaded guilty July 24 in Franklin County Common Pleas Court to one count of workers’ compensation fraud, a first-degree misdemeanor, after a BWC investigation revealed he was working as a web development supervisor while receiving benefits from BWC from October 2017 to January 2018. The judge sentenced Ferguson to five years of community control and ordered him to pay restitution of $6,473 to BWC. If he violates the terms of his community control, he will serve 60 days in jail.

 

Ruth Asamoah of Columbus

On July 13, Asamoah pleaded guilty to one count of workers’ compensation fraud, a fifth-degree felony, for working while receiving BWC disability benefits. BWC investigators found Asamoah worked for eight employers, performing the same or similar jobs she was doing when she was injured. A Franklin County judge ordered her to pay $15,020 in restitution and sentenced her to an 11-month jail sentence, suspended for five years of probation.

 

Jeffrey Berkley of Taylor, Michigan

BWC investigators found Berkley working as a driver, transporting cars around the Midwest, while receiving BWC benefits from July 2014 to September 2014. On July 7, Berkley pleaded guilty in Franklin County to one count of workers’ compensation fraud, a first-degree misdemeanor. The judge sentenced him to a 12-month suspended jail sentence and ordered him to pay restitution of $2,668 to BWC. Berkley paid the full amount of restitution to the clerk of courts prior to the plea.

 

Marguerite Cervantes of Perrysburg

Cervantes pleaded guilty July 2 to one count of workers’ compensation fraud, a fifth-degree felony, in the Franklin County Court of Common Pleas. A BWC investigation revealed Cervantes had returned to work as a clinical nurse from April to October 2016 while collecting temporary total disability benefits. The judge sentenced her to an 11-month suspended jail sentence, five years of probation, and ordered her to pay restitution of $16,885.

 

Angela Berardelli of North Canton

A BWC investigation revealed Berardelli was working at a restaurant while receiving BWC benefits from January 2016 to June 2017. On June 30, Berardelli pleaded guilty to one count of workers’ compensation fraud, a first-degree misdemeanor. She received a sentence of 90 days in jail suspended for 12 months of community control. The judge ordered Berardelli to pay restitution of $10,194 to BWC. She made a payment of $6,500 at the time of plea.

 

Patricia Black of Cincinnati

Black pleaded guilty June 16 in Franklin County to one count of workers’ compensation fraud, a fifth-degree felony. An investigation by BWC found Black working as an office cleaner while receiving BWC benefits from January 2018 to October 2018. Black was ordered to pay $18,407 in restitution and sentenced to 12 months in prison, suspended for three years of non-reporting community control.

 

To report suspected workers’ compensation fraud, call 1-800-644-6292 (Option 4, Option 0, Option 1) or visit bwc.ohio.gov.

 

Dayton claims representative is BWC’s Fraud Finder of the Year

By Jeff Baker, Program Administrator, BWC Special Investigations Department

A claims service specialist (CSS) in our Dayton Service Office is our 2019 Fraud Finder of the Year award winner.

We can’t name the employee because we don’t publicly identify our fraud tipsters, but this longtime BWC veteran tipped us off about a claimant collecting disability benefits after going to prison for shooting a SWAT officer.

“Thanks to this employee’s actions, we were able to save the BWC system more than $2 million,” said Jim Wernecke, director of our Special Investigations Department (SID), referring to the estimated cost over the life of the claim.

With characteristic humility, the CSS, who referred five other allegations to SID during fiscal year 2019, said, “I was just doing my job.”

About a fourth of the nearly 3,000 fraud allegations we received in fiscal year 2019 came from BWC personnel around the state. These included claims representatives, employer representatives, and others who suspected illicit behavior on the part of injured workers, employers, health-care providers or others connected to Ohio’s workers’ compensation system. Our investigations led to an estimated $5.9 million in savings to the BWC system.

“We encourage all BWC employees and the general public to contact us immediately if they suspect fraudulent behavior in our system, even the slightest hint of it,” said Director Wernecke. “We will conduct a thorough investigation, and the sooner we get started, the better.”

To report suspected cases of workers’ compensation fraud, call 1-800-644-6292 (then select option 0, option 4, option 1) or visit www.bwc.ohio.gov.

How employers can prevent workers’ compensation fraud

February 7, 2020 1 comment

By Dan Fodor, Assistant Director, BWC Special Investigations Department

Workers’ compensation fraud can be costly, so it’s important to know how to protect your organization. Here are five ways you can prevent fraud.

1. Make employees aware of workers’ compensation fraud. Employees should know that workers’ compensation fraud has a price. Individuals who are caught may face a felony criminal record.

2. Promote a zero-tolerance fraud policy. Promoting a zero-tolerance policy encourages employees to be active in reporting and preventing fraud. Ensure that employees are aware of how and where they can report suspected fraud at any time.

3. Know the red flags. As an employer, it is important to know the indicators of potential fraud while reviewing incident reports. Some of these red flags include:

    • Late reporting of the incident without a reasonable explanation.
    • Inconsistent descriptions of initial report of injury.
    • The individual is hard to reach.
    • Individuals who perform seasonal work that is about to end when they file a claim.

4. Create safe working conditions. Prioritizing the safety of your employees is an effective method in preventing fraud. Train your employees to identify possible safety hazards at work and how to report them.

5. Use your resources. If you suspect an individual of fraud, contact BWC’s Special Investigations Department and let them investigate. Special investigations professionals pursue cases of claims fraud, medical provider fraud or employer fraud. Also, if you suspect other organizations may be operating without workers’ comp coverage, you should contact BWC.

If you suspect workers’ compensation fraud, submit a Fraud Allegation Form or call 1-800-644-6292, and follow the options.

Thank you!

November 22, 2019 1 comment

Thanks for following, liking and sharing our International Fraud Awareness Week posts!

It’s great to be part of a large network of individuals and organizations with the same mission – to #StopFraud!

We appreciate the opportunity to share our story and learn what our counterparts are doing in their fight to stop all kinds of fraud.

While we hope you never come across workers’ comp fraud, if you do, we want you to know how to recognize it and where to find us.

 

BWC secures 14 fraud-related convictions in October

Fraudsters owe BWC more than $283,000 in restitution

The Ohio Bureau of Workers’ Compensation (BWC) secured 14 fraud-related convictions in October, with those convicted owing BWC a combined $283,146 in restitution.

Those convicted include injured workers found working while collecting disability benefits, family members collecting their deceased parent’s compensation benefits, and business owners whose coverage had lapsed.

“When people cheat BWC or fail to cover their own employees, they are cheating the injured workers who really need our help and the employers in our system that follow the law,” said BWC Administrator/CEO Stephanie McCloud.

In order of most recent court appearance, those convicted in October include:

Bruce Starkey of Cincinnati, Ohio
Starkey pleaded guilty Oct. 17 and was sentenced in Hamilton County Common Pleas Court Nov. 4 on one count of workers’ compensation fraud, a fifth-degree felony. Starkey received 100 hours of community service and was required to pay BWC full restitution for the $1,459 in permanent total disability benefits he took from his mother’s bank account after she passed. He failed to inform BWC of her passing and wrote 15 checks, forging his mother’s signature.

Cecil Piner of Xenia, Ohio
Piner pleaded guilty Oct. 31 in Franklin County Common Pleas Court on one count of workers’ compensation fraud, a fifth-degree felony, after BWC found him driving a school bus while receiving $17,901 in disability benefits. He was sentenced to five years’ probation in lieu of 12 months in jail and ordered to pay court costs and full restitution.

Kyle Foreman of New Carlisle, Ohio
Foreman pleaded guilty Oct. 30 in Clark County Municipal Court on two counts of failure to comply, both second-degree misdemeanors. His coverage for Kyle S. Foreman Enterprises had lapsed since November 2017, and he failed to pay the premiums before taking his company into bankruptcy. He was ordered to pay a $100 fine and court costs for each count.

Michelle Smith of Cincinnati, Ohio
Smith, 57, pleaded guilty Oct. 23 to one count of workers’ compensation fraud, a fifth-degree felony, after BWC discovered she owned and ran two businesses, Expression Unique LLC and Later in Life Brides, while collecting BWC benefits for workers deemed permanently and totally disabled. A Franklin County judge ordered Smith to pay BWC $40,873 dollars in restitution and serve five years of non-reporting community control (probation). If she violates her probation, she must serve a year in prison.

Louis Tombazzi of Cleveland, Ohio
BWC found Tombazzi owed the agency approximately $75,000 in premiums after letting the policy lapse for his business, Garda Architectural Fabrication. He pleaded guilty Oct. 16 in Cleveland Municipal Court to one count of failure to comply, a second-degree misdemeanor, and was ordered to serve 90 days in jail (suspended), pay a $400 fine, and serve two years’ probation. He also was ordered to report monthly to the court his effort to reduce or pay off his BWC obligation.

Natalia Daniels of Concord Township, Ohio
Daniels pleaded guilty Oct. 16 to one count of workers’ compensation fraud, a first-degree misdemeanor, after receiving $3,600 in BWC disability benefits while working as a bus driver for a senior living facility and as a laborer for an insurance company. A judge ordered her to pay full restitution to BWC and serve 18 months of probation in lieu of a 180-day jail sentence.

Vicki Aloisio of West Chester, Ohio
Aloisio was convicted Oct. 11 on two counts of failure to comply, both second-degree midemeanors, for failing to carry BWC coverage on her business, Richard Aloisio Trucking Inc., despite numerous BWC attempts to assist her. Aloisio owes $28,000 in past-due premiums and penalties. Sentencing in a Butler County courtroom is scheduled for Dec. 6.

Ahmad Al-thamra of Akron, Ohio
Al-thamra pleaded guilty Oct. 10 in Akron Municipal Court to two counts of failure to comply, both second-degree misdemeanors, for failing to maintain workers’ compensation coverage on his business, The Family Corner Store. He was ordered to pay $300 in fines and ordered to pay court costs and obey all laws for one year.

Jason Gaschler of Cheswick, Pennsylvania
Gaschler pleaded guilty Oct. 10 of one count of theft, a first-degree misdemeanor, for operating a construction company, General License Contracting, in Pennsylvania while receiving $6,864 in BWC benefits. He was sentenced to one day in jail (time served) and made full restitution at the time of his hearing.

Jason Rissner of Rockford, Ohio
Rissner pleaded guilty Oct. 9 in Mercer County Common Pleas Court to one count of petty theft, a first-degree misdemeanor, after he was caught operating his own construction company while receiving $35,261 in temporary total disability benefits from his employer, O’Reilly Auto Parts. He was ordered to spend 180 days in jail, which would be suspended if he committed no more crimes within a year and pay full restitution to O’Reilly.

Brian Franklin of Sharonville, Ohio
Franklin avoided conviction on one charge of workers’ compensation fraud, a fifth-degree felony, after he agreed Oct. 8 in Franklin County to pay BWC $18,081 in restitution. BWC found Franklin working at a community center in 2018 while collecting BWC benefits.

Marshann Kinman of Cedar Grove, Ohio
Kinman pleaded guilty Oct. 8 to one count of workers’ compensation fraud, a fifth-degree felony, in Hamilton County Common Pleas Court. Kinman failed to let BWC know her mother had passed so she could take $6,321 in BWC widow death benefits intended for her mother. Kinman received two years of community service and was ordered to pay BWC full restitution.

Charles Ayler of Cincinnati, Ohio
Ayler pleaded guilty Oct. 3 to one count of workers’ compensation fraud, a first-degree misdemeanor, after BWC found him working while receiving BWC benefits. He was sentenced to 180 days in jail, which was suspended for two years of community service, the promise to avoid similar offenses, and to pay BWC full restitution of $6,090 and court costs of $150 by Dec. 31, 2020.

Ronald J. Dorfeld of Brunswick, Ohio
Dorfeld must pay BWC $78,957 in restitution after pleading guilty to a fifth-degree felony charge of workers’ compensation fraud Oct. 1 in a Franklin County courtroom. BWC found Dorfield operating his own business, Xtreme Multimedia Marketing, while receiving disability compensation. A Franklin County judge sentenced Dorfeld to ninth months in jail, which was suspended for five years’ probation and full restitution.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Happy Anniversary to Us!

On Nov. 14, 2019, our BWC Special Investigations Department celebrated the second anniversary of its Fraud Hotline system.

We launched this system during Fraud Awareness Week 2017 as an important new customer service tool for external sources to report their suspicions of workers’ compensation fraud. What a successful launch and two years it has been!

We’ve received more than 3,300 calls since then, an average of nearly seven each work day!

If you suspect workers’ compensation fraud in Ohio, call us on it.

We look forward to hearing from you. Give us a call at 1-800-644-6292. We will conduct an investigation and determine the facts. Together, we are successfully combatting workers’ compensation fraud in Ohio – one most important call at a time.

Today, during International Fraud Awareness Week 2019, we thank you for your support!

A letter from Jim Wernecke – Director of BWC Special Investigations

As Director of the BWC Special Investigations Department (SID), I am honored to kick off Fraud Awareness Week. I invite you to view my video message, “Fraud Hurts Us All.

In the video I discuss how workers’ compensation fraud increases premiums for employers, which reduces the money employers can invest in their employees, community and future growth. I explain how BWC employees are improving workplace health and safety, getting injured workers back to work, and keeping premium rates low for employers. I describe how SID employees protect the State Insurance Fund by detecting, investigating, and deterring fraud.

Lastly, I invite viewers to report, via an online form, suspected workers’ compensation fraud.

I also invite you to check back daily as we share success stories in our efforts to combat workers’ comp. fraud. Some stories we will highlight are:

We would not have achieved these successes without the dedicated staff members who serve our department with great skill, resourcefulness, and determination to bring justice to those who cheat our system. Their efforts create safer workplaces and ensure those who attempt to commit fraud in workers’ compensation are held accountable to the fullest extent of the law. Since our inception in 1993, we have identified over $1.9 billion in savings, as well as:

  • Completed over 69,000 investigations
  • Referred 5,420 subjects for prosecution
  • Secured 2,941 criminal convictions

We are honored and eager to join our fraud-fighting colleagues around the country and abroad each November to participate in International Fraud Awareness Week.

The campaign, which runs through Saturday, was established by the Association of Certified Fraud Examiners to highlight the issue of fraud and minimize its impacts.

Most weeks, you’ll find us sharing our fraud news on #FraudFriday. But this week, we’ll have a new fraud feature each day! So keep an eye here on our blog and on our Facebook and Twitter pages!

Happy Fraud Awareness Week!

Northeast Ohio business owners owe BWC nearly $1.3 million following fraud convictions

Two northeast Ohio businessmen must pay the Ohio Bureau of Workers’ Compensation (BWC) nearly $1.3 million in restitution following their recent convictions on multiple fraud charges in separate, unrelated cases.

“We look forward to recouping these dollars and directing them where they belong — taking care of injured workers, creating safe workplaces, and giving employers excellent coverage and service,” said BWC Administrator/CEO Stephanie McCloud.

Sentenced Monday in a Cuyahoga County courtroom, Robert E. Fitz must pay BWC $961,956 in monthly installments and serve five years of probation for his Sept. 30 conviction on a fourth-degree felony charge of workers’ compensation fraud.

Fitz, an attorney and owner of Action Maids residential cleaning company in Westlake, Ohio, had refused to cooperate with BWC to bring his lapsed policy into compliance, leaving the agency to pick up the costs on 43 injury claims since 2003, five in the last five years.

On Oct. 21 in Stark County, a judge ordered an Alliance man to pay BWC $300,230 in restitution after BWC found him defrauding the agency in multiple ways, including working at two businesses he owned while collecting workers’ compensation for work injuries he claimed left him permanently and totally disabled.

Roger L. Kale, Jr., 51, also must serve five years of probation and perform 100 hours of community service. BWC’s Special Investigations Department also found the following:

  • To establish his compensation rate for his 2009 workplace injury, Kale reported wages for himself that were higher than what he reported on his BWC payroll reports for all of his employees combined.
  • Kale operated A-1 Brosch Tree Service without workers’ compensation coverage required by Ohio law.
  • Kale under-reported his payroll and misclassified his employees to lower the cost of his BWC premiums.
  • Kale presented clients an altered BWC certificate of coverage to make it appear his business had coverage when it did not. One client reported Kale to BWC.

Video obtained from the Ohio State Highway Patrol shows Kale operating a tow truck while claiming to be permanently disabled.

Kale pleaded guilty to one count of tampering with records, a fourth-degree felony; three counts of workers’ compensation fraud, all fourth-degree felonies, and two first-degree misdemeanor charges of workers’ compensation fraud.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Fraud hurts us all

Fraud hurts us all, says Jim Wernecke, head of BWC’s special investigations department, in this video.

 

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Auld Lang Syne…

Standout fraud cases in 2018

By Melissa Vince, BWC Public Relations Manager

Soon we’ll all be counting down and singing that classic New Year’s song to say farewell to 2018 and hello to 2019. Or maybe you’re like me and you’ll wake up at 12:05 a.m. to realize you missed another countdown.

In the spirit of Auld Lang Syne, which roughly translates as “for old times’ sake,” we thought we’d look back at some of our more notable cases in 2018. Since January, we shared 48 blogs covering claimant, provider and employer workers’ compensation fraud cases. The following cases stand out in our memory:

Thanks for your support this year. We were proud to celebrate our 25th year of investigating, detecting and deterring fraud in Ohio. Now it’s on to 26!

And thanks for following the BWC Fraud Blog. We hope you’ll stay tuned here in 2019 for more on the latest news and information on workers’ comp fraud in Ohio. Don’t forget to also follow our Facebook page.

Cheers! Okay, everyone now: Should auld acquaintance be forgot….

IFAW: That’s a wrap

It’s time to wrap another impressive International Fraud Awareness Week.

We specialize in workers’ comp fraud but enjoy hearing about what our counterparts are doing in their fight to stop all kinds of fraud. We also appreciate the opportunity to share our story with you.

We’ve shared a lot about ourselves, including what we do, why we do it, a little about how we do it, how Ohioans can help and much more.

Thanks for connecting with us this week. While we hope you never come across workers’ comp fraud, if you do, we want you to know how recognize it and where to find us.

If you do still have questions, don’t worry, we’re here all year long.

Our fraud hotline is, well, hot! Thanks for making us aware of fraud all year long!

November 16, 2018 1 comment

By Jeff Baker, Program Administrator, BWC Special Investigations Department

We have received more than 2,300 calls since we launched our new Fraud Hotline system on November 14, 2017, during International Fraud Awareness Week 2017.

The nearly 200 calls a month, means we have received 9 each work day, or more than one every working hour!

In our November 14, 2017 blog, we noted that calling the BWC Fraud Hotline is the most interactive and direct way for you to report an allegation of fraud. Our hotline puts you in direct contact with an agent in our Special Investigations Department, one ready and willing to listen to, document, and promptly act upon, your concerns.

We look forward to hearing from you, so give us a call at 1-800-644-6292 if you suspect fraud. We will conduct the investigation and determine the facts. Together, we are successfully combatting workers’ compensation fraud in Ohio – one most important call at a time.

Today, during International Fraud Awareness Week 2018, we thank you for your support!

‘Records told the story’ in fraud case: Northeast Ohio business overbills agency; owner found guilty of workers’ comp fraud

November 15, 2018 1 comment

By Jennifer Cunningham, Assistant Director, BWC Special Investigations Department

The bills coming from a Northeast Ohio health care facility to the Ohio Bureau of Workers’ Compensation (BWC) looked suspicious.

Too many, it seemed, were for treatment to a company co-owner and others closely connected to the business. Our agency had paid more than $110,000 for claims on one of those cases alone and $27,000 for treatment provided to co-owner Jeffrey L. Guerin. So, in late winter of 2013, our special investigations department decided to take a closer look at PT Plus LLC of Willoughby Hills, a provider of physical therapy and massage therapy about 20 miles northeast of Cleveland.

After a preliminary investigation by our Health Care Provider Team, we used an undercover agent posing as an injured worker to get an inside look at the practice. In roughly 23 visits over three months our agent observed — and records later proved — PT Plus billed BWC for services that weren’t rendered to patients. In one case, our agent witnessed an injured worker refuse treatment, but PT Plus billed BWC anyhow, using spurious treatment notes to support the claim.

Our agents subsequently interviewed three former PT Plus employees, all of whom alleged co-owner Guerin committed health care fraud out of the business. Specifically, they claimed Guerin billed BWC and other third-party payers for treatment not rendered to patients. They said Guerin managed the day-to-day operations of the business and had total control over the billing process. They said he altered the units of service recorded on fee sheets and the patient’s in/out time recorded on treatment notes to correspond with the amount of treatment billed to BWC.

As we were investigating, PT Plus went out of business around July 2014. Our agents learned the business records and patient charts were stored at Guerin’s business partner’s residence. We conducted a search warrant and interviewed the co-owner, who denied any involvement in the company’s day-to-day operations and billing responsibilities. That was Guerin’s role, he said.

Our agents interviewed Guerin, who admitted sole responsibility for billing and overseeing his company’s daily operations. He told our agents that beginning in 2009 he had auditors review his businesses records to look for discrepancies. He said they found that he had actually under-billed BWC about 60 percent of the time, thus shorting his business money. For the audits that revealed overbilling, it didn’t amount to much money, he said. Taken collectively, it was all a wash and that’s why he didn’t inform BWC or any other third-party payer, he explained. But that’s not what our agents found.

During the interview, Guerin retrieved the audit worksheets from his basement and surrendered them to the agents. The agents conducted a cursory review and discovered the majority of the 2014 audit worksheets recorded overbilling. “He offered bizarre justifications and excuses for the records,” one agent told me. “He was cooperative, but we could tell he wasn’t truthful. I think he felt he could explain his way out of it, but the records told the story.

Back at the office, the health care provider team conducted its own audit. The methodology entailed comparing the type, amount (Units of Service) and length (In/Out Times) of treatment that the therapists recorded on the billing and treatment records with the bills Guerin sent to BWC. The audit revealed more than 170 instances where Guerin altered data so he could bill and receive reimbursement for more treatment than was rendered.

On May 18, 2018, Guerin pleaded guilty to one count of workers’ compensation fraud, a first- degree misdemeanor, in Franklin County Municipal Court. He paid BWC restitution in the amount of $7,154 on the same day.

Let’s talk workers’ comp fraud

November 13, 2018 2 comments

By Melissa Vince, BWC Public Relations Manager

Fraud (/frôd/), noun
Definition: Wrongful or criminal deception intended to result in financial or personal gain.

In other words, cheating to get one over on others. There are countless ways people try to commit fraud. Check fraud, identify theft, pyramid schemes, credit card fraud and so on.

What do we do in the Ohio Bureau of Workers’ Compensation Special Investigations Department? We pursue workers’ compensation fraud.

BWC insures Ohio employers for workplace injuries and cares for employees who are hurt on the job. The vast majority of Ohio workers, employers, medical providers and others are interested in nothing other than getting injured workers healed and back on the job. There are a few though who have other ideas.

We define workers’ compensation fraud as knowingly making a false representation of a material fact to obtain or to deny workers’ compensation benefits or to avoid responsibility under the law. Workers’ compensation fraud increases premiums for employers, which reduces the money employers can invest in their employees, community and future growth.

There are a number of ways fraudsters can seek to manipulate the system, for example:

  • When an employer misrepresents the amount of payroll or classification of its employees.
  • When a medical provider intentionally receives payments to which he or she is not entitled.
  • When a worker fakes an injury, or returns to work while receiving benefits.

And there are many more detailed on our website, bwc.ohio.gov.

What’s our goal? #StopFraud in Ohio’s workers’ compensation system. You’ll see in this infographic highlighting a few stats from the last year that we work hard every day to achieve that goal.

Anyone committing fraud, or thinking of trying to get one over on us should remember this word:

ex·pose (/ikˈspōz/), verb
Definition: make (something) visible, typically by uncovering it.

2,000 Fraud Hotline calls in 10 months!

By Jeff Baker, Program Administrator, BWC Special Investigations Department

We have received 2,000 calls since we launched our new Fraud Hotline system ten months ago during International Fraud Awareness Week 2017. The 200 calls a month, means we have received nearly 10 each work day, or more than one every working hour!

In our November 14, 2017 blog, we noted that calling the BWC Fraud Hotline is the most interactive and direct way for you to report an allegation of fraud. Our hotline puts you in direct contact with an agent in our Special Investigations Department, one ready and willing to listen to your concerns.

Our hotline agents have years of investigative knowledge, skills and experience securing the essential information from sources. Whether the fraud hotline agent is Connor, Jake, Jeff, Karen, Karie or Loryn, or any of our 25 fraud analysts assigned to our special investigations unit statewide, callers know within seconds that they have reached a committed, respectful professional.

These same agents also receive and process fraud referral forms submitted by sources who report their suspicions via a Report Fraud link on bwc.ohio.gov. Just last month, for example, the convictions of Jason C. Smith and Walter M. Patterson were the result of fraud referral forms submitted to our hotline.

If you’re concerned about the alleged fraudster discovering your identity, rest assured. Your identity may remain either anonymous or confidential, depending on your preference. In addition, you don’t need to prove any facts or even have 100 percent confidence in your suspicion. You need only to suspect that fraud may have occurred or continues to occur. We’ll take care of the rest.

We look forward to hearing from you, so give us a call at 1-800-644-6292 if you suspect fraud. We will conduct the investigation and determine the facts. Together, we are successfully combatting workers’ compensation fraud in Ohio – one call and referral form at a time.

Thank you for your support!

Special investigations department finishes FY2018 with impressive results

By Jim Wernecke, Director, BWC Special Investigations Department

It’s getting harder and harder for the criminally minded to rip off BWC and the State Insurance Fund and get away with it.

That was the message I took to BWC’s board of directors Thursday afternoon when I presented the board with the Special Investigations Department’s annual report for FY2018, which closed June 30. The report details another impressive year of our department’s efforts to deter, detect, investigate and prosecute workers’ compensation fraud.

Here are some highlights in what was our 25th year as a department:

  • We closed 1,622 fraud cases, 448 more than in 2017.
  • We secured 101 convictions of claimants, employers and health care providers who defrauded our agency.
  • For every dollar we spent on our efforts, we saved the state fund nearly five ($4.81), or $1.33 more than last year.
  • We reduced our investigation time per case by 23 days on average, our lowest number on this measure since 2005.
  • All told, we saved the state fund $60.1 million in 2018, a 44 percent jump over 2017’s numbers.

We couldn’t have achieved this success without the 121 dedicated staff members who serve our department with great skill, resourcefulness and determination to bring justice to those who cheat our system. We also owe a great deal of credit to advances in technology and a key operational change we made last year to increase our efficiency and productivity.

Drones and Workplace Safety
The drone program we implemented in 2017 for our safety investigators proved itself a worthy investment in 2018. Our safety investigators relied on the tool at 10 workplace safety violation sites last year, including two that would have been especially difficult and dangerous, if not impossible, to properly investigate without it. The most challenging case involved flying the drone into an elevator shaft. Another involved an old factory site where the factory was being torn down. Thanks to our drones, our safety investigators could remain at a safe distance while navigating the drones to survey the sites and take accident scene pictures.

We have three drone pilots certified with the Federal Aviation Administration and three more waiting in the wings, so to speak. And while they find the drones fun and exciting, their enthusiasm is tempered in knowing that each operation is tied to tragedy and unfortunate events. Their drive is to ensure they gather accurate data and conduct unbiased investigations.

Hotline
In November we rolled out a new method for collecting fraud allegations. Until then, outside callers would report allegations to BWC personnel that staffed our customer contact centers. Now the callers reach our investigators directly, which allows our team to ask follow-up questions and obtain more precise information to jumpstart the investigation. It also reduced or eliminated the wait times for callers, which led to fewer dropped calls. The bottom line is the new hotline system led to a more comprehensive and detailed fraud allegation packet that we could send to our field teams.

Looking ahead
As we commence our 26th year in FY 2019, we remain united in our commitment to protecting the state insurance fund and the Ohio workers and employers it serves. We join our colleagues throughout this agency in delivering the people of this state the world-class workers’ compensation system they deserve.

Youngstown auditor is BWC’s Fraud Finder of the Year

By Jeff Baker, Program Administrator, BWC Special Investigations Department

An external auditor in the Youngstown Claims Office received the 2017 Fraud Finder of the Year award May 22 from BWC’s special investigations department (SID).

The auditor, who does not want to be identified given the sensitive nature of his job, received the award for alerting SID to a case in which an employer failed to report payroll and failed to respond to multiple attempts to schedule a premium audit. An investigation by the SID Employer Fraud Team revealed that most of the employer’s Ohio employees were reported to ODJFS, but not to BWC. The referral resulted in the identification and recovery of $804,352 in savings to the state insurance fund.

“Thanks to this employee’s vigilance and timely referral, we were able to stop fraud and save the BWC system nearly a million dollars,” said SID Director Jim Wernecke. “Our success in uncovering fraud protects resources we need to take care of injured workers, create safe workplaces and provide the best service possible to employers at affordable rates.”

The auditor, who handles employer policy underwriting and premium audits, said he appreciates the recognition and is glad he could help.

“This is why we do what we do,” he said. “After spotting a red flag in this case, I dug a little deeper and found more red flags. Persistence paid off, and it’s a good thing, because this kind of behavior drives up our costs and hurts all the honest players in our system.”

SID received 2,320 allegations of fraud in 2017, with about a fourth of those coming from BWC personnel around the state — claims representatives, employer representatives and others who suspect illicit behavior on the part of injured workers, employers, health care providers or others connected to the BWC system. During 2017, SID closed 311 cases referred by 158 BWC employees. The SID investigations found fraud in 146 of the 311 cases and generated $2,724,426 in identified savings.

To show their appreciation, SID leaders conducted a thank-you tour and red flag training from March through May, presenting Fraud Finder Award certificates to BWC employees in customer service offices across Ohio.

“We encourage all BWC employees to contact us immediately if they suspect fraudulent behavior in our system, even the slightest hint of it,” said Director Wernecke. “We will conduct a thorough investigation, and the sooner we get started, the better.”

To report suspected cases of workers’ compensation fraud, call 1-800-644-6292 (then select option 0, option 4) or visit www.bwc.ohio.gov.

1,000 Fraud Hotline calls in 6 months!

By Jeff Baker, Program Administrator, BWC Special Investigations Department

We have received 1,000 calls since we launched our new Fraud Hotline system six months ago during International Fraud Awareness Week 2017. That’s 167 calls a month, a little more than seven a day, or one nearly every working hour!

In our November 14, 2017 blog, we noted that calling the BWC Fraud Hotline is the most interactive and direct way for you to report an allegation of fraud. Our hotline puts you in direct contact with an agent in our Special Investigations Department, one ready and willing to listen to your concerns. (Under our old system, you reached a representative in BWC’s Customer Contact Center.)

Our hotline agents have years of investigative knowledge, skills and experience securing the essential information from sources. Whether the fraud hotline agent is Connor, Jake, Jeff, Karen, Karie or Loryn, or any of our 25 fraud analysts assigned to our special investigations unit statewide, callers know within seconds that they have reached a committed, respectful professional.

You, the general public, are essential in helping us fight fraud, waste, and abuse in workers’ comp. We are celebrating our 25th year since the creation of our Special Investigations Department in 1993 and thousands of our closed, founded cases started with a call to our Fraud Hotline.

Just last month, for example, the convictions of Rodney Alberino, James Harris and Donna Steele were each the result of just such a call.

If you’re concerned about the alleged fraudster discovering your identity, rest assured. Your identity may remain either anonymous or confidential, depending on your preference. In addition, you don’t need to prove any facts or even have 100 percent confidence in your suspicion. You need only to suspect that fraud may have occurred or continues to occur. We’ll take care of the rest.

We look forward to hearing from you, so give us a call at 1-800-644-6292 if you suspect fraud. We will conduct the investigation and determine the facts. Together, we are successfully combatting workers’ compensation fraud in Ohio – one call at a time.

Thank you for your support!

Ohio Safety Congress & Expo for 2018: Another complete success

By Jeff Baker, Program Administrator, BWC Special Investigations Department

As part of our Special Investigations Department (SID) mission to effectively and proactively prevent losses to the workers’ compensation system and to deter, detect, investigate and prosecute workers’ compensation fraud, we recognize the importance of educating and informing our stakeholders about how they may join us to combat fraud.

That’s why we annually schedule and conduct dozens of fraud presentations to groups of internal and external stakeholders throughout the state.

On March 7 and 8, at the Ohio Safety Congress & Expo 2018, Shawn Fox, a SID special agent in charge, facilitated a workers’ compensation fraud presentation and Josh Grappy, a forensic computer specialist with the SID digital forensics unit, conducted a session on commercial uses, regulations and best practices for drones.

This annual event was another complete success. To a packed house, we shared techniques used to combat workers’ compensation fraud and to investigate safety violations. In the photo above SID Special Agent in Charge Shawn Fox walks attendees of a BWC Safety Congress & Expo through the steps he and his staff take when investigating a fraud allegation.

SID employees consistently promote fraud prevention strategies to stakeholders by means of social media, articles in periodicals, and presentations, such as participation in the annual Ohio Safety Congress & Expo, safety councils, MCOs and community-based organizations. These efforts educate, inform and build understanding of the BWC’s overall mission “to protect Ohio’s workers and employers through the prevention, care and management of workplace injuries and illnesses at fair rates.”

Since July 1, 2017, SID has conducted 51 fraud presentations describing and demonstrating how we accomplish our mission. Our SID employees share examples of successful cases and furnish all attendees with the means to detect and report suspected fraud.

We welcome requests for fraud presentations from all interested organizations. To schedule a fraud presentation, simply e-mail your request to Jeffrey.B.1@bwc.state.oh.us and we will promptly contact you to discuss your group’s event.

We hope you’ll contact us and look forward to meeting you soon!

For more details pertaining to our fraud prevention efforts, view our Annual Report here.

Working while receiving?

By Jeff Baker, Program Administrator, BWC Special Investigations Department

Working while receiving benefits is one of the most common types of fraud our investigators uncover. In fiscal year 2017, 57 out of 133 criminal convictions were claimants working while receiving lost time benefits to which they were not entitled.

Working while receiving is one of the most obvious and flagrant abuses of the system. It is particularly regrettable since the claimants were, at one time, truly injured and entitled to workers’ compensation benefits.

We make every effort to ensure that each claimant knows the well-established rules. The fraud warning messages are clear, explicit and conspicuously placed on forms. For example, a fraud warning message (pictured below) appears on the BWC form to be signed by a claimant to request temporary total lost time benefits.

Fortunately, the vast majority of claimants return to work when they are able and notify BWC that they intend to do so. They understand and accept that their lost time benefits achieved their essential purpose – they provided compensation while the claimant temporarily could not work and was recuperating from an accident, illness or injury.

No matter how clever an individual may be, if he or she commits the crime of returning to work while receiving workers’ compensation benefits, the tell-tale signs remain. Rest assured, we are looking for, investigating, and prosecuting these cases. They will lose their lost time benefits and perhaps their freedom as well.

Thanks for your allegations, especially 34,634 calls to our Fraud Hotline!

By Jeff Baker, Program Administrator, BWC Special Investigations Department

In observance of Thanksgiving, we are giving thanks for the vigilance of everyday citizens and their willingness to detect and report suspected fraud committed against the Ohio workers’ compensation system.

We realize that such partnerships are necessary to achieve our fraud prevention goals. Since the creation of our Special Investigations Department (SID) in 1993, tens of thousands of our allegations have been furnished by external sources. Each and every reported allegation is entered by an agent into our secure database and reviewed. Effective this week, as a result of calls to our BWC Fraud Hotline, 34,634 allegations have helped us achieve over 1.7 billion in savings.

An investigative professional will promptly answer your call and conduct a brief and effective interview. These agents have years of investigative knowledge, skills and experience securing the essential information from sources like you. Whether your fraud hotline agent is Jake, Taylor, Karen, Connor, Jeff, or any of eight of our most experienced fraud analysts assigned to special investigations units (SIUs) statewide, you will know within seconds that you have reached a committed, successful professional.

Your fraud hotline agent will know and promptly secure the information needed by our teams of 125 SID employees. You do not need to have proven any facts; you do not even need to have 100 percent confidence in your suspicion. You need only to suspect that fraud may have occurred or continue to occur. We will conduct the investigation and determine the facts. Your Fraud Hotline call initiates the process, and in as few as five minutes.

A suspicion can also be reported by means of any of the following: an “after hours” message to our Fraud Hotline voicemail 614.728.2617, online, an email to our secure BWC Allegations@bwc.state.oh.us account, the U.S. Postal Service or in-person at any BWC claims office. Calling the BWC Fraud Hotline is the most interactive and direct way that you, our partners in fraud prevention and detection, can help.

So, thank you for your 34,634 (and counting) calls to our Fraud Hotline! We are indeed thankful for each one.

What do you know about workers’ comp fraud? Our sleuths have questions – and answers!

By Melissa Vince, BWC Public Relations Manager

We’ve had a great time talking workers’ comp fraud this International Fraud Awareness Week. We enjoyed sharing what we do to detect, deter and put a stop to workers’ compensation fraud in Ohio.

Our fraud investigators especially look forward to participating every year because they want to raise awareness and encourage tips from the public, but also because they truly enjoy what they do.

And we appreciate them because they do a great job. So, in honor of them, we let them take a little break to have some fun putting together this quiz challenging your knowledge of workers’ compensation fraud.

So, fire up that brain and let’s get started. Just flip your monitor over for the answers listed at the bottom.

Thanks for following us this week! We’ll be back next year for Fraud Awareness Week, but don’t go away because we’re here all year long on our blog, Twitter and Facebook.

  1. True or false?
    Fraud and abuse are the same.
  2. True or false?
    Proving fraud requires evidence of “knowledge and intent”
  3. True or false?
    Abuse can be criminally prosecuted under the law.
  4. BWC has teams focused on investigating the following types of fraud:
    a) Claimant
    b) Employer
    c) Medical provider
    d) All of the above
  5. Which is an example of fraud?
    a) Billing for services not rendered (a doctor bills for procedures not performed)
    b) Classifying full-time employees as independent contractors/subcontractors.
    c) A claimant performing physical activity outside of his or her restrictions
    d) All of the above
  6. What are the two most common fraud allegations our investigators receive related to medical providers?
    a) Billing for services not rendered (a doctor bills for procedures not performed)
    b) Unlicensed provider (not licensed to practice medicine in the State of Ohio)
    c) Unbundling (charging separately for bundled services)
    d) Upcoding (billing for a more expensive service than the one provided to the claimant)
  7. What is the most common fraud allegation our investigators receive related to employers?
    a) No coverage
    b) Lapsed coverage
    c) Falsified certificate of premium coverage
    d) Underreporting payroll
  8. What is the most common fraud allegation our investigators receive related to claimants?
    a) Physical activity (performing physical activity outside of his or her restrictions; malingering)
    b) Work/Comp (working while receiving lost time benefits)
    c) False claim (staged accidents; false injuries)
    d) Altered documents

 

Suspect fraud? Call our Fraud Hotline!

November 14, 2017 6 comments

By Jeff Baker, Program Administrator, BWC Special Investigations Department

In recognition of International Fraud Awareness Week 2017, we are increasing awareness of fraud and the vigilance of everyday citizens to report suspected fraud committed against the Ohio workers’ compensation system.

A suspicion can be reported online, by email to our secure BWC Allegations@bwc.state.oh.us account, U.S. Postal Service or by calling our Fraud Hotline at 1-800-644-6292. Calling the BWC Fraud Hotline is the most interactive and direct way that you, our partners in fraud prevention and detection, can help.

We realize that such partnerships are necessary to achieve our fraud prevention goals. Since the creation of our Special Investigations Department (SID) in 1993, thousands of our closed, founded cases started with a call to our Fraud Hotline. For example, the conviction of Tim Tokles on August 30, 2017 was the result of just such a call.

You may suspect someone is working while receiving compensation, filed a false claim for an injury that did not happen or is committing another type of workers’ compensation fraud. Calling a fraud hotline may seem rather intimidating. We understand that it can be a nerve-wracking decision to make the call. The person you suspect of fraud could be a friend, a loved-one or even an immediate family member.

Above all, we realize the importance of personal security and safety to each caller.

When you call the SID Fraud Hotline, you will speak with a real person on the other end, one who is ready and willing to listen to your concerns and has years of investigative knowledge, skills and experience securing the essential information from sources like you. Whether your fraud hotline agent is Jake, Taylor, Karen, Connor, Jeff, or any of eight of our most experienced fraud analysts assigned to special investigations unit (SIUs) statewide, you will know within seconds that you have reached a committed, successful professional.

Your fraud hotline agent will know and promptly secure the information needed by our teams of 125 SID employees. Your identity will remain either anonymous or confidential, depending upon your preference. You do not need to have proven any facts; you do not even need to have 100 percent confidence in your suspicion. You need only to suspect that fraud may have occurred or continue to occur. We will conduct the investigation and determine the facts.    

The entire process entails as few as five minutes. Nonetheless, collecting the right information from a caller requires our SID Fraud Hotline professionals to devote as much time as the caller’s unique allegation merits.

When calling, please provide the information you have, including:

  • The name and address (if known) of the subject you’re reporting;
  • A description of the suspect’s behavior; and
  • Any other information that might pertain to the suspected fraudulent activity.

It is through the vigilance of citizens like you, that we are combatting workers’ compensation fraud in Ohio.

 

In pursuit of fairness – #FraudWeek 2017

November 13, 2017 1 comment

By Jim Wernecke, Director, BWC Special Investigations Department

I have always appreciated the importance of fairness and integrity. I have used these virtues as a guide throughout my career, from early on when I supervised 15 employees at a small manufacturing company, to my 25 years with the Ohio State Highway Patrol and now as head of the Ohio Bureau of Workers’ Compensation’s Special Investigations Department.

I am privileged to lead 122 professionals who work to deter, detect and investigate workers’ compensation fraud in the state of Ohio. We pursue cases of claimant, medical provider and employer fraud.

What drives a claimant to file a false claim; an employer to purposely misclassify their workers; or a physician to fudge paperwork to secure higher service payments? We can debate the reasons, and they probably vary in each case, but my drive to halt wrongdoing comes from an appreciation for standards, rules and enforcement of the law that are conducted uniformly, fairly and systematically. In short, I want to know that others are following the same rules you and I follow.

It is easy to translate this philosophy into the world of workers’ compensation when you think about employer premiums, medical services and protection of our injured workers. Injured workers deserve a fair system that’s focused on their care and recovery. Employers want their competitors to play by the same rules, and they want assurance that any employee who attempts to gain undeserved benefits will be held accountable. And we all want truthful and professional physicians delivering our medical care.

These are among the many reasons I count fairness and integrity among the most important qualities you’ll find in a person. Treat people fairly, and treat them the way you want to be treated. Our integrity is on the line when we don’t accept the responsibility and tell the truth. Once trust is lost, it’s likely gone forever. I’m sure many of you feel the same.

We take great care to protect the dollars Ohio employers set aside to care for their injured workers. We’re not too shy to say we think we do a pretty good job, but we’re always seeking improvement. That’s why we enjoy taking part in International Fraud Awareness Week each year. We’re not only able to highlight our successes, but also engage and learn from our fraud-fighting peers across the country. This year will be no different.

Those of you who follow workers’ comp fraud in Ohio know we share our fraud news weekly on “Fraud Friday,” but we always take it to another level during IFAW. Please join us this week and all year long as we share new cases, tips for identifying and preventing fraud, insights from our investigators, and much more on our Facebook and Twitter pages.

Happy Fraud Awareness Week!

Dayton claims rep is BWC’s Fraud Finder of the Year

A claims service specialist (CSS) in the Dayton service office received the 2016 Fraud Finder of the Year award Jan. 26 from BWC’s Special Investigations Department (SID).

The CSS received the award for alerting SID to a case in which an injured worker claimed to be wheelchair bound and unable to ambulate. Surveillance video in SID’s subsequent investigation, however, showed the claimant shopping, going to the movies and climbing steps at a football game, all without a wheelchair or assistance of any kind.

“Thanks to this CSS’s vigilance and timely referral, we were able to stop fraud in its tracks and save the BWC system tens of thousands of dollars, if not more,” said SID Director Jim Wernecke. “Our success in uncovering fraud protects scarce resources needed to create safe workplaces in Ohio and to take care of those who are legitimately injured on the job.”

The CSS, who handles permanent total disability cases, said she was delighted to receive the award.

“I was surprised,” she said. “It makes you feel good to be recognized.”

SID received 2,700 allegations of fraud in 2016, with about a fourth of those coming from BWC personnel around the state — claims representatives and others who suspect illicit behavior on the part of injured workers, employers, health care providers or others connected to the BWC system.

To show their appreciation, SID leaders conducted a thank-you tour from November through mid-February, presenting Fraud Finder Award certificates to CSSs in customer service offices across Ohio.

“We encourage all BWC employees to contact us immediately if they suspect fraudulent behavior in our system, even the slightest hint of it,” said Director Wernecke. “We will conduct a thorough investigation, and the sooner we get started, the better.”

To report suspected cases of workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Limo driver takes work comp system for a ride, now owes BWC $80,000

robert-willie-jr-booking-photoA former school bus driver caught working as a limousine driver while receiving injured workers’ benefits must pay the Ohio Bureau of Workers’ Compensation $80,000 and serve five years probation.

“Thanks to responsible citizens who report fraud, we were able to stop a workers’ comp cheat and return BWC dollars to their rightful purpose — creating safer workplaces across Ohio and helping workers who are legitimately injured on the job,” said BWC Administrator/CEO Sarah Morrison.

Robert Willie, Jr., 57, of Columbus, pleaded guilty Tuesday in the Franklin County Court of Common Pleas to one count of workers’ compensation fraud, a fifth-degree felony. In addition to restitution and probation, a judge warned Willie that he would serve six months in jail if he violated the terms of his probation.

Willie started collecting BWC benefits in 2010 after getting injured while working as a school bus driver. Acting on an anonymous tip to the BWC Fraud Hotline, BWC’s Special Investigations Department reviewed bank and employment records and found Willie had worked off and on for much of the time between March 2010 and May 2015, all while collecting BWC benefits. Willie worked as a limousine driver and office clerk for a Columbus company.

A photo of Willie can be found here.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Fraud funnies: Workers’ comp cheats say the darndest things

November 18, 2016 1 comment

By Tony Gottschlich, Public Information Officer, BWC Communications Department

SID Badge and SealMany of us have read funny reports of the ridiculous excuses criminals give police for their illicit behavior, from, “We’re not stealing; we thought it was free,” to Winona Ryder’s, “I shoplifted to prepare for an acting role.”

Our agents in the Special Investigations Department have heard a few whoppers over the years, too. In honor of International Fraud Awareness Week, here’s a sampling. (Note: Each subject was ultimately convicted and sentenced.)

During surveillance, the claimant suspect would appear to drive as if he knew he was under investigation.  He would drive south, north and in circles before going to a job site. During the interview, I asked him if he knew he had been under surveillance. His answer was, “No, I drove that way just in case I was under investigation.”


While wearing boots and standing in wet concrete with a concrete trowel in hand, the claimant suspect stated he was only a “stock holder” in the business.


Upon commencing an interview of the claimant suspect, agents asked him if he was “Joe.” The subject replied, “No.”  He was wearing a shirt with his employer’s name and his own name on it. He confessed to his misdeeds.


A doctor was getting increasingly frustrated during an interview when he was trying to explain to Health Care Provider Team agents why he billed BWC for services not rendered. Each time he gave his “explanation,” the agent replied, “So, you billed services that were not provided.”  The doctor told the agent he was not listening and again launched into his “explanation.”  After the third or fourth round of this conversation, the agent basically restated that the services billed were not provided, but used the same made-up words the doctor had used.  The doctor smacked the table and shouted, “By God, now you’ve got it!”


We were conducting an undercover operation in a small village restaurant in Northwest Ohio to document that our subject was working as a waitress. After our subject took our food order, delivered our food and drink, she gave us our check. We paid it, gave her a tip, and showed her our credentials, asking her if she worked there. She immediately froze, stared at the badge while behind the cash register and said, “No, I ain’t workin’ here.”   Our agent replied, “We want our tip back.”

Another type of BWC certificate: Showing our appreciation to yet another employer source

By Jeff Baker, Program Administrator, BWC Special Investigations Department

Normally, when our readers think of the words “BWC” and “certificate,” they think of the BWC Certificate of Coverage. This makes sense. The certificate is widely seen and easily recognized. It is the official document employers often frame to display within their business.

Understandably, the law-abiding business owner wants every employee and customer to see that they have secured workers’ compensation coverage from our agency. They know that others see it as proof of the business’s legitimacy and a sign of the owner’s prudence.

That might explain why Vice President of Operations Philip Koster and Human Resources Generalist Lisa Lucas with the Columbus-based business MedCare Ambulance were surprised when we contacted their organization asking to present them with another type of BWC certificate: a Certificate of Appreciation.

Scott Lape, Lisa Lucas, Philip Koster and John Koehl

Scott Lape, Special Agent in Charge of the Southeast Regional Claimant Special Investigations Unit (SIU) within the Special Investigations Department (SID), explained that the certificate acknowledges the business’s referral of a fraud allegation to BWC. The referral, submitted via an online fraud allegation form, had resulted in the successful prosecution of a subject on Sept. 6.

medcare-certificateSigned by SID Director Jim Wernecke, the framed certificate is a simple way to demonstrate our thanks to MedCare Ambulance and others who are our partners in combating fraud.

Significantly, Philip Koster and Lisa Lucas received the Certificate of Appreciation from Scott Lape and Columbus SIU Fraud Analyst John Koehl during International Fraud Awareness Week (IFAW) 2016. Sponsored annually by the Association of Certified Fraud Examiners, IFAW is dedicated to the prevention, identification and investigation of fraud – wherever it might occur throughout the world.

Just like the talented and dedicated professionals with MedCare Ambulance, you are our eyes and ears in Ohio! Thank you for your help in stamping out fraud, and please, keep those tips coming. To report workers’ comp fraud to BWC, click here or call our fraud hotline at 1-800-644-6292.

International Fraud Awareness Week: Spotlight on Doug Fisher

Justice, putting bad providers out of business motivates longtime BWC fraud fighter

By Tony Gottschlich, Public Information Officer, BWC Communications Department

SID Badge and SealAs a special agent in the bureau of diplomatic security for the U.S. State Department in the 1980s and early 1990s, Doug Fisher protected royal families, foreign presidents, Nelson Mandela and U.S. Secretary of State James Baker, among others.

As a police detective earlier in his career, Fisher served on the vice and narcotics unit in High Point, North Carolina, scrubbing the streets of drug dealers, prostitutes, racketeers and other nefarious sorts.

And today at the Ohio Bureau of Workers’ Compensation, as he’s done for the last 23 years, this veteran of the Special Investigations Department (SID) pursues crooks, cheats and others who try to rip off the state’s insurance fund for injured workers.

But contrary to appearances, Fisher’s long career in law enforcement isn’t rooted in “saving the world and all that,” at least in the beginning anyway.

“I was working in a factory, and I said, ‘Hey, that looks like a job where I won’t have to get dirty,’” Fisher recalled with a slight chuckle. “I didn’t want to work in a factory anymore.”

BWC Special Agent in Charge Doug Fisher (right), of SID's Health Care Provider Team, conducts a search warrant with Digital Forensic's Manager Joe Lopez in Northeast Ohio earlier this year.

BWC Special Agent in Charge Doug Fisher (right), of SID’s Health Care Provider Team, conducts a search warrant with Digital Forensic’s Manager Joe Lopez in Northeast Ohio earlier this year.

Fisher is Special Agent in Charge of SID’s largest unit, the health care provider team, which investigates allegations of fraud committed by medical providers, pharmacies and managed care organizations. He usually shuns the spotlight and deflects any credit he’s earned to his team, but after some arm twisting from his boss, he agreed to be featured in this article to promote SID and International Fraud Awareness Week.

“He hates the publicity, every minute of it,” said a smiling Jennifer Cunningham, SID’s assistant director and a 20-year colleague of Fisher’s. “He doesn’t go to work parties and he never wants recognized for anything. That’s just who he is, very humble.”

A Wisconsin native, Fisher joined BWC in 1993 and was one of SID’s founding members that year. The department has grown since then into a 118-member force that investigates hundreds of fraud cases a year involving workers, employers, medical professionals and others in the BWC system. In fiscal year 2016, the department’s work led to 127 convictions and $56.6 million in savings. Fisher’s team closed 51 cases, landed five convictions and identified $15 million in savings.

He said the job, though, is about more than prosecutions and protecting the State Insurance Fund.

“We knock a lot of bad providers out of the system,” Fisher said from his Mansfield office. “These are people who practice crappy medicine or no medicine at all – they’re just prescribing painkillers to people and it’s a shame.”

One recent case he’s proud of involves a chain of Cleveland-area medical clinics that was indicted Oct. 26 on racketeering and other charges related to scamming BWC out of $216,000.

A 170-count indictment returned by a Cuyahoga County grand jury accuses Dr. Stephen Bernie and an associate of billing for procedures never performed and inflating the percentage of disability for injured workers, making them eligible for higher payments from the state. Dr. Bernie is also accused of writing prescriptions for medications without examining or monitoring patients, and signing prescriptions for powerful opioids that were distributed while he was on vacation.

BWC Special Agent in Charge Doug Fisher, of SID's Health Care Provider Team, spends much of his time in the field, but works out of the Mansfield Service Office.

BWC Special Agent in Charge Doug Fisher, of SID’s Health Care Provider Team, spends much of his time in the field, but works out of the Mansfield Service Office.

Said Fisher, “Cases like that are some of the most satisfying – agents working a hard, long case that takes several years and lots of frustration and they drive it to a conclusion.”

Cunningham calls Fisher a “visionary” who looks at the big picture, studies the latest trends and enjoys outfoxing the fraudsters he’s after.

“He’s always thinking, trying to be one step ahead of the bad guys,” she said.

Fisher, 56, and his wife, Debbie, live in Northeast Ohio and are the parents of two adult children. An avid reader and long-distance runner, he also teaches criminal science part time at Stark State College in North Canton.

He said he plans to retire from BWC within the next year.

Raising awareness during Fraud Awareness Week, combating fraud every day

BSID Badge and Sealy Melissa Vince, BWC Public Relations Manager

When the Ohio Bureau of Workers’ Compensation created its Special Investigations Department (SID) in 1993, the new department boasted a staff of a dozen people and offices in just three cities to combat fraud across Ohio’s 88 counties. Data was stored in paper files and agents relied on such state-of-the-art equipment as pagers, payphones and binoculars, not to mention video cameras the size of small SUVs.

SID looks vastly different today. Staffed with 118 agents, supervisors and support personnel, the department works out of 11 offices across the state and investigates hundreds of fraud cases a year, from workers who fake injuries to physicians running pill mills. Agents are armed with smart phones and sophisticated investigatory devices they don’t talk about publicly.

In 23 years, SID has identified more than $1.7 billion in savings, as well as:

  • Researched 117,820 allegations;
  • Completed 64,255 investigations;
  • Referred 4,897 subjects for prosecution; and
  • Secured 2,595 criminal convictions.

Says SID Director Jim Wernecke: “Even after all these successes, we know fraud still persists, and our goal remains the same after more than two decades: to detect and deter workers’ compensation fraud in Ohio and return misappropriated funds to caring for injured workers and improving workplace safety.”

While tried and true techniques remain important to a successful case, we’re also committed to keeping pace with the most up-to-date resources, such as digital forensics and analytical intelligence, including predictive modeling, to root out otherwise undetected fraudulent activity. We also use social media and specialized presentations to educate and build awareness.

fraud-week-logo2016One of many ways we build awareness is by eagerly joining our fraud-fighting colleagues around the country and abroad each November to participate in International Fraud Awareness Week. The campaign, which runs until Saturday, was established by the Association of Certified Fraud Examiners to highlight the issue of fraud and help minimize its impacts.

Most weeks, you’ll find us sharing our fraud news on #Fraud Friday. But this week we’ll have a new fraud feature each day, including tips for identifying and preventing fraud, new cases, and insights from our investigators on what they do here every day to stop workers’ comp fraud in Ohio.  So keep an eye here on our blog and on our Facebook and Twitter pages for fresh content.

Happy Fraud Awareness Week!

And don’t forget to keep those tips coming. To report workers’ comp fraud in Ohio, click here or call our fraud hotline at 1-800-644-6292.

 

Spotlight: Eric Brown – From college extern to special agent in charge of two elite teams

By Jeff Baker, Program Administrator, BWC Special Investigations Department

eric-brown-picMembers of the Special Investigations Department (SID) congratulate Eric Brown. On Oct. 17, 2016, Eric was promoted to special agent in charge (SAC) of the intelligence unit (IU) and the safety violations investigation unit (SVIU).

Eric started his career with BWC in September 2007 as a college extern with SID Administration’s fraud hotline team. Well-deserved promotions soon followed. Since March 2008, Eric has served the department as a college intern with IU, and full time as a criminal investigator and special agent with the health care provider team (HCPT).

intelligence4While working with SID, Eric  completed two degrees. He earned a Bachelor of Arts from The Ohio State University, with a major in Political Science and a minor in Sociology/Criminology, and a Master of Business Administration  from the University of Cincinnati.

Throughout his career, applying insight, initiative and perseverance, Eric  has significantly contributed to the department’s success. For example, he:

  • Initiated and developed the SID Case Management application;
  • Initiated and co-administered the SID Social Media campaign;
  • Co-initiated the SID 2014 Electronic Surveillance Equipment Symposium;
  • Co-initiated, staffed and co-executed the SID Technical Operations Group.

Eric was one of four special agents on Sept. 14 to receive a 2016 Innovator award. He and his co-recipients met criteria including: developed trend-setting initiatives, created an original idea or uniquely adapted an existing program, process or concept, which resulted in a long term benefit to the department; developed new work methods that reduced waste or stretched resources; and provided creative suggestions that saved the department time or money.

safety-violations2Certainly, for all of the above reasons, you can see why we thank and congratulate SAC Brown! We look forward to his continued leadership and success in our department.

For more information about IU, see our Jan.22 article, Spotlight: Intelligence Unit — Predicting even more results, here.

For more information about SVIU, see our 2011 article, SVIU: Investigating suspected violations of specific safety requirements, here, or our 2013 article, Completing the circle of coverage: A look at our Safety Violations Investigation Unit, here.

For more information about the SID see our most recent annual report here.

Spotlight: Dan Fodor – From college intern to assistant director, special investigations central operations

October 14, 2016 1 comment

By Jeff Baker, Program Administrator, BWC Special Investigations Department

fodor-picMembers of the Special Investigations Department (SID) congratulate Dan Fodor. In June 2016, Dan (shown presenting at the 2016 SID in-service meeting on Sept. 14) was promoted to assistant director, central operations.

Assistant director (AD) Fodor started his career with BWC in June 1991 as a college intern with the internal audit department. During this time, Dan completed his degree and became a certified public accountant. He earned a bachelor’s in accounting from The Ohio State University. In December 1991, Dan commenced his initial full-time position with BWC as a  financial/operational auditor and consultant. By the autumn of 1996, he had earned the title of audit senior and commenced his stellar management career.

sid-text-3In November 1999, Dan joined SID as the special agent in charge of the intelligence unit (IU), providing essential support to special investigations unit field agents through fraud detection and data analysis. Given his knowledge, skills and successes with IU, Dan accepted, in June 2014, the additional responsibility of supervising the safety violations investigation unit (SVIU), a team devoted to investigating alleged safety requirement violations that have resulted in a workplace injury, illness or death.

Throughout his career, applying uncanny intuition, uncommon sense and diligence, AD Fodor has energetically prompted our agency’s success and earned the respect of his SID colleagues.

A few examples from his 25-year career, include:

  • Guided and directed the department’s effective use of the agency’s data warehouse;
  • Developed and executed SID performance measurements and management reporting;
  • Effectively partnered with other BWC operational areas and external entities;
  • Co-administered the SID strategic planning process for several five-year plans;
  • Since 2000, IU has detected 18,950 fraud allegations, resulting in the identification of $473 million in savings; and
  • Between 2000 and June 30, 2016, IU’s fraud allegations resulted in 948 criminal referrals and 480 convictions.

These performance results demonstrate, in part, why Dan is highly qualified to direct our SID central operations. Certainly, for all of the above reasons, you can see why we thank and congratulate AD Fodor! We look forward to his continued guidance, direction, leadership and success in our department.

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For more information about IU, see our Jan.22 article, Spotlight: Intelligence unit — Predicting even more results, here. For more information about SVIU, see our 2011 article, SVIU: Investigating suspected violations of specific safety requirements, here, or our 2013 article, Completing the circle of coverage: A look at our safety violations investigation unit, here. For more information about the SID, see our most recent annual report here.

SID Annual in-service training – An opportunity to recognize our own – Part 3 of 3

By Jeff Baker, Program Administrator, BWC Special Investigations Department

In our constant quest for improvement, all members of the Bureau of Workers’ Compensation Special Investigations Department (SID) annually complete in-service training. On Sept. 14, led by SID Director James Wernecke, we shared investigative successes, acknowledged team results, and presented individual awards.

Preparations: In August, all 126 SID employees had been invited to nominate a peer to receive an individual award. A management committee furnished behavioral characteristics for use by SID employees when submitting written justifications for any peer nomination. These characteristics varied according to the type of award: Innovator; Excellence; and Leadership. In reviewing all nominations, the committee members found that imminently qualified professionals were nominated by their colleagues. Ultimately, the committee selected the six most-worthy SID employees.

Presentations: These talented and dedicated professionals received their awards at the culmination of the Sept. 14 event.

Four special agents with the SID Health Care Provider Team (HCPT) received Innovator awards. They met criteria including: developed trend-setting initiatives, created an original idea or uniquely adapted an existing program, process or concept, which resulted in a long term benefit to the department; developed new work methods that reduced waste or stretched resources; and provided creative suggestions that saved the department time or money.

josh-g-1A special agent with considerable field training officer experience from the southeast regional claimant special investigations unit (SIU) earned the Excellence award. The special agent met four standards including: performing duties or providing services to others that are beyond the professional’s assigned responsibilities; working on special projects within the department; volunteering or contributing to organizations outside the department; and demonstrating an ability and willingness to work positively, respectfully and effectively with people inside or outside of the department.

Josh Grappy, a forensic computer specialist with the SID digital forensics unit (DFU), received the Leadership award fromDirector Wernecke and SID Assistant Directors Jennifer Cunningham and Dan Fodor. Here are just some of the reasons he was nominated:

josh-g-2“Josh does not sit back and watch the world go by, he is making things happen within our organization. Josh has a high level of perseverance, stick-to-itiveness and drive. He can be counted on to get things done. Josh not only meets the customers’ expectations, he regularly exceeds them.”

Please, join us in thanking and congratulating each of the SID award nominees and recipients. They are the reason we are able to meet our mission: To effectively and proactively prevent losses to the workers’ compensation system and to deter, detect, investigate and prosecute workers’ compensation fraud.

You can read the first article about our Sept. 14 event here, the second article about the event here, and our most recent annual report here.

BWC SID: Annual in-service training – Part 1 of 3

September 23, 2016 2 comments

By Jeff Baker, Program Administrator, BWC Special Investigations Department

admin-morrison-sid-mtgIn our constant quest for improvement, all members of the Bureau of Workers’ Compensation Special Investigations Department (SID) gathered on September 14, 2016 at our Mansfield service office to successfully complete annual in-service training.

BWC Administrator/CEO Sarah Morrison welcomed the 125 attendees and opened the meeting. In her opening remarks, Administrator Morrison praised the department’s more than 20 years of success. She noted that strategies identified and implemented during the past twelve months, under the leadership of SID Director James Wernecke, have positioned the department to extend its tradition of excellence.

Following these remarks, Administrator Morrison, SID Director Wernecke, and SID Assistant Directors Jennifer Cunningham and Dan Fodor presented service pins to 22 SID employees. These recipients included two employees with 30 years of service to the State of Ohio: Shawn Miller, a fraud analyst with the southeast regional claimant special investigations unit (SIU); and Lisa Ray, SID training manager.

Pictured left to right: Sarah Morrison, James Wernecke, Lisa Ray, Shawn Miller, Jennifer Cunningham and Dan Fodor.

Subsequently, Director Wernecke thanked Administrator Morrison for her executive leadership, essential support for SID’s mission and compelling presence at the annual event. All of members of the Special Investigations Department joined Director Wernecke in thanking Administrator Morrison for inspiring us to realize our departmental mission to deter, detect, investigate and prosecute workers’ compensation fraud.

In the coming two weeks, we will offer more details from September 14 training event. Stay tuned for part two of the series, which acknowledges specialized training we received at the event.

In the meantime, you can read the past posts about our SID Director here and our most recent annual report here.

Under the table: summertime fraud

We’re already well into the heat of the summer, a time of year when we all enjoy barbeques, gardening, vacations and freshly cut grass. But on those outdoor chores on the hottest of August days, some of us would rather pay the young person down the street to weed the flowerbeds and clear the gutters.

It’s a pretty simple transaction, really. The neighbor isn’t an “employee” in the official sense, and you hand him the cash when the job is done.

A problem arises, however, if instead of a high school sophomore trimming your trees and bushes, the work is done by an injured worker receiving workers’ compensation benefits.

If that’s the case, there’s a big problem. There are two acts of fraud taking place. The first lies with the worker who is working while receiving compensation benefits. If you’re on comp, you can’t work.

The second would apply to you, the person who hired the injured worker. If you knowingly employ a worker who is simultaneously receiving workers’ compensation benefits, you are also liable and you could also face charges of fraud and conspiracy to conceal wages. This is precisely why attorney Otha Jackson was convicted in federal district court of one felony count of mail fraud and one felony count of conspiracy to commit an offense against the United States. Our investigation proved that Jackson had knowingly hired an injured worker, Renee Jefferson, and conspired to conceal her wages. Jefferson was sentenced to serve 18 months in federal prison. Jackson was sentenced to serve 21 months in federal prison.

BWC’s Special Investigations Department (SID) is constantly on the lookout, especially during the summer months, for fraudulent companies operating in the great outdoors with claimants receiving workers’ comp and trying to hide their earnings by taking cash under the table. SID is able to track official wage reports, and we’re also aware of ways those who commit fraud try to work around them. Our investigators are also out in full force. We know the extended daylight hours that draw injured workers into public view act as a spotlight to shine attention upon their activities. Cameras capture evidence of their crimes.

Don’t let fraud get in the way of a summer that should be about sunshine, family and fun.

Have presentation, will travel

As part of our mission to effectively and proactively prevent losses to the workers’ compensation system and to deter, detect, investigate and prosecute workers’ compensation fraud, we recognize the importance of educating and informing our stakeholders about how they may join us to combat fraud.

That’s why we annually schedule and conduct dozens of fraud presentations to groups of internal and external stakeholders throughout the state. These groups have included other BWC departments, public and private employers, third party administrators, medical providers, MCOs and members of associations, such as chambers of commerce, safety councils and bar associations.

During fiscal year 2015, we conducted 44 presentations describing and demonstrating how we accomplish our mission. Our SID employees share examples of successful cases and furnish all attendees with the means to detect and report suspected fraud.

In the photo below SID Special Agent in Charge Shawn Fox walks attendees of BWC’s 2016 Safety Congress & Expo through the steps he and his staff took when investigating the Hammond fraud case. More on that case here.

sid presentation

We welcome requests for fraud presentations from all interested organizations. To schedule a fraud presentation, simply e-mail your request to Jeffrey.B.1@bwc.state.oh.us and we will promptly contact you to discuss your group’s event.

We hope you’ll contact us and look forward to meeting you soon!

For more details pertaining to our fraud prevention efforts, view our Annual Report here.

Employer Fraud: When your competition isn’t paying… you pay more!

Fraudulent employers hurt honest employers. When employers cheat the system, honest employers have to pay additional premiums and are placed at a competitive disadvantage. Here’s how:

BWC maintains a State Fund to pay for services provided to injured workers. This fund can be seen as a pot of money that must be filled by Ohio’s employers. For every dollar dishonest employers don’t contribute, honest employers are forced to pay an extra dollar. Fraudulent employers are then able to undersell honest employers due to their lower labor costs.

We recognize the impact this causes to Ohio’s employers. In 2005, our department created the Employer Fraud Team to exclusively investigate this type of fraud. Since its existence, the Employer Fraud Team has identified the following common employer fraud schemes:

  • Employers operating without workers’ compensation coverage or ceasing to pay for their workers’ compensation coverage;
  • Underreporting payroll by misclassifying and misrepresenting types of employees;
  • Falsifying a BWC Certificate of Premium Coverage to appear to be compliant; and
  • Shifting payroll to different policies to avoid negative experience ratings.

Do you suspect an Ohio employer isn’t playing by the rules? Let the Employer Fraud Team know. Visit http://bit.ly/reportfraud to anonymously report fraud online, or call 1-800-644-6292 to speak with a fraud hotline agent.

Join us at OSC16 to learn about BWC’s efforts to fight workers’ comp fraud

By Melissa Vince, Public Relations Manager

While you’re catching up on your workplace safety training at the Ohio Safety Congress & Expo (OSC16) next week, consider stopping by the BWC booth to meet our fraud investigators. BWC’s Special Investigations Department will be on hand to answer your questions, tell you about everything they’re doing to put an end to workers’ comp fraud and even take your tips if you suspect fraud. This map will help you find your way to BWC’s booth (#419).

Our investigators will also be busy leading educational sessions you should plan to attend.

Get a behind-the-scenes look at how BWC investigates workers’ comp fraud cases. Supervisors from BWC’s Special Investigations Department will present “Workers’ Compensation Fraud: A Case Study,” session 631, March 9 from 8:15-9:15 a.m.  The class will offer an in-depth look into a workers’ compensation fraud criminal investigation. All aspects of one intriguing case will take the audience from the initial steps of assessing the allegation, to conducting surveillance, collecting records and interviewing witnesses. The presenter will explain the investigation process from beginning to end.  Attendees will come away able to describe the complete investigative process, recognize the difference between fraud and abuse and identify how BWC’s special investigations department works a fraud investigation.

And don’t forget about session 651, “Safety Violations Investigations,” on Thursday, March 10 from 8:15 to 9:15 a.m. In this class, you can learn about BWC’s role in conducting investigations of potential violations of safety codes. Attendees will gain an understanding of the investigation process and types of investigations performed. The presenters make employers aware of the information required from them, the financial impact of violation of specific safety requirement (VSSR) awards and the administrative hearing process.

If you’re not yet registered to attend OSC16, there’s still time! OSC16 will be held March 9 to 11 in Columbus, at the Greater Columbus Convention Center. The conference offers more than 200 educational sessions, 225 exhibitors and free continuing education credits. In addition to learning about fraud, those attending Safety Congress can learn to prevent workplace injuries and illnesses, achieve better outcomes for injured workers, reduce workers’ compensation claims costs and keep Ohio’s work force healthy and productive.

Admission to OSC16 is free to all Ohio employers and employees. A full schedule of sessions is available by clicking here.

A forged relationship: The victimization of a claimant

By Jeff Baker, Program Administrator, BWC Special Investigations Department

In a September 23, 2011 blog, “Dishonored memories: Deceased claimants with dishonest relatives,” we described how dishonest relatives may express their grief over the death of a loved one quite differently than law-abiding citizens. We noted that criminals may choose to dishonor the memory of deceased relatives by committing workers’ compensation fraud in the personal, confidential records of a deceased claimant.

These criminals falsely report to us that their deceased relatives continue to live. They pretend to be the claimants themselves, sometimes even adopting the voice of an opposite gender’s voice and/or an elderly person in an attempt to deceive us. These charlatans scheme 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 may inappropriately access and use monies to which they are not entitled, by concealing the claimant’s death.

Of course, such deceptive acts, born out of greed, are not limited to the relatives of our claimants. Forgery and uttering crimes are also committed by non-relatives, such as neighbors or other acquaintances. And some claimants are victimized before death, such as when the criminal uses a power of attorney to grab benefits intended for a claimant who has been deceived, often while incapacitated or otherwise dependent.

A Case In Point

blog pic 1Consuelo “Connie” Griffin and David Lusk (Cincinnati, Hamilton County) both pleaded guilty Jan. 14 in the Hamilton County Court of Common Pleas to counts of theft after they were discovered cashing BWC benefit checks for a claimant who had died.

SID opened an investigation after receiving an allegation from BWC’s claims department, which was unable to contact a claimant receiving permanent total disability for a workplace injury. The claims department reported that claimant’s phone was disconnected.

The investigation found that while the claimant passed away in June 2014, the BWC checks that were mailed to his home continued to be cashed. Griffin and Lusk lived in the same apartment complex as the deceased and when he was hospitalized, Griffin signed a power of attorney document giving her control over his finances. Griffin also had the claimant’s mail forwarded to her address and the pair moved into his apartment when he was hospitalized. Griffin confessed to signing Harrell’s name on the checks and cashing them. Griffin also took money out of his bank account while he was ill and wrote checks from his account to herself for cash. His account was soon closed because Griffin and Lusk spent all the money and failed to pay any of his nursing home expenses.

blog pic 2Lusk pleaded guilty to count of theft and one count of theft from the elderly, both fifth-degree felonies. Griffin also pleaded guilty to two counts of theft, both fifth-degree felonies. The court sentenced them to 10 months in jail, suspended, and ordered them to repay restitution of $5,072.62. They also received three years of probation.

For other case examples or more information about the SID, see our Special Investigations Department Fiscal Year 2015 Annual Report.

To report suspected fraud via a fraud referral form click here or call the BWC fraud hotline at 1-800-644-6292.

Spotlight: Intelligence Unit – Predicting even more results

By Jeff Baker, Program Administrator, BWC Special Investigations Department

FraudOne of the many integral parts of the Special Investigations Department’s (SID) success is the heard-but-not-seen work done by our Intelligence Unit (IU). Its key functions are to provide support to BWC SID field agents through fraud detection and data analysis. For decades, the unit has generated significant results. In FY 2015, the IU detected 720 fraud allegations, resulting in the identification of $37,087,770 in savings. More recently, during the first six months of FY 2016, the unit detected 323 fraud allegations, resulting in the identification of $23,983,867 in savings.

Here is how the IU generates these results. The unit reviews BWC data about claimants, medical providers and employers. All data tells a story and some stories, unfortunately, include red flags that identify possible fraudulent activities. The knowledge, skills and experience of IU professionals enable them to detect possible fraud, even in massive data sets containing millions of data elements. Here, the unit employs data analysis, including predictive modeling, to proactively detect fraud.

The daily efforts of the IU uncover filed claims that are potentially false, benefit compensation to which claimants are not entitled, diversion of prescription drugs, medical billing fraud and failure of employers to pay workers’ compensation premiums.

The IU is made available to SID special agents who depend on the unit to deliver accurate information that supports ongoing field investigations conducted by Special Investigations Units (SIUs). During the first six months of FY 2016, the IU completed 1,499 data requests from the SIUs and assisted with analyses of case information.

These data analysis and detection efforts examine not only information provided to BWC, but also our external partners. The IU exchanges data with other state agencies to further detect fraud. For example, the unit was the source of the allegations that resulted in the recent criminal convictions of Latonia Almon and Michelle Green, the subjects of a Jan. 22, 2016 SID social media article, “Columbus home health aides sentenced for workers’ comp fraud.” In those cases, a crossmatch of data with the Ohio Department of Job and Family Services tipped the IU off to possible fraud.

Any law enforcement or other criminal investigative agency interested in partnering with the IU should contact Becky Donchess at (614) 466-8090 or Rebecca.D.1@bwc.state.oh.us.

For more information about the SID or its IU, see our Special Investigations Department Fiscal Year 2015 Annual Report.

Categories: Fraud Awareness

A form of referral

By Jeff Baker, Program Administrator, BWC Special Investigations Department

Every day members of our BWC Special Investigations Department are reminded why we created our on-line fraud referral form. It works. Effective December 1, we had received more than 8,000 allegations from external sources via the referral form. And, since fiscal year 2002, the percentage of new allegations we have received from external sources via referral forms has steadily increased from one percent to 17 percent.

allegations

Here is how the form works: simply select the type of subject you suspect – injured worker, employer, provider, or other – and the interactive form will prompt you for pertinent information. To “complete” the form, just post whatever information you have to a few screens. No field is required. You decide how much or little information you care to furnish us. You may advance past any screen at your discretion. Many sources have furnished their allegations in a matter of a minute or two.
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The form will display a confirmation that we have received your allegation. All members of our SID intake team immediately receive an e-mail containing all information from the form. They promptly enter the allegation into our secure database, the Fraud Management System, and commence their review and research of the subject. If you elect to furnish us with a contact phone number or e-mail address, a SID professional will contact you with an investigative update within 14 days. They will also re-contact you when we have a known outcome, such as a criminal conviction and/or sentencing.

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For example, as recently as December 11, we reported on the conviction of Rachel Madison, a Bedford woman who pleaded guilty to workers’ compensation fraud. She was ordered by the Franklin County Court of Common Pleas to pay $12,319 in restitution to the BWC. SID commenced its investigation of Madison after an acquaintance confidentially reported his/her suspicions via a fraud referral form.

To report suspected fraud via the fraud referral form click here. You may also report suspected fraud by calling either the BWC fraud hotline at 1-800-644-6292 or Jeff in SID Administration at 1-614-466-7837.

Spreading holiday joy with toy drive

By Jeff Baker, Program Administrator, BWC Special Investigations Department

BWC’s Special Investigations Department (SID) has been busy again this holiday season, collecting gifts to donate to toy drives around Ohio. Spreading joy to children in need is a tradition in SID.

toy drive 2

toy drive

James Wernecke, Director of Special Investigations; Karen McMahan, Registered Nurse with SID Health Care Provider Team; Sarah Morrison, Chief Legal Officer

“I’m proud of our department’s commitment to make the holidays a little brighter for children in need,” said SID Director James Wernecke. “We have an impressive team of dedicated professionals who not only do outstanding work all year, but give their best when they celebrate the season each December by making a difference in their communities.”

We encourage you to join the generosity, and find ways to make a difference in your community this holiday season.

Thank you for reading our blog, and happy holidays!

Short-term thinking and short-sighted vision: Employers operating without coverage

By Jeff Baker, Program Administrator, BWC Special Investigations Department

Several of our earliest blogs in this Fraud Awareness Series addressed the critical topic of employer fraud. In “Turning a blind eye to the pot: Employers that operate without coverage,” dated August 10, 2011, we advised readers:

Financial Planning“Ohio law requires employers with one or more employees to obtain workers’ compensation coverage. Noncompliant employers are responsible dollar for dollar for claim costs incurred during a non-covered period.”

This point is certainly worthy of emphasis and reiteration. More than four years later, we continue to close investigations in which we have found employers failed to maintain coverage while employees sustained work related injuries or illnesses. Eventually, their noncompliance would have been detected and investigated without the filing of a claim. However, just one employee’s injury or illness immediately identified the employers as noncompliant. Yes, some of owners and operators initially tried to float an alibi: asserting that the injured employee wasn’t really an employee, just a “volunteer” or a “contracted laborer”. But, of course, truth being the truth – and given the knowledge, skill and experience of our fraud analysts and special agents – the facts disproved the lies. And an employer’s deceit proved the fraud.

Why did the owners and/or leaders of these organizations operate without coverage? Why did they make the unwise decision to incur such risk?

Well, greed is the simplest answer. However, a more full explanation is that the noncompliant owners or operators sought to maximize short-term profitability. Their short-term thinking resulted in short-sighted vision and a failure to recognize future risks – risks that were wholly unnecessary and avoidable. Ultimately, by their noncompliance and incurring dollar for dollar for claim costs, they dramatically increased their operating costs and decreased their long-term profitability. Short-term thinking generated long-term losses.

These noncompliant employers also subjected themselves to criminal and civil proceedings, such as felony workers’ compensation fraud charges, liens and injunctions. These outcomes were probably not consistent with the established vision or mission statement for their business. Moreover, the notoriety they experienced at the point of their criminal sentencing likely did not help them achieve their local marketing and promotional goals.

This was likely the case when Ayed Kanaan, owner of Yaya Food Mart in Cleveland (Cuyahoga County) was sentenced recently after he pled guilty to operating without workers’ compensation coverage. Kanaan did not maintain his coverage even after BWC attempted to work with him to bring the business back into compliance with state law. He will be responsible for the entire cost of a claim that was filed when he didn’t have coverage. Kanaan received a 90 day suspended jail sentence, one year of community control and was ordered to pay restitution in the amount of $7,477.

By their short-term thinking and short-sighted vision, non-compliant employers are blinded to the truth that criminal behavior is never a viable business strategy.

Did you know?

For more information about employer fraud, see page 4 of our Special Investigations Department Fiscal Year 2015 Annual Report.

What you can do.

You can determine if an employer operating in Ohio has workers’ compensation coverage by visiting BWC’s online employer lookup at: https://www.ohiobwc.com/provider/services/mcolookup/nlbwc/default.asp.

If you suspect that an employer is operating without workers’ compensation, let us know. You can report it online at http://bit.ly/reportfraud or you can speak with a fraud hotline agent by calling 1-800-644-6292.

Another type of BWC certificate: Showing our appreciation to yet another source

By Jeff Baker, Program Administrator, BWC Special Investigations Department

Normally, when our readers think of the words “BWC” and “certificate”, they think of the BWC Certificate of Coverage. This makes sense. The certificate is widely seen and easily recognized. It is the official document employers often frame to display within their business.

Understandably, the law-abiding business owner wants every employee and customer to see that they have secured workers’ compensation coverage from our agency. They know that others see it as proof of the business’s legitimacy and a sign of the owner’s prudence.

DSCF0421

Special Agent in Charge Scott Lape, Shelly Long, and Fraud Analyst Stuart Lee

That might explain why Shelly Long, the co-founder and co-owner of a Cambridge business, Acute Nursing Care LLC, was surprised when we contacted her, asking to present her with another type of BWC certificate: a Certificate of Appreciation.

Scott Lape, a Special Agent in Charge with the Special Investigations Department (SID), explained to Mrs. Long that the certificate acknowledges the business owner’s referral of a fraud allegation to BWC – a referral that had resulted in the successful prosecution of the subject. Mrs. Long promptly advised that she had read about the July 27 conviction of the subject, James E Harris (Guernsey County), when she visited the SID Facebook page.

SigneCertificate fraudd by SID Director Jim Wernecke, the framed certificate is a simple way to demonstrate our thanks to Shelly Long and others who are our partners in combating fraud.

Significantly, Mrs. Long received her Certificate of Appreciation during International Fraud Awareness Week (IFAW) 2015. Sponsored annually by the Association of Certified Fraud Examiners, IFAW is dedicated to the prevention, identification and investigation of fraud – wherever it might occur throughout the world.

Just like Shelly Long, you are our eyes and ears in Ohio! Thank you for your help in stamping out fraud, and please, keep those tips coming. To report workers’ comp fraud to BWC, click here or call our fraud hotline at 1-800-644-6292.

Categories: Fraud Awareness

Massillon woman bets wrong; fraud scheme ends up a bust

Brenda Pumphrey of Massillon (Stark County) claimed a workplace injury caused her to lose use of each hand, one arm and one leg. After surveillance at a West Virginia casino showed no limp and full use of her arms, Pumphrey’s luck ran out and she ended up pleading guilty to workers’ compensation fraud.

An investigation into Pumphrey’s claim started with a speeding ticket. SID received an allegation from a BWC Customer Service Specialist that Pumphrey was issued a speeding ticket in Stark County on a date following her claimed loss of her ability to use her upper extremities.

A case was opened and a review of the claim showed that Pumphrey’s physician of record had continuously advised that she was unable to use her extremities but was reluctant to obtain some treatment that was advised.

Agents conducted surveillance of Pumphrey visiting her doctor’s office. Additionally, Pumphrey’s bank records showed a high volume of ATM and debit card activity at the Mountaineer Casino, located in Chester, West Virginia. Video from the casino showed Pumphrey walking with no noticeable limp and with full use and range of motion of both arms.

The physician concluded after seeing the casino video that it appeared Pumphrey had intentionally deceived him. The Ohio Industrial Commission terminated her Permanent Total Disability benefits.

On Friday, Oct. 16, Brenda Pumphrey was sentenced on her previously entered guilty plea to a felony count of workers’ compensation fraud. She was placed on community control for three years and ordered to pay restitution of $9,192.75. Pumphrey will serve six months in jail if she violates the terms of community control.

Fraud, integrity the focus of recent conference

fraud badge 2 2015Two fraud analysts and a special agent from the Ohio Bureau of Workers’ Compensation’s Special Investigations Department (SID) attended the two-day Targeting Fraud: Safeguarding Integrity conference in Columbus. During the conference, they gleaned ideas from the latest information on specialized investigative topics, such as cybercrime, ethics laws, surveillance, social media and the investigative use of geocoded photo metadata.

The SID employees will share what they’ve learned with their colleagues, and use those strategies while conducting joint investigations with other law enforcement professionals, some of whom also attended the conference on November 4 and 5.

Ultimately, using what they learned at this and other training seminars, SID professionals seek to secure even more results than the $60.5 million in savings they identified last year, as outlined in our FY 2015 annual report.

For more articles from our blog, please visit ohiobwcfraud.wordpress.com.

 

The big business of health care provider fraud

As you can see from reading this blog, we take all types of fraud seriously and fraud committed by health care providers is no different.

In fact, in 1994 we created the Health Care Provider Team (HCPT) to exclusively investigate this type of fraud.

This past fiscal year HCPT closed 64 cases, identified $19M in savings, made 11 criminal prosecution referrals, and obtained 3 convictions.

Just to give you an idea of the types of fraud committed by health care providers, here are a few of our most notable, recent cases.

Lawanna Porter, of Shaker Heights, who operated Palladium Healthcare, a home healthcare agency with more than 100 employees, failed to report having employees to various state agencies or to secure workers’ compensation, and failed to report her payroll to BWC. SID conducted this joint investigation with the Ohio Attorney General’s Office, Medicaid Fraud Control Unit. In addition to restitution, Porter was ordered to pay BWC $15,000 in investigative costs, for a total of $139,573. She was also sentenced to five years of community control. If she violates the terms of her sentencing, Porter could be sent to prison for 11.5 years.

Nelsonville chiropractor Michael L. Brown, D.C., whose patients were not at his office on days that he billed BWC for treating them, including dates his office was closed, and who fabricated the amount of treatment he provided to patients to receive a higher payment for services. Brown was ordered to pay $394,021 in restitution, which includes approximately $60,000 in investigative costs. He was sentenced to five years of probation. If he fails to comply with the terms of his probation, Brown could be sentenced to serve nine months in jail. Brown voluntarily decertified himself as a BWC health care provider.

Jeffrey Stychno, D.C., an Ohio chiropractor was sentenced to pay $89,000 in combined restitution to Medicaid and the Bureau of Workers’ Compensation (BWC). Stychno was ordered to pay $69,781 to BWC and $19,715 to Medicaid after he was convicted of fraudulent billing practices during his time as co-owner of Integrated Health in Warren, Ohio.

Joseph J. Yurigan, D.C., a chiropractor who formerly practiced in Weirton and Wheeling West Virginia was sentenced for health care fraud and tax evasion. Our investigation revealed Yurigan was routinely and consistently billing for services that he never provided to undercover operatives. The Federal Bureau of Investigations, the West Virginia Department of Insurance Commission, United States Treasury Department and the United States Attorney’s Office became involved in the investigation and executed a search warrant. Yurigan pleaded guilty and yesterday was ordered to make restitution totaling $836,066.

After reading these cases you have most likely come to the same conclusion…this big business is just not worth it!

BWC SID: Our Journey to Excellence – Part 2 of 3

By Jeff Baker, Program Administrator, BWC Special Investigations Department

Fraudweek 1

Toby Smith commences his presentation.

In our constant quest for improvement, all members of the Bureau of Workers’ Compensation Special Investigations Department (SID) gathered on October 22, 2015 at our Mansfield service office to successfully complete annual in-service training. The theme of this year’s training event was “Our Journey to Excellence: Past, Present and Future.” Led by SID Director Jim Wernecke, we shared investigative successes, learned how to use new technology recently secured, and committed to operational strategies for even greater effectiveness.

We’ve found that one of the chief ways to find new or alternate methods of fraud detection and investigation is to consult counterpart agencies. Such collaboration allows SID to examine its own methods to see where improvements can be made, how tasks can be accomplished more efficiently, and what new strategies or technologies can be used in the course of an investigation.

fraudweek2

Toby Smith holds certificate presented by Jim Wernecke.

This is why Director Wernecke wisely invited Toby Smith, a talented Assistant Director of Security Services with the Industrial Commission of Ohio, to be our keynote speaker. In fewer than 90 minutes, the retired sergeant with the Ohio State Highway Patrol increased our awareness and skills in conducting “Crucial Conversations” to enhance organizational communication and investigative team work.

To acknowledge our appreciation of his training, Director Wernecke presented Assistant Director Smith with a certificate, noting that it is an honor for us to recognize, praise and thank him. We respect and appreciate all of our law enforcement colleagues for their dedication to serving and protecting the citizens of the state of Ohio. Thanks to their willingness to effectively guide others on their respective journeys, we may be confident in soon reaching our intended destination.

You can read the first article about the October 22 event here and our most recent annual report here.

Who we are, what we do and why we do it…

Combating workers’ comp fraud in Ohio

It’s International Fraud Awareness Week and we’re on board to help educate the public about workers’ comp fraud.

In a nutshell, here’s who we are, what we do and why we do it…

Questions? Don’t hesitate to leave a comment below.

The following statistics are through June 30, 2015.

SID infographics 2

Fraud Awareness Week begins Nov. 15!

Fraud Week LogoThanks to the Association of Certified Fraud Examiners sponsorship and the power of social media, fraud awareness is spreading. We’re joining forces with more than 150 companies and organizations to educate the public about different types of fraud happening all over the world.

This campaign encourages business leaders and employees to promote anti-fraud awareness and education to help minimize fraud’s impacts.
We’re taking a stand and making it clear to potential fraudsters we’re on the lookout and using sophisticated detection methods to find them. Ultimately, there’s a serious price to pay for committing fraud.

Since 1993, our Special Investigations Department has researched and reviewed 115,474 allegations of workers’ compensation fraud, completed 62,985 investigations resulting in 2,485 criminal convictions and identified nearly $1.7 billion in savings.

Workers’ compensation fraud can be committed by an employer who isn’t truthful about the amount of payroll reported for workers’ compensation premiums, a claimant faking an injury to get some time (and money) away from work, or a medical provider who is overbilling. These are just a few examples.

Read more about International Fraud Awareness Week here and stay tuned throughout the next week for tips, articles and new cases here on our blog, ohiobwcfraud.wordpress.com, and also on Twitter, Facebook and YouTube.

Seated at the summit: Benchmarking for peak performance

By Jeff Baker, Program Administrator, BWC Special Investigations Department

To meet our ongoing commitment for improvement, BWC’s Special Investigations Department (SID) works to foster an ongoing exchange with our counterparts both in Ohio and nationally to keep on top of the best fraud prevention strategies.  Last week, we participated in an Ohio Insurance Fraud Summit, sponsored by our colleagues in the Ohio Department of Insurance.

SID Dan FodorDan Fodor, the special agent in charge of the SID Intelligence Unit, participated as a subject matter expert on two panel discussions: “Emerging Fraud Trends” and “Data Mining as Part of a Fraud Prevention Plan”. He is uniquely qualified to speak on these topics. The Intelligence Unit he has successfully supervised since 1999, identified $37 million in savings during the last fiscal year alone.

Of course, the specific content of the panel discussions is confidential. Otherwise, would-be fraudsters might think themselves capable of using the “inside information” to avoid detection. Access to the summit was restricted by invitation only to those with a demonstrated need to know. Nonetheless, we can report that the effective benchmarking that occurred at the summit will generate even greater performance results for each participating law enforcement agency. As Dan noted, following the summit:

“It was a great opportunity to share some of our successes and experience in detecting insurance fraud. Bottom line, you have to think like a criminal to catch one.”

Thanks to effective collaborations, such as this summit, SID and its allies are increasingly realizing their mission to deter, detect, investigate and prosecute insurance fraud.

You can read the past posts about our SID Director here and our most recent annual report here.

What workers’ compensation fraud looks like

In honor of International Fraud Awareness week, we’ve put together a new fraud awareness video. Check it out!

Does something seem suspicious?

November 18, 2014 1 comment

Does something seem suspicious-

Our sources say the darndest things

Sources say the darndest things

International Fraud Awareness Week: BWC and workers’ comp fraud

November 17, 2014 1 comment

We’re the Ohio Bureau of Workers’ Compensation and we’re tough on fraud.Fraud Awareness Week 2014

BWC is partnering with the Association of Certified Fraud Examiners for International Fraud Awareness Week to educate the public and prevent future occurrences of fraud.

Since 1993, BWC’s Special Investigations Department has researched and reviewed more than 112,405 allegations of workers’ compensation fraud, and completed 61,359 investigations and identified $1,621,856,667 in savings.

Workers’ compensation fraud can be committed by an injured worker faking an injury to get some time (and money) away from work, a medical provider who is overbilling, or an employer isn’t truthful about the amount of payroll reported for workers’ compensation premiums. These are merely a few examples.

For Fraud Week, we’re expanding our usual Fraud Friday coverage into a week’s worth of tips, articles and new cases here on our blog, ohiobwcfraud.wordpress.com, and also on Twitter, Facebook and YouTube. Stay tuned!

Workplace security cameras reduce fraud, capture evidence

A person’s character may be best measured by how they act when they think no one is looking. BWC’s fraud investigators routinely find that criminals act as if no one is looking.

However, it is increasingly likely that many people are looking and recording actions. The number of installed and active security cameras has increased, capturing more surveillance video evidence 24/7. These cameras protect the safety and security of all – both law-abiding citizens and criminals alike – in public areas, at workplaces and in residences. It only takes one video clip to bring a criminal to justice. Such was recently the case with one our fraud subjects.

Last week, we reported that Glenn Jones of Cleveland faked a workplace injury that was captured on his employer’s security video. Jones can be seen stomping a hole in the wooden floor the night before he said he was injured. On the following day, he lowers his foot into the floor and lies down on the platform, feigning injury.

Jones claimed he suffered multiple significant injuries. As part of a thorough investigation, BWC’s fraud investigators reviewed the security video provided by the employer. The video evidence confirmed that the injury did not occur as Jones had reported, and that a false claim had been filed. Jones pleaded guilty to and was sentenced Sept. 30 in Cleveland Municipal Court on one count of workers’ compensation fraud, a first-degree misdemeanor.

As the security video shows, before lying down on the platform to complete his staged accident, Jones looked around. He apparently sought reassurance that he was not being observed by co-workers. Fortunately, he overlooked the security camera that was constantly observing him.

For more details pertaining to our fraud prevention efforts, view our current annual report.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

South Euclid woman ordered to repay $32K in workers’ comp benefits

OLYMPUS DIGITAL CAMERAColumbus – A South Euclid (Cuyahoga County) woman was ordered to repay more than $32,000 in connection with working while collecting workplace injury benefits. Laura Brown pleaded guilty April 9 in Franklin County Court of Common Pleas to workers’ compensation fraud, a fifth-degree felony.

“Ms. Brown’s employment was discovered through a cross-match report from the Ohio Department of Jobs and Family Services,” said BWC Administrator/CEO Steve Buehrer. “We partner with other agencies and with the general public, and request that anyone who suspects workers’ compensation fraud contact us. Your tips are anonymous, and they assist us in our ongoing efforts to protect the State Insurance Fund.”

The Special Investigations Unit (SIU) received the cross-match report, which indicated that wages were reported for Brown in 2011 and 2012. Interviews and employment records enabled the SIU to confirm that Brown returned to work as a home health aide while receiving temporary total disability and living maintenance benefits.

Brown was ordered to repay $32,928.05 in restitution to the BWC. She was sentenced to serve 11 months in prison, which was suspended for five years of community control. If she violates the terms of community control, Brown will serve that time in prison.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov. Check out our latest cases at ohiobwcfraud.wordpress.com, follow Fraud Fridays on Twitter @OhioBWCFraud, or join in the conversation at facebook.com/ohiobwcfraud. View and share BWC’s workers’ comp fraud awareness video on our YouTube channel.

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Fraud plans ‘scrapped,’ Grove City man ordered to repay $30K in workers’ comp benefits

Dale Richards booking photoColumbus – A Grove City (Franklin County) man was ordered to pay more than $30,000 in restitution for working while collecting workplace injury benefits. Dale Richards pleaded guilty March 12 to workers’ compensation fraud, a fifth-degree felony, after an investigation by the Ohio Bureau of Workers’ Compensation (BWC) revealed he was earning a living selling scrap metal.

“In addition to selling scrap metal, Mr. Richards also engaged in additional restricted work and physical activity,” said BWC Administrator/CEO Steve Buehrer. “An anonymous allegation put this investigation into motion. We take these allegations very seriously because they often help us put an end to fraud cases like this one.”

The Columbus Special Investigations Unit (SIU) received an allegation that Richards was working while receiving BWC benefits. The investigation showed that Richards was involved in construction and remodeling projects as well as selling scrap metal. He sold 74 tons of scrap metal in Columbus from 2009 to 2012 while receiving temporary total disability benefits.

Richards was ordered to pay $30,381.48 in restitution to the BWC. He was also sentenced to serve eight months at the Ohio Department of Rehabilitation and Correction, which was suspended for three years of community control as long as he doesn’t violate probation rules and pays restitution.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Working while receiving?

Working while receiving benefits is one of the most common types of fraud our investigators uncover. So far, in 2014, 11 out of 16 criminal convictions were claimants working while receiving lost time benefits to which they were not entitled.

Working while receiving is one of the most obvious and flagrant abuses of the system. It is particularly regrettable since the claimants were, at one time, truly injured and entitled to workers’ compensation benefits.

We make every effort to ensure that each claimant knows the well-established rules. The fraud warning messages are clear, explicit and conspicuously placed on forms. For example, a fraud warning message (pictured below) appears on the BWC form to be signed by a claimant to request temporary total lost time benefits.

C84 statement

Fortunately, the vast majority of claimants return to work when they are able and notify BWC that they intend to do so. They understand and accept that their lost time benefits achieved their essential purpose – they provided compensation while the claimant temporarily could not work and was recuperating from an accident, illness or injury.

No matter how clever an individual may be, if he or she commits the crime of returning to work while receiving workers’ compensation benefits, the tell-tale signs remain. Rest assured, we are looking for, investigating, and prosecuting these cases. They will lose their lost time benefits and perhaps their freedom as well.

Categories: Fraud Awareness

Macedonia man ordered to pay more than $5K for workers’ comp fraud

Daniel Verlinger

Columbus – A Macedonia (Summit County) man was ordered to pay more than $5,000 in restitution for working while collecting workplace injury benefits. Investigators with the Ohio Bureau of Workers’ Compensation caught Daniel Verlinger on camera as they posed as customers of his shoe repair store. Verlinger pleaded guilty Feb. 26 in the Franklin County Court of Common Pleas to a charge of attempted theft, a first-degree misdemeanor.

“We received an allegation that Mr. Verlinger continued to work at his business while receiving BWC benefits intended to assist injured workers who are unable to work,” said BWC Administrator/CEO Steve Buehrer. “Workers’ compensation fraud is a crime. Our agents conducted a thorough investigation, and were able to get compelling evidence on video to bring this crime to light.”

While conducting undercover operations and surveillance, agents with BWC’s Northeast Regional Special Investigations Unit (SIU) observed Verlinger arriving at Together Leather and Shoe Repair, assisting customers and completing leather/shoe repairs. The SIU confirmed that Verlinger continued working while collecting temporary total benefits from October 2011 through April 2012.

Verlinger was sentenced to serve 90 days in jail, which was suspended for five years of community control. He is to pay $5,371.95 in restitution to BWC as a condition of his community control.

Surveillance video of Verlinger is available here. A photo is available here.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov. Check out our latest cases at ohiobwcfraud.wordpress.com, follow Fraud Fridays on Twitter @OhioBWCFraud, or join in the conversation at facebook.com/ohiobwcfraud. View and share BWC’s workers’ comp fraud awareness video on our YouTube channel.

Former Barberton man sentenced to prison for workers’ comp fraud

February 28, 2014 1 comment

Joshua Collmar, formerly of Barberton (Summit County), was sentenced for working while collecting workplace injury benefits.

Booking Photo - CollmarBWC’s Special Investigations Department (SID) began investigating after receiving an allegation that Collmar was scrapping junk vehicles while collecting temporary total disability benefits. SID agents obtained evidence from scrap yards and interviewed customers, who verified that Collmar scrapped junk vehicles and was paid cash for his services.

Injured workers are not permitted to work while receiving temporary total disability benefits.

Collmar pleaded guilty Feb. 24 to one count of workers’ compensation fraud, a fifth-degree felony. He was sentenced to six months of incarceration and was credited for serving six months in jail. He’s currently serving a prison sentence until 2015 for an unrelated matter. The overpayment amount is $6,021.07.

Lima man fled Ohio after he was caught on camera committing workers’ comp fraud

February 28, 2014 1 comment

John Neeley Booking PhotoColumbus – A Lima (Allen County) man was ordered to pay nearly $7,000 in restitution and investigative costs for working while collecting workplace injury benefits. John Neeley pleaded guilty Feb. 19 in Franklin County Court of Common Pleas after undercover investigators with the Ohio Bureau of Workers’ Compensation caught him on video working while he was supposed to be recovering from a workplace injury.

“We received an allegation that Mr. Neeley was working while collecting BWC disability benefits, and once he became aware of the investigation, he fled to Florida,” said BWC Administrator/CEO Steve Buehrer. “Thanks to the anonymous tipster and our hard-working investigators, he has now been sentenced for his crime.”

Investigators gathered records and surveillance video, which confirmed Neeley’s return to work; they discovered he performed concrete installation jobs for several customers between July and October 2012.


Neeley pleaded guilty to one count of workers’ compensation fraud and was sentenced to 180 days in jail. He received 59 days of jail time credit, and the remaining 121 days were suspended for three years of community control. The terms of his community control include basic supervision, with telephone reporting allowed as long as he makes a good faith effort to obtain/maintain employment and pay $4,878.14 in restitution and $2,000 in investigative costs to the BWC. The judge ordered Neeley to pay $250 per month to the BWC. He must pay at least $2,250 by Dec. 31, or he will be sent to jail to serve the rest of his sentence.

Surveillance video of Neeley is available here. A photo is available here.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov. Check out our latest cases at ohiobwcfraud.wordpress.com, follow Fraud Fridays on Twitter @OhioBWCFraud, or join in the conversation at www.facebook.com/ohiobwcfraud. View and share BWC’s workers’ comp fraud awareness video on our YouTube channel.

Butler County man ordered to repay nearly $60K in workers’ comp death benefits

??????????????????????Columbus – A Monroe (Butler County) man was ordered to repay nearly $60,000 in workers’ compensation death benefits. Adam Osterman pleaded guilty Feb. 13 in the Franklin County Court of Common Pleas to one count of workers’ compensation fraud, a fifth-degree felony.

“As the son of a worker killed on the job, Mr. Osterman was eligible to receive death benefits up to age 25, if he enrolled at an accredited educational institution,” said BWC Administrator/CEO Steve Buehrer. “Our investigators found that he submitted proof of enrollment at a community college in Dayton, but didn’t attend classes or dropped the classes afterward. Thanks to the hard work of our Special Investigations Department, the money Mr. Osterman improperly received will be returned to the BWC.”

Investigators opened a case after receiving an allegation that Osterman bragged about enrolling in classes and dropping them to receive BWC death benefits. They found that from 2010 to 2012, Osterman submitted documentation that he enrolled in community college classes, but either didn’t attend or dropped those classes after submitting documentation to the BWC.

Osterman was placed on community control for five years. Conditions of his community control include repaying $59,213.83 in restitution to the BWC, obtaining and maintaining employment, and paying court costs. Osterman will serve eight months in prison if these terms are violated.

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov. Check out our latest cases at ohiobwcfraud.wordpress.com, follow Fraud Fridays on Twitter @OhioBWCFraud, or join in the conversation at www.facebook.com/ohiobwcfraud. View and share BWC’s workers’ comp fraud awareness video on our YouTube channel.

2013: A Year in Review

The staff of the special investigations department (SID), like many individuals, views the start of a new calendar year as an opportunity to reflect on the past and look forward to the days ahead. 2013 represented another year of success for SID. However, we know 2014 can be a year of further achievement and greater improvement.

During the last year, SID identified more than $50 million in savings to the state insurance fund.  From emerging trends to ongoing methods, SID remained focused on our goal to prevent workers’ compensation fraud. We also worked to strengthen interagency partnerships critical to our success. Furthermore, 2013 saw the lowest number of cases open at year-end and the highest number of terabytes of data processed by SID’s digital forensics unit

2013 also marked the 20th Anniversary of SID. Since 1993, SID has and will continue to uphold its dual functions of deterring workers’ compensation fraud and its subsequent investigation if we suspect fraud.

Nonetheless, much of SID’s work could not be possible without the integrity and vigilance of hardworking Ohioans. To show our appreciation for his commitment to protect the Ohio State Insurance Fund, SID presented Toledo business owner Greg Bryant with a Certificate of Appreciation. The certificate acknowledges his referral of a fraud allegation to BWC that resulted in a conviction, sentencing and nearly $50,000 in savings.

Now that 2013 has ended, SID looks forward to the opportunities the new year will bring. A committee of talented SID professionals, in partnership with the Ohio State Highway Patrol, has begun planning for our first Electronic Surveillance Equipment Symposium. Scheduled for April 17, 2014, the symposium will feature a variety of presentations and equipment demonstrations. We expect the symposium will benefit each attendee as well as the law enforcement agencies they represent. More information will be available in the coming weeks.

Much has changed throughout the last 20 years, from digital advancements to more sophisticated methods of committing crimes. However, the SID’s mission remains unaltered: To deter, detect, investigate and prosecute workers’ compensation fraud, and preserve the Ohio State Insurance Fund.

Fraud red flags: Recognizing fraud wherever it exists

December 20, 2013 1 comment

fraud picWorkers’ compensation fraud takes many forms and we rely on all law-abiding citizens to provide tips when they notice suspicious behavior.

However, we understand the untrained person may notice warning signs, but not recognize them as fraud red flags. To assist, we created a one-page brochure for printed distribution to safety councils throughout the state – and to you. This resource lists signs of potential fraud committed by claimants, health-care providers and employers. Of course, detection of any of those signs does not necessarily mean that fraud exists. Our investigators carefully collect and analyze the facts to determine whether fraud was committed.

We hope our ongoing efforts to educate and provide awareness about workers’ compensation fraud further your understanding of our mission to protect the State Insurance Fund.

You are our eyes and ears! Thank you for your help in stamping out fraud. Please, use these fraud red flags and keep your tips coming. To report workers’ comp fraud in Ohio, click here or call our fraud hotline at 1-800-644-6292.

Categories: Fraud Awareness

Another type of BWC certificate — Showing our appreciation to a source

November 22, 2013 2 comments

Normally, when our readers think of the words “BWC” and “certificate”, they think of the BWC Certificate of Coverage. This makes sense. The certificate is widely seen and easily recognized. It is the official document employers often frame to display with pride within their business.

Understandably, the law-abiding business owner wants every employee and customer to11.22.13 blog post see that they have secured workers’ compensation coverage from our agency. They know that others see it as proof of the business’s legitimacy and a sign of the owner’s prudence.

That might explain why Greg Bryant, the owner of a Toledo business, Snyder Snow Service, Inc. was surprised when we contacted him, asking to present him with another type of BWC certificate: a Certificate of Appreciation.

A SID Special Agent in Charge explained to Mr. Bryant that the certificate acknowledges the business owner’s referral of a fraud allegation to BWC – a referral that had resulted in the criminal conviction and sentencing of the subject, just weeks earlier.

Signed by our SID Director of Investigations Rick Gregory, the Certificate of Appreciation read, in part:

“In recognition of your exemplary citizenship and proven commitment to protecting the integrity of the Ohio State Insurance Fund for all Ohio employers. Your prompt reporting of suspected fraud resulted in a criminal conviction and the identification of more than $50,000 in savings. On behalf of all BWC Special Investigations staff, we extend our appreciation.”

We believe that the simple certificate is the least we are willing to do to demonstrate our thanks to Greg Bryant and others who are our partners in combating fraud.

Significantly, Mr. Bryant received his Certificate of Appreciation on November 8th, the Friday of International Fraud Awareness Week.

Just like Greg Bryant, you are our eyes and ears! Thank you for your help in stamping out fraud, and please, keep those tips coming. To report workers’ comp fraud in Ohio, click here or call our fraud hotline at 1-800-644-6292.

Check out our new video!

November 5, 2013 1 comment

In recognition of International Fraud Awareness Week, we’ve put together this video to raise awareness about workers’ comp fraud and generate more tips from the public.

We welcome your thoughts.

Raising awareness during International Fraud Awareness Week

SID Badge and SealWe’re tough on workers’ compensation fraud. Since its inception in 1993, the Special Investigations Department of the Ohio Bureau of Workers’ Compensation has researched and reviewed more than 108,000 allegations of workers’ comp fraud, completed 58,000 investigations and identified more than $1.5 billion in savings.

During International Fraud Awareness Week, we’ll share more tips and cases here on our blog as well as on our Facebook page and on Twitter. We’ve also put together a video that includes footage of several notable cases that were successfully prosecuted in hopes of raising awareness about workers’ comp fraud and generating more tips from the public.

International Fraud Awareness Week is a campaign that was established by the Association of Certified Fraud Examiners. It encourages business leaders and employees to promote anti-fraud awareness and education to help minimize fraud’s impacts.

You are our eyes and ears! Thank you for your help in stamping out fraud, and please, keep those tips coming. To report workers’ comp fraud in Ohio, click here or call our fraud hotline at 1-800-644-6292.

Categories: Fraud Awareness

All hands on deck: SID sails into the future

October 25, 2013 1 comment
IMG_0431 (2)

From left: Jennifer Saunders, SID Assistant Director; Rick Gregory, SID Director; Amy Huth, Employer Services Specialist; and Steve Buehrer, BWC Administrator/CEO. Amy received a certificate in recognition of her extraordinary performance in pursuit of excellence.

In our constant quest for improvement, all members of the Special Investigations Department (SID) gathered last week at our Columbus main headquarters to successfully complete in-service training. We call this particular type of training event an “All Hands” meeting – as in all hands on deck. Led by SID Director Rick Gregory, we shared investigative successes, learned how to use new technology recently secured, and committed to operational strategies for even greater effectiveness.

We’ve found that one of the chief ways to find new or alternate methods of fraud detection and investigation is to consult counterpart agencies. Such collaboration allows SID to examine its own methods to see where improvements can be made, how tasks can be accomplished more efficiently, and what new strategies or technologies can be used in the course of an investigation. This is why Director Gregory invited a Department of Public Safety expert from the Ohio State Highway Patrol (OSHP) to be our “All Hands” keynote speaker (and what a prudent and wise decision it was!) In just 60 minutes, the dedicated and talented OSHP colleague increased our awareness and skills in ensuring agent safety while conducting effective criminal investigations.

It is an honor for us to recognize, praise and thank our OSHP colleagues. We respect and appreciate all of our law enforcement colleagues for their dedication to serving and protecting the citizens of the state of Ohio. Thanks to their willingness to effectively collaborate, our sails are filled.

You can read the past posts about our history here and our current efforts here.

Exceptional criminals? – No way, but those who commit workers’ compensation fraud are exceptions

Browsing through the cases summarized on our OhioBWCFraud Facebook page, one might draw the conclusion that those who commit workers’ compensation fraud are lurking behind every tree and signpost. Admittedly — thanks to all of our fraud allegation sources — we have had success in identifying and prosecuting fraud.

Therefore we have dozens of Facebook articles that highlight many of the cases we have closed founded in just the last two years. In fact, the more than $23 million in savings we have identified this fiscal year (since July 1, 2013), increases our all time results to nearly $1.6 billion in savings identified since 1993.

However, what is probably not obvious to our readers is most often our thorough and objective investigation proves the suspect has not committed fraud. This is why, since 1993, just 24,169 (or 40.7 percent) of our 59,335 closed investigations have found that a loss was sustained by the State Fund.

We are successful each time we close a case unfounded — because fraud was not committed. Our purpose is not to “catch suspects committing crimes,” rather it is to determine the truth. This may seem like a fine distinction to some, but for the investigative professional it is a critical difference. Further, each time we close an unfounded case, we are reminded that we are meeting the first part of our departmental mission to relentlessly deter crimes against the State Insurance Fund.

When the State Fund is protected, we minimize the premiums paid by compliant employers, while nonetheless ensuring the system is adequately funded. This ensures the State Fund’s essential resources are available to pay for the effective treatment and lost-time benefits deserved by all legitimately injured or ill workers.

As our Director of Investigations Rick Gregory recently noted in an August 29, 2013 Associated Press interview: “When people follow the rules and do it right, they are punished by virtue of the fact that other people don’t do it right,” Gregory said. “And I just think that’s unfair.”

Therefore, we continue to need and want every fraud allegation. Do not hesitate to report your suspicions using our online form or our calling our toll-free fraud hotline, 1-800-OHIOBWC. Know that we will faithfully do our jobs, determining whether or not the State Fund has been victimized.

Thank you for your interest in learning more about a workers’ compensation system that serves hundreds of thousands of deserving, law-abiding citizens in the State of Ohio. Check out archived articles in OhioBWCFraud to learn more about how you may help us protect the State of Ohio.

Committing workers’ comp fraud doesn’t make cents

September 27, 2013 1 comment

We’re often asked why people commit fraud against the Ohio Bureau of Workers’ Compensation (BWC). Fortunately, we have answers. Well, of a sort, anyway. We have the justifications offered by suspects themselves. We document the flimsy rationalizations blustered by suspects during their confessions. We hear the statements made in court by newly-convicted felons just before they’re sentenced.

As career criminologists, we know that our suspects exhibit one common behavior: they miscalculate the “risk versus reward” of workers’ compensation fraud. In their greed, they focus on their motive, opportunity and means to commit a crime against the State Fund. They calculate the apparent “reward” of their crime. However, they rashly dismiss and/or wildly underestimate the relentless resolve and well-honed skillfulness of fraud analysts, special agents and criminal investigators with the BWC Special Investigations Department (SID) to do the following:

  • To detect fraud, even while suspects are still in the process of perpetrating their crimes;
  • To heed – research, analyze and investigate – each suspicion reported to BWC by all sources;
  • To conduct a thorough and objective investigation, securing evidence to determine the truth;
  • To testify, as needed, in an administrative hearing to ensure the suspect’s BWC order is enforced;
  • To refer the case for criminal prosecution by local, state and federal prosecutors;
  • To locate via our Fugitive Task Force all fleeing defendants and to have them extradited to stand trial in criminal court on our charges;
  • To testify in court – telling the truth, the whole truth and nothing but the truth – to secure a conviction by means of the defendant’s guilty plea, or a guilty verdict from either a judge or jury;
  • To submit detailed Victim Impact Statements to the court prior to the convicted felon’s sentencing;
  • To request the court sentence convicted defendants to a serve a period of incarceration and to pay BWC full restitution, including the cost of our BWC investigation, to pay fines and court costs;
  • To work with a probation officer to fully collect the court-ordered restitution from those convicted and sentenced; and
  • To request the court revoke the felon’s probation and impose incarceration, if the debt is not paid in full, according to the court’s order.

Ultimately, since 1994, these miscalculations have contributed to the SID’s identification of more than $1.5 billion in savings to the State of Ohio. Clearly, it just doesn’t make sense to commit workers’ compensation fraud against the State of Ohio.

Check out archived articles in OhioBWCFraud to learn more about helping us continue to protect the State of Ohio. Complete an online form or contact our toll-free fraud hotline, 1-800-OHIOBWC, to report any suspicion of Ohio worker’s compensation fraud.

Categories: Fraud Awareness

Anatomy of a criminal – Who commits workers’ compensation fraud?

September 20, 2013 1 comment

Have you ever wondered what kind of person would commit workers’ compensation fraud against the Ohio Bureau of Workers’ Compensation (BWC)? We are often asked this question. Usually the questioner implies a belief that our answer should include a data-based “profile” of the so-called “typical” white-collar fraudster. Admittedly, we have analyzed millions of data records pertaining to fraud committed against our State Fund. Sure, we have all the means necessary to identify suspect key characteristics and discern patterns of criminal behavior. However, what our experience proves to us is something altogether different. Namely, we know with certainty that those who commit workers’ compensation fraud vary dramatically by age, location, culture, nationality, ethnicity, level of education, income bracket, criminal history, etc. They come in all forms with a multitude of backgrounds. Motivated by greed, the perpetrators who attempt to victimize the State of Ohio fit no one’s stereotype of a criminal.

This is true in part because workers’ compensation – in any workers’ compensation system in all countries, states or other jurisdictions – involves so many different “actors” or parties to a claim.

You need only browse through the cases summarized on our OhioBWCFraud Facebook page to see criminals who have committed workers’ compensation fraud, including:

  • Employees who hide the fact that they have returned to work in order to continue to be paid lost time benefits or who use deception to illegally receive prescription medicine. For examples, see any of the following August convictions of Angel Ocasio, Randy Bartosh, Bob Morgan, Stephen Byrne, or Lawrence Blakeley.
  • Business owners who knowingly employ lost time benefit recipients and fail to report their wages or who underreport payroll and misclassify employees in order to pay less than the true premium amounts owed (see Sarah Barajas, dba Bane Specialty Services); and
  • Health-care providers who bill for medical treatments they have not rendered, upcode bills to charge us for more expensive treatment than they actually furnished, or unnecessarily prescribe narcotics to innocent claimants until these patients are addicted (see the Sept. 9, 2013 case summary pertaining to Joseph J. Yurigan, D.C.).

Ultimately, the variability in our suspects, while it may challenge our detection skills, simply serves to remind us of the importance of our mission to relentlessly deter, detect, investigate and prosecute crimes perpetrated by anyone against the State Fund.

Thank you for your interest in learning more about those criminals who seek to cheat a system that so effectively serves hundreds of thousands of deserving, law-abiding citizens in the State of Ohio. As our BWC Administrator/CEO Steve Buehrer recently noted: “Investigating and putting a stop to fraud helps protect the benefits of injured workers and keep employers’ premiums down. Those who break the rules are interfering with our ability to serve Ohio’s employers and truly injured workers.”

Check out archived articles in OhioBWCFraud to learn more about how you may help us protect the State of Ohio.

Categories: Fraud Awareness

Confidentially speaking – Reporting suspected fraud as an anonymous source

Have you ever heard or seen something related to workers’ compensation that seems suspicious? If so, you are not alone. Thousands of citizens have suspected fraud and reported these suspicions to BWC. In fact, since 1993, SID has received and reviewed more than 100,000 fraud allegations. Many of these allegations were reported by anonymous sources, just like you.

All of these sources had at least three things in common:See it, report it, stop it!_Page_1

  • They suspected fraud. Perhaps, they read an article posted to our Facebook page. The article may have described examples of common fraud schemes, cases we’ve investigated, and suspects that were brought to justice. Something in a case example may have “clicked” and prompted them to realize they had knowledge of a person or business who is doing something similar. They may have also visited ohiobwc.com and learned more about the red flags of claimant, provider, and employer fraud.
  • They figured out how to report their suspicions to us. Some used an article posted to our Facebook page to learn that they could easily report fraud at ohiobwc.com. They were likely reassured when they learned that to report workers’ compensation fraud to BWC, they needed only to suspect that fraud may have been committed. Further, they realized our trained and experienced special agents conduct the investigation and testify in court, while they remain anonymous.
  • They determined to do the right thing. They took immediate advantage of the online form or our toll-free fraud hotline, 1-800-OHIOBWC, to report their suspicions.

Ultimately, these sources are the reason why we have identified more than $1.5 billion in savings to the State of Ohio… and counting.

Thank you for being our eyes and ears!

Help us detect fraud

BWC takes fraud very seriously. Since January 2011, the BWC’s fraud department obtained 290 convictions and identified $128 million in savings for the State Insurance Fund. We receive a 6-to-1 return on investment in fraud detection.

Injured workers, providers and employers alike may be involved in fraudulent activity. Keeping fraud at bay helps BWC achieve its goals of providing high-quality care to injured workers and financial stability for Ohio’s employers.

Visit ohiobwc.com to review the red flags that may indicate fraudulent activity.
If you suspect fraud, let us know by filling out our online form or by calling 1-800-OHIOBWC.

Check here for frequent updates about recent fraud cases and other items of interest. Follow us on Twitter @OhioBWCFraud and visit our Facebook page as well!

See it, report it, stop it!

Our updated fraud brochure includes red flags, case summaries and more!  Please share and use it as a resource on workers’ comp fraud.Image

 

 

 

 

 

 

Smart phones call for even smarter forensics

Digital forensics unit gravatarEach day, there are at least 10 times more mobile devices being produced in the world than babies being born (Global). Recent research conducted by the Ohio Bureau of Workers’ Compensation Special Investigations Department examined such growth in mobile technology, its uses within the workers’ compensation realm, and its future implications on fraud investigations. Mobile devices are projected to be the most common way Americans access the Internet by 2015, with a compound annual growth rate of 16.6% according to the International Data Corporation (DeGrasse). 

The health information field is leading the growth, with investment in companies that make health information mobile apps rising 78% in 2011 to $766 million (Edney; Bloomberg). In 2012, nearly 420 million smart phones and 44 million tablets will ship worldwide (Canalys). With smart phones and tablets increasingly being used to perform work previously done on a laptop or PC, the workers’ compensation system can expect to see increased use of mobile devices and applications in the daily activities of its healthcare providers, employers, and workers.

Taking advantage of recent trends, the BWC formulary went mobile in April 2012, allowing healthcare professionals immediate access to a formulary at the point of care and helping to ensure prescription safety and accuracy. Epocrates, Inc., available through app stores, can also be utilized by employers and workers. Another app, called PillManager, boasts of “unparalleled connectivity between consumer and pharmacy” where consumers can track their own medications and submit a repeat request for any prescription directly from their handheld device.

Mobile devices can be used outside of the healthcare realm, however, with apps aiding employers and workers during work activities. The U.S. Department of Labor and OSHA teamed up to allow worksite heat index tracking in order to reduce heat-related illnesses for workers outdoors. Using GPS data and information from the U.S. National Oceanic and Atmospheric Administration the app addresses risk levels and advises of rest breaks, fluid consumption, and adjustment of work operations. The NIOSH Lift Calculator app is also within the public domain, utilizing real-time feedback to reduce lower-back injuries; the app uses variables, such as horizontal distance, to calculate stress on the lower back during lifts.

Conversely, workers’ comp officials are concerned that injury exposure may grow as more workers go mobile – 2012 is expected to see nearly 35 million people working from home or other locations (Simpson). Mobile devices, although helpful in many realms, can prove to be a dangerous distraction while walking or driving; if the devices are owned by the employer, injuries while using such devices may present unclear compensability situations.

Mobile phones are being used in virtually all levels of criminal activity, making it easier for investigators to use mobile technology as incriminating evidence in an investigation. Personal surveillance has evolved with social media and mobile technology; as a result, officials can conduct investigations through “open source intelligence”. It has become common for investigators to identify false worker’s comp claims from social media websites like Facebook and Twitter documenting able-bodied activity (Newberry).

In addition, mobile applications create a full electronic audit trail enabling the tracking of people and transactions in both space and time. Within workers’ compensation, claims data can be correlated with information from apps to identify “hotspots” of activity at different pharmacies; problem pharmacies or providers can be identified and investigated more quickly (Savitz; Forbes).

Mobile technology, although helpful in a variety of field investigative aspects, can prove to be a challenge to a digital forensic examiner. The number of operating systems is much greater for mobile devices (>10) than for desktops (3) and each OS differs from the next in the way data is stored and security is provided. DFE’s must have the knowledge and tools to access information from each type of OS. In addition, the move to mobile technology has increased the use of cloud data storage, making it commonplace; Strategy Analytics forecasts U.S. spending on cloud services to grow $50 billion by 2016. Digital evidence has shifted to the cloud, where information may be found in multiple places and on a variety of platforms; also, data processing is decentralized in the Cloud, with a lack of physical access to servers (Grispos, Glisson, & Storer). As a result, traditional approaches to evidence collection are void Investigators must identify that an individual is using the cloud, obtain a search warrant, and overcome the final obstacle that current digital forensics tools are intended for media that is under the investigator’s control. As the transition is made to mobile device storage, investigators must be ready to make the change to better (and more expensive) technology for digital forensics labs.

As technology changes, the BWC Special Investigations Department continues to change its investigative efforts.  While the majority of people use technology to improve business operations or enhance communication, we are prepared to investigate those that use these types of technologies to commit fraud against the Ohio BWC.

To report suspected workers’ compensation fraud, call 1-800-OHIOBWC, visit ohiobwc.com, or visit www.facebook.com/ohiobwcfraud.

Sources:

Apple App Stores. Available from: http://www.apple.com/iphone/from-the-app-store or http://www.apple.com/ipad/from-the-app-store; 2012 [accessed 06.26.12]

“App stores; direct revenue to exceed $14 billion next year and reach close to $37 billion by 2015.” Canalys. Available from: http://www.canalys.com /newsroom/app-stores-direct-revenue-exceed-14-billion-next-year-and-reach-close-37-billion-2015; 2012 [accessed 06.26.12]

DeGrasse, M. “Mobile devices projected to overtake PCs as connections to Internet.” RCR Wireless. Available from: http://www.rcrwireless.com /blog/20110912/devices/mobile-devices-projected-to-overtake-pcs-as-connections-to-internet/; 2012 [accessed 06.26.12]

Edney, A. “iPad-toting doctors spur venture funding in medical apps.” Bloomberg Report. Available from: http://www.bloomberg.com/news/2012-06-18/oprah-aids-doctors-as-app-investments-soar-health.html; 2012 [accessed 6.26.12]

Grispos, G., Glisson, W., & Storer, T. “Calm before the storm: the emerging challenges of cloud computing in digital forensics.” 2009. [accessed 06.26.12]

Hobson, E. “Securing the cloud: digital investigations for the cloud.” Qinetiq. 2010. [accessed 06.26.12]

Newberry, L. “Social media footprint helps Pa. investigators.” Officer.com. Available from: http://www.officer.com/news/10731208/social-media-footprint-helps-pa-investigators; 2012 [accessed 06.26.12]

Ohio BWC Web. [accessed 06.26.12]

Savitz, E. “5 ways mobile apps will transform healthcare.” Forbes. Available from: http://www.forbes.com/sites/ciocentral/2012/06/04/5-ways-mobile-apps-will-transform-healthcare/; 2012 [accessed 06.26.12]

Simpson, A. “As more workers go mobile, workers’ compensation exposure grows.” Insurance Journal. Available from: http://www.insurancejournal.com /news/national/2011/06/01/200720.htm; 2012 [accessed 06.26.12]

Pharmacist Sentenced to Two Years in Prison for Illegal Distribution of Oxycodone, Structuring and Filing False Income Tax Return

On January 9, 2012, the United States Attorney’s Office, Southern District of Ohio, issued the following press release:

‘Harold Eugene Fletcher, 43, owner of the East Main Street Pharmacy in Columbus, was sentenced in U.S. District Court to 24 months in prison for illegally distributing the painkiller oxycodone, structuring financial transactions to avoid reporting requirements, and filing false income tax returns for five years.

Carter M. Stewart, United States Attorney for the Southern District of Ohio, Robert L. Corso, Special Agent in Charge, U.S. Drug Enforcement Administration (DEA), and Darryl Williams, Special Agent in Charge, Internal Revenue Service (IRS), announced the sentence handed down today by U.S. District Judge Algenon L. Marbley.

Fletcher was also sentenced to spend five years under court supervision after he completes his prison term. He will spend the first year of supervised release on home confinement and perform 208 hours of community service during the second year.

The sentence includes a $75,000 fine and restitution of $275,000 to the IRS. He is also required to cooperate with the IRS to file any corrected income tax returns for 2005 through 2009. His sentence includes a lifetime ban on practicing as a pharmacist or having any connection with a pharmacy or the distribution of drugs.

Fletcher owned and operated the East Main Street Pharmacy at 1336 East Main Street in Columbus. He pleaded guilty on January 11, 2011.

Fletcher is the first pharmacist convicted and sentenced to prison in the Southern District of Ohio for the illegal distribution of drugs.

According to a statement of facts read during the plea hearing, Fletcher distributed oxycodone outside the usual course of professional practice and without any legitimate medical purpose in February 2006. Fletcher also structured bank deposits of more than $100,000 by breaking the cash amounts into deposits of less than $10,000 each in an attempt to evade federal reporting requirements regarding cash deposits. Fletcher also admitted to filing false federal income tax returns for five years.

“We will continue to prosecute those involved in the illegal distribution of prescription drugs,” Stewart said. “This should send a message of deterrence to any licensed medical professional or others involved in such actions.”

Stewart commended the cooperative investigation by IRS and DEA agents and diversion investigators, along with Assistant U.S. Attorneys Michael Marous and David J. Bosley, and Special Assistant U.S. Attorney Brad Tammaro with the Ohio Attorney General’s Office and former Special Assistant U.S. Attorney Segev Phillips, who prosecuted the case.’

For more information about the United States Attorney’s Office, Southern District of Ohio, see http://www.justice.gov/usao/ohs/.

For information about the BWC Special Investigations Department be sure to read our SID FY 2011 Annual Report.

If you suspect anyone is committing workers’ compensation fraud in Ohio, 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.

Safe and secure: BWC Security ensures we are both

The Bureau of Workers’ Compensation is comprised of 1,985 dedicated professionals providing exemplary workers’ compensation services from 15 customer service offices located in 16 facilities throughout the state. Some of these facilities also host employees of the Industrial Commission (IC) of Ohio, including the hearing officers who conduct all IC claim-related administrative hearings. Moreover, the site of our main headquarters – the William Green Building, 30 West Spring Street, in Columbus, Ohio – furnishes office space to other agencies, such as the Ohio Ethics Commission, Ohio Industrial Commission, Ohio Department of Alcohol and Drug Addiction Services, and Ohio Administrative Knowledge Systems. The William Green Building also hosts many large events throughout the year in its auditorium which seats 375 audience members.

BWC facilities annually experience tens of thousands of visits from employees, customers and members of the general public. Moreover, from these BWC facilities, employees also annually experience hundreds of millions of direct customer service interactions. These include more than one hundred million hits to our e-commerce based Web site, www.ohiobwc.com; and hundreds of thousands of incoming and outgoing telephone calls, more than four million pieces of mail, and countless e-mails. Each employee, customer, and visitor deserves and receives our very best. Most essentially, all interactions must be safe and secure.

Ensuring the safety and security for employees and customers is the mission of BWC Security. To meet its mission, a team of 41 dedicated professionals furnishes security services, threat assessments and investigations for all BWC staff statewide. The team uses dozens of key strategies, including:

  • Co-conduct security and safety training for all BWC employees located in each facility;
  • Conduct audits of each facility’s access control cards;
  • Provide quick reference guides detailing the optimal response to any building emergency;
  • Budget security equipment enhancements for facilities;
  • Monitor the security equipment installations and upgrades in all facilities;
  • Maintain an Automated Critical Asset Management System in conjunction with the Ohio Department of Homeland Security and the Ohio Department of Public Safety for first responders during a building emergency;
  • Initiate an Employee Emergency Notification System due to any business interruption or office closure; and
  • Conduct joint investigations with local and state law enforcement officers.

A Case In Point

The BWC SID safety violations investigation unit (SVIU) received an anonymous voice mail message. The caller threatened to “blow up” the SVIU office. BWC Security worked with the SVIU, Ohio State Patrol, and other Special Investigations Department staff to identify the threatening caller as a management employee of an employer investigated by the SVIU.

In the Franklin County Court of Common Pleas, the management employee was charged with two second-degree misdemeanor counts of telephone harassment and one fourth-degree misdemeanor count of disorderly conduct. The defendant pled guilty to one second-degree misdemeanor count of telephone harassment. The court sentenced the convicted subject to serve one year of community control and to pay $189 in court costs, a $100 fine and a $50 probation fee.

Be on the Lookout

This concludes our fraud awareness series. Be sure to read more about BWC 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.

SVIU: Investigating suspected violations of specific safety requirements

November 28, 2011 4 comments

Most employers are ever seeking to improve workplace safety. Their desire to reduce workplace accidents and illnesses is motivated by so much more than merely reducing the operational costs that result from unsafe workplaces. They desire to protect the health and welfare of each member of the organization. Unfortunately, other employers — perhaps motivated by greed, sloth or both — fail to foster and maintain fundamental workplace safety. In fact, these entities often ignore the best safety practices, even to the point of violating specific safety requirements established by regulation(s).

This is why our BWC SID safety violations investigation unit (SVIU) is so essential. SVIU’s primary function is investigating alleged safety requirement violations that have resulted in a workplace injury, illness or death. Thus, the SID SVIU accomplishes its mission to provide impartial and comprehensive investigations regarding grieved industrial and construction deaths, injuries and/or illnesses for determination by Industrial Commission of Ohio staff hearing officers on alleged violations of Ohio’s specific safety requirements and regulations. To meet the ongoing demand for its services, the SVIU has dedicated staff state-wide, exclusively investigating alleged violations of specific safety regulations (VSSRs).

Compensation via VSSR awards:  If a worker is injured, contracts an illness or is killed on the job because of a violation of a specific safety requirement (VSSR) as outlined in the Ohio Administrative Code, the worker, surviving spouse or dependents may be eligible to receive an additional compensation award, ranging from 15 percent to 50 percent of the injured workers’ maximum allowable weekly compensation rate.

The investigative process:  An SVIU investigation commences when an injured worker or the injured worker’s attorney files an application (IC 8/9) for Violation of Specific Safety Requirement in a Worker’s Compensation Claim within two years of the injury, death or initial diagnosis of illness. Our investigative action steps commonly include:

  • Obtain the injured worker’s affidavit;
  • Contact and interview witnesses;
  • Secure and analyze injury reports, machine maintenance records and other documents;
  • Inspect and photograph the work site, machinery and other evidence;
  • Use high-resolution video to document the sights and sounds of a workplace injury scene; and
  • Re-enact events that led up to a workplace injury or death. Employers, demonstrating good faith, often assist us in these re-enactments.

The SVIU’s investigation concludes when the assigned investigator compiles his or her information in a comprehensive Report of Investigation. The SVIU sends the report to the Industrial Commission (IC) of Ohio and all parties to the claim. The IC then conducts a hearing to determine the eligibility of the worker or surviving dependents to receive a VSSR award. The SVIU Report of Investigation plays a critical role in the IC hearing.

Since 1990, the unit has completed 8,562 investigations.

Outcomes:  The IC hearing culminates in the issuance of an administrative order, granting or denying the additional award. The hearing order may impose upon an employer a penalty, fine and also a requirement to correct specific safety regulation violations.

A Case In Point

On March 28, 2011 an employee died at a demolition site in Montgomery County. The injured worker was a member of a demolition team tasked with razing a vacant industrial facility. SVIU responded to the scene and obtained preliminary information. The SVIU investigation revealed the owner of the company had failed to secure coverage with the Ohio Bureau of Workers’ Compensation. Upon the death of the injured worker, the owner of the company fled from the United States. SVIU met with the injured worker’s widow and other family members. A BWC claim was filed on behalf of the decedent. SVIU worked with BWC to establish an employer policy and the claim was subsequently allowed and charged to the employer’s policy.

Be on the Lookout

Red flags that may indicate the employer is operating an unsafe workplace in violation of specific safety regulations:

  • Employer has placed tarps or large equipment to act as “shields” around perimeters of construction trenching sites to block the view of the public and/or safety inspectors;
  • Employer requires workers to provide their own required personal protective equipment;
  • No trained or qualified “competent person” exclusively oversees the job site;
  • Employer fails to require and/or furnish training or certification to workers prior to permitting them to operate industrial vehicles;
  • Equipment is devoid of any sign or label warning workers of dangerous areas or zones;
  • Emergency quick drench stations are non-operational or in need of maintenance;
  • Employer permits persons within construction sites who are not wearing hardhats and/or other required personal protective equipment;
  • Employer permits workers to work at elevated heights or rooftops without fall arrest equipment;
  • Employer makes no modification or change in response to reported “close calls” / near injuries; and
  • Current BWC certificate of coverage is not posted and/or has been altered.

Look for our next fraud awareness article that will discuss our BWC Security operation. Meanwhile, be sure to read more about SVIU investigations in our SVIU 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.

The long arm of the law: The SID Fugitive Task Force in action

November 21, 2011 3 comments

Handcuffed

The scenario is all too common in the criminal justice system. By means of a grand jury indictment, a defendant is charged with a crime. Yet – although presumed innocent until proven guilty – the defendant fails to show up in court for a scheduled arraignment hearing. Without even entering a plea to the criminal charge, the defendant has fled. The court promptly issues a bench warrant for the defendant’s arrest. The defendant has become a fugitive from the law.

Many fugitives go into hiding, apparently hoping the court will somehow forget about them. Some leave our state, or even our country, seemingly believing the best bet is to put distance between themselves and their crime. However, little do they understand that they can indeed run, but they certainly cannot hide.

It was for this very reason that, back in 1999, SID assembled an elite team comprised of a fraud analyst and several special agents. This BWC Fugitive Task Force (FTF) – as it was soon to be known – immediately commenced coordinating action with law enforcement agencies to bring our BWC fugitives to justice. The FTF accomplishes its mission by identifying the location of each fugitive, guiding law enforcement to execute the fugitive’s arrest and, where needed, ensuring the fugitive’s extradition to the respective jurisdiction where s/he faces a criminal charge. Of course, the key action step is the first action step – namely, locating the fugitive. To do this, the FTF uses many sources of information, including the databases of other governmental and law enforcement agencies. Often FTF members conduct surveillance. Sometimes they execute undercover operations. Always, these investigative strategies are carefully planned and coordinated to secure otherwise hidden information.

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.

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. 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

You may see the identities and photos of current BWC “Wanted Fugitives” on our SID Facebook page: ohiobwcfraud.

Look for our next fraud awareness article that will discuss our Safety Violations Investigation Unit (SVIU). 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, or if you suspect you know the location of a BWC fugitive, 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 digital forensics unit: Ensuring justice for even the smartest criminals

Digital forensics unit gravatar

In our digital age almost all data elements are stored electronically – whether on computers, laptops, servers, digital recorders, iPads or smartphones. Even criminals who think they are too smart to be detected, investigated and prosecuted, routinely use one or more of these electronic devices in the course of their crimes.

To bring these criminals to justice, the SID digital forensics unit (DFU) provides a full range of technical support for special agents conducting workers’ compensation fraud investigations. In fact, the unit’s primary duties include the forensic imaging and analysis of digital data from electronic devices. For example, when executing search warrants, the forensic analysts make exact copies of the storage from these devices. Then, employing specialized training, these uniquely talented professionals use specialized forensic software to filter through a vast amount of information.

During just the last year, the unit has processed 12.88 terabytes of data. This quantity is equivalent to 6,282,923,587 printed pages. These pages, if stacked, would be stretch 397 miles high – or the length of 6,981 football fields.

A Case In Point

Forensic analysts are often required to gain access to proprietary software, such as office billing and point-of-sale software, in order to provide data to investigators. In a recent case, the unit worked with a software developer to successfully gain back-door access to the sales and time keeping software of a long-defunct business. The data provided essential information to SID special agents. The evidence proved to be a very important component of the case, which identified almost $350,000 in savings to the BWC State Fund.

Be on the Lookout

Look for our next fraud awareness article that will discuss our SID Fugitive Task Force. 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.

Paying for crime…

iStock_000005139523XSmall

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.

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.

Lost Years and Lives: Prescription Drug Abuse

September 27, 2011 1 comment

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.

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.

Make ‘em pay for it: The Employer Fraud Team

When employers fail to comply with the workers’ compensation system, SID’s Employer Fraud Team responds to ensure compliance and integrity of the system. During the last two years, their investigations have resulted in over 160 criminal referrals and 60 convictions. Be sure to read more about the Employer Fraud Team’s success in our SID FY 2011 Annual Report.

SID has recently increased its staffing to combat employer fraud, such as, misclassifying employees as independent contractors.

Misclassification: A National Issue

BWC, as well as other federal and state agencies, continue to see misclassification as a major issue. Employers that misclassify their employees as independent contractors have an unfair advantage as they compete against employers operating legitimately.

What’s misclassification? Here’s a quick overview:

Misclassification occurs when an employer claims a person as an independent contractor, when they should be classified as an employee.

Workers are generally considered employees when someone else controls how and when they perform their work. In contrast, independent contractors are generally in business for themselves and control how and when they perform services.

In addition to legitimate businesses, federal, state and local governments also lose when employers intentionally misclassify employees. Employers are required to withhold taxes from employees’ pay and also pay taxes, such as Social Security, Medicare, unemployment and workers’ compensation, based on their employees’ wages. Employers generally do not have to withhold or paid taxes for independent contractors.

Misclassification costs the State of Ohio millions. A 2009 report by the Ohio Attorney General estimated that Ohio has 92,500 misclassified workers. This level of misclassification annually costs the state up to $20 million in unemployment taxes, up to $103 million in workers’ compensation premiums and up to $36 million in income tax revenue.

To combat this issue, the Internal Revenue Service (IRS) launched a program last year to randomly examine 6,000 companies over the course of three years to specifically address employee misclassification. The federal government estimates the program will generate $7 billion in 10 years through tighter enforcement.

BWC’s Special Investigations Department continues to pursue exchanging data with partners and reviewing our own data to ensure employers pay their fair share or else we make ‘em pay for it.

This concludes our employer fraud awareness series. Look for our next fraud series awareness series on claimant fraud.

If you suspect that an employer is not paying their fair share of premiums, 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.

Make ‘em pay correctly: BWC Premium Audit Department

Checking balanceBy Michael Glass, Director, Premium Audit Department

BWC’s Premium Audit Department is responsible for ensuring proper payroll reporting and manual classification assignment. By auditing employers’ payroll, the Premium Audit Department strives for a fair and equitable rating structure.

The Premium Audit Department works closely with the Employer Compliance Department and the Special Investigations Department in BWC’s efforts to fight fraud. For example, Special Investigations Department staff may request an audit when an employer subject’s amount of premium is needed to support a criminal case. The Premium Audit Department refers policies to the Special Investigations Department when, in the course of an audit, it is suspected that willful and possibly illegal activity has occurred.

A Case In Point

The Special Investigations Department received a referral from the Premium Auditing Department that a Kenton pizzeria was operating their business with lapsed workers’ compensation coverage. The Premium Auditing Department contacted the employer several times in an attempt to bring the employer into compliance but the employer failed to secure coverage. An investigation by the Special Investigations Department confirmed that several employees work at the business, thus confirming the need for workers’ compensation coverage. Investigators requested that the Premium Auditing Department conduct an audit to calculate premiums owed, however, the owner of the company failed to cooperate with the audit. The owner pled guilty to one second degree misdemeanor count of failure to comply.

If you suspect that an employer is not paying their fair share of premiums, 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.