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Posts Tagged ‘Health Care Fraud’

BWC Investigations Result in Five Workers’ Comp Fraud Convictions in November

December 21, 2011 1 comment

Ohio Bureau of Workers’ Compensation (BWC) Administrator/CEO Stephen Buehrer announced five individuals were convicted of or pleaded guilty to charges related to defrauding Ohio’s workers’ compensation system during the month of November. The court actions are the result of investigations conducted by BWC’s Special Investigations Department (SID), which works to deter, detect, investigate, and prosecute workers’ compensation fraud. The cases bring the total number of convictions this year to 119.

“With another month comes five more fraud convictions, the result of our investigators’ outstanding work following up on leads and proactively identifying fraud,” said Buehrer. “What many perpetrators often do not understand is that if their activity does not generate tips from suspicious neighbors, co-workers or others surrounding them, their activity will raise red flags among BWC staff trained to detect suspected fraud.”

Following are four of the cases that resulted in a guilty plea or conviction during the month of November.

Michael Roe Booking PhotoMichael Roe (Middletown, Butler County) was sentenced November 28 for working while receiving benefits. SID received an allegation through BWC’s fraud hotline indicating Roe was working for a friend while collecting temporary total disability benefits. Investigators found Roe was working as a part-time tow truck driver for Lightening Towing and Recovery in Middletown. Roe pleaded guilty in the Franklin County Common Pleas Court to a felony count of workers’ compensation fraud. Roe was ordered to pay restitution of $5,163.91, and another $2,000 for investigative costs. He was also placed on community control for two years. Roe must pay full restitution by June 15, 2012 and obtain no further felony convictions or he will serve six months in jail.

James Mann (Toledo, Lucas County) was sentenced November 30 for fraud after he was found treating injured workers without a medical license. BWC’s Health Care Provider team investigated Mann after an employer reported inconsistencies with the treatment provided to an injured worker by Mann, owner of Toledo Medical Evaluators, LLC. The team found Mann was performing disability exams and file reviews in both Ohio and federal workers’ compensation cases although he lost his license to practice medicine in 1991 after he was convicted of illegal processing of drug documents. Mann was attempting to conceal the fact that he was personally conducting exams by erroneously reporting that one of the licensed physicians in his practice conducted the exam. Mann then submitted the fraudulent exam reports to the Ohio Industrial Commission. Mann pleaded no contest to a bill of information in Lucas County Common Pleas Court to one count of workers’ compensation fraud. He was sentenced to serve five years of probation and pay $90,278 in restitution, in addition to $10,530 for investigative costs. Mann previously pleaded guilty in the United States District Court, Northern District of Ohio, to three counts of Mail Fraud.

Thomas McallisterThomas McAllister (Steubenville, Jefferson County) pleaded guilty to deception to obtain narcotics. BWC’s Intelligence Unit identified Thomas McAllister as potentially receiving prescriptions from several physicians and pharmacies. SID’s investigation confirmed that he used deception to obtain 11 prescriptions from three prescribing physicians. McAllister entered a guilty plea in October to a felony count of deception to obtain dangerous drugs. A Franklin County judge sentenced McAllister November 30 to 30 days in jail. He was also ordered to pay $424 in restitution, and his driver’s license will be suspended for six months.

Gary Metz (Sharonville, Hamilton County) was sentenced November 22 for working while receiving benefits. BWC’s Special Investigations Department investigated Metz after receiving a tip and found he was working as a cable technician for his brother’s company Comteam, Inc., while receiving Living Maintenance and Non-Working Wage Loss benefits. Metz pleaded guilty in the Franklin County Common Pleas court to one felony count of workers’ compensation fraud. He was ordered to pay restitution of $6,165 and investigative costs of $1,000. He was also sentenced to six months in Ohio Department of Rehabilitation and Correction, suspended if he pays restitution and court costs by Dec. 30.

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.

https://www.ohiobwc.com/home/current/releases/2011/121511.asp

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We are hiring!

We are hiring various investigative positions throughout the state. Apply to each position below or visit http://careers.ohio.gov/.

Canton

Position

Team

Closing Date

Fraud Investigator

Region 1

12/14/2011

Cincinnati

Position

Team

Closing Date

Fraud Investigator

Health Care Provider Team

12/14/2011

Cleveland

Position

Team

Closing Date

Fraud Investigator

Region 1

12/14/2011

 Fraud Investigator 

Employer Fraud

12/14/2011

 

Columbus

Position

Team

Closing Date

Criminal Investigator

Region 2

12/14/2011

Lima

Position

Team

Closing Date

Criminal Investigator

Region 3

12/14/2011

Fraud Investigator

Employer Fraud

12/14/2011

Mansfield

Position

Team

Closing Date

Fraud Investigator

Region 1

12/14/2011

Regional Locations TBD (Canton, Cleveland, Mansfield and Youngstown)

Position

Team

Closing Date

Assistant Special Agent In Charge

Region 1

12/08/2011

Lack of medical license not enough to keep Toledo man from treating injured workers

James E. Mann sentenced for workers’ comp fraud

A Toledo (Lucas County) man who treated injured workers without a medical license must repay the Ohio Bureau of Workers’ Compensation (BWC) more than $100,000 as a result of his sentencing yesterday for workers’ compensation fraud. James E. Mann owned and operated Toledo Medical Evaluators, LLC, and performed disability exams and file reviews in both Ohio and federal workers’ compensation cases although he lost his license to practice medicine in two decades ago.

“We cannot endanger the health of injured workers by allowing anyone who is not a licensed physician to direct their care,” said BWC Administrator/CEO Stephen Buehrer. “Employers have workers’ comp coverage to ensure their workers receive quality care and they rightfully do not expect their premiums to go to anyone who would take advantage of the system.”

Mann, who has not held a medical license since his conviction in 1991 on nine counts of illegal processing of drug documents, contracted with two licensed physicians to perform exams on injured workers. However, an investigation by the BWC Special Investigations Department showed Mann personally conducted exams and erroneously reported that one of the licensed physicians conducted the exam. Mann then submitted the fraudulent exam reports to the Ohio Industrial Commission.

Mann pleaded no contest to a bill of information charging him with one felony count of Workers’ Compensation Fraud. Judge James Jensen of the Lucas County Court of Common Pleas found him guilty and ordered he pay $90,278.86 in restitution and $10,530.17 in investigative costs, as well as court costs and a supervision fee. Mann was also sentenced to five years of community control. He will serve 12 months in prison if he violates community control.

Mann previously pleaded guilty in the United States District Court, Northern District of Ohio, to three counts of mail fraud. He was sentenced in that case on November 21 to one year of supervised release. Judge James Carr ordered Mann to pay $91,482.81 in restitution to the federal workers’ compensation program, in addition to a $100,000 fine and a $300 special assessment fee.

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.

https://www.ohiobwc.com/home/current/releases/2011/120111a.asp

BWC Investigations Result in 13 Workers’ Comp Fraud Convictions in October

 Ohio Bureau of Workers’ Compensation (BWC) Administrator/CEO Stephen Buehrer today announced 13 individuals were convicted of or pleaded guilty to charges related to defrauding Ohio’s workers’ compensation system during October. The court actions are the result of investigations conducted by BWC’s special investigations department (SID). The department works to deter, detect, investigate and prosecute workers’ compensation fraud. The cases bring total convictions in calendar year 2011 to 114.

“Cases like these remind us why detecting and prosecuting fraud must be a very high priority,” said Buehrer. “Whether it’s an injured worker, an employer or provider, it is incredible that anyone would game the system to gain something is not rightfully theirs, at the expense of others who end up paying the bill.”

Below is a sampling of cases that resulted in a guilty plea or conviction during October.

James Landis (Canfield, Mahoning County) pleaded guilty Oct. 24 to a felony count of workers’ compensation fraud for working while receiving benefits. An anonymous tip led to an investigation into whether Landis was working at his business, Mum’s The Word Florist, while receiving workers’ comp benefits. Landis stated on multiple occasions that he was incapable of working in any capacity. However, SID verified Landis was the primary operator of the business while on temporary total disability. He interacted with customers, arranged and delivered flowers, set up floral displays at events, and did all administrative paperwork. Landis is scheduled to be sentenced on Dec. 15. As a condition of his sentencing, he has agreed to repay $8,065.81 in investigative costs. He has repaid 19,000 he received improperly.

Roger Bolin (Nelsonville, Athens County) pleaded guilty Oct. 17 to workers’ compensation fraud and deception to obtain after he filed a false claim to receive narcotic prescriptions. SID received an allegation from an employer indicating Bolin filed a false claim. He indicated he was injured in September 2010, although he not worked for the company since June. Investigators obtained documentation showing Bolin did file a false claim and obtained a narcotic prescription by deception. The Hocking County Common Pleas Court sentenced Bolin to eight months prison to run consecutively on each count. Bolin is currently serving a prison sentence related to a parole violation. The court ordered the new charges to be served consecutively to this sentence.

Donald Johnson (Trenton, Butler County) was sentenced Oct. 17 for deceptively obtaining numerous BWC paid narcotics from multiple physicians and using multiple pharmacies. SID identified Johnson for possible doctor shopping for narcotic drugs and an investigation revealed his deception to obtain narcotics. Johnson agreed in the Butler County Common Pleas Court to pay restitution owed the amount of $2,177.86.

Daniel Engle (Shaker Heights, Cuyahoga County) pleaded guilty to one count of workers’ compensation fraud for working while receiving benefits. SID opened an investigation after a BWC claims service specialist noted that Engle’s employer, the city of Shaker Heights, submitted a letter prepared by Engle. In the letter, Engle informed the city that he was resigning to start his own computer business. SID’s investigation verified Engle owned and operated DNC Computer while receiving BWC temporary total disability benefits. He claimed he was incapable of working in any capacity. Investigators established that Engle repaired computers, sold computers, and sold computer parts. Additionally, Deluxe Transportation/New Valley Taxi employed Engle as a taxi driver. Engle entered a guilty plea in Franklin County Municipal. He was sentenced to 180 days in jail suspended in lieu of three years probation. The court also ordered Engle to pay a $75 fine, court costs and investigative costs in the amount of $4,000. Engle has paid $15,500 in restitution.

Thomas McAllister (Amsterdam, Jefferson County) was sentenced for deception to obtain dangerous drugs. BWC’s intelligence unit began investigating McAllister after suspecting he was receiving narcotic prescriptions from several physicians and pharmacies. The investigation confirmed that McAllister used deception to obtain narcotic medication from various prescribing physicians. On Oct. 12, McAllister entered a plea of guilty to deception to obtain dangerous drugs, a fifth degree felony. The parties agreed to $424 in restitution. McAllister will be sentenced Nov. 30.

Mark Robinson (Fairfield, Butler County), pleaded guilty Oct. 2 to one count workers’ compensation fraud for working while receiving benefits. Robinson worked as a general contractor for Bed and Breakfast properties in Hamilton while collecting temporary total disability. He performed maintenance and contractor work at various rental properties. Robinson paid back the full criminal overpayment of $6,463.25 and investigative costs of $1,207.38 for a total of $7,670.63 restitution paid to the BWC.

Daren Snyder (Chillicothe, Ross County) pleaded guilty Oct. 3 in a Franklin County courtroom to fraud for working while receiving benefits. SID opened an investigation after receiving an allegation indicating Snyder was working while receiving temporary total disability and living maintenance. Investigators found Snyder did return to work as a self-employed plumber during the period he received benefits. Sentencing is scheduled for Dec. 2.

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.

https://www.ohiobwc.com/home/current/releases/2011/111511a.asp

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.