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Posts Tagged ‘Fraud Awareness Series’

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]

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Hannah News reported: “State Secures First Pill Mill Conviction of 2012”

On January 6, 2012, Hannah News reported as follows:

‘Another Ohio pill mill has fallen to a multi-agency initiative launched by the Ohio Attorney General’s Office, the Ohio Pharmacy Board and State Medical Board, the Ohio Bureau of Workers’ Compensation, the Regional Agencies Narcotics & Gun Enforcement Task Force (R.A.N.G.E.), as well as local and federal authorities. Dr. Han M. Yang is the latest conviction, pleading guilty Thursday to eight felony counts.

Yang, 69, could get 17 years in jail and $80,000 in fines for his trouble. That would add to $100,000 in drug profits he has already surrendered.

State, local and federal officers raided his Dayton and Bethel Township offices in Montgomery and neighboring Clark counties in October as part of a year-long investigation into prescription drug abuse, medical fraud, and money laundering. (See The Hannah Report, 10/3/11.) Authorities found would-be customers lined up outside for quick prescriptions, though facilities were largely bereft of exam tables and other equipment needed for legitimate medical services. Undercover agents previously witnessed Yang writing prescriptions within minutes of a patient’s arrival, and with no examination.

Formerly affiliated with Good Samaritan Hospital and Miami Valley Hospital in Dayton, Yang was since charged with six counts of trafficking in prescription drugs, including five fourth-degree felonies and one fifth-degree felony; one second degree count of engaging in a pattern of corrupt activity; and one fourth-degree count of theft by deception involving health care fraud. Clark County Common Pleas Court Judge Richard O’Neill accepted Yang’s guilty plea Thursday.

“We are committed to driving pill mills, and their trail of suffering and death, out of Ohio,” Attorney General Mike DeWine said in a statement. “More work remains, but rest assured we will continue the fight.”

In addition to state and federal officials, the investigation involved Clark County Sheriff Gene Kelly, Montgomery County Sheriff Phil Plummer, Clark County Prosecutor Andrew Wilson, and Montgomery County Prosecutor Mat Heck. A local pharmacist had alerted authorities in October 2010 after a woman nine months pregnant showed up with a prescription written by Yang for powerful painkillers.

DeWine said sentencing will be announced later, but indicated Yang faces penalties ranging up to 18 years in prison and fines up to $77,500.

The arrest and conviction follows at least four convictions, investigations and/or license revocations involving Ohio physicians in 2011, including Dr. James Lundeen, Dr. Victor Georgescu, Dr. George D.J. Griffin, and a fourth doctor who colluded in a prescription drug scheme with former Cincinnati attorney Kenneth Lawson, who was stripped of his law license in September. (See The Hannah Report, 4/5/11, 9/20/11, 12/15/11, 12/20/11.)

The governor, state Legislature and DeWine launched the coordinated offensive against pill mills and over-prescribing doctors in early 2011. (See The Hannah Report, 2/8/11, 2/9/11, 2/21/11.)’

For more 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, 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.

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…

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

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

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

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

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

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

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

A Case In Point

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

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

Be on the Lookout

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

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

In summary: SID Health Care Provider Team (HCPT)

October 27, 2011 1 comment

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

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

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

Be on the Lookout

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

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