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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.

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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 2 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.