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Posts Tagged ‘Prescription Drugs’

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.

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.

BWC Investigations Result in Nine Workers’ Comp Fraud Convictions in July

Ohio Bureau of Workers’ Compensation (BWC) Administrator/CEO Stephen Buehrer today announced nine individuals were convicted of or pleaded guilty to charges related to defrauding Ohio’s workers’ compensation system during the month of July. 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.

“Several of these individuals went to great lengths in their attempts to cheat the system so they could receive undue compensation and access to prescription drugs,” said Buehrer.  “They likely did not anticipate the expertise and dedication our investigators have when it comes to finding and eliminating fraud.”

Following is a sampling of cases that resulted in a guilty plea or conviction during the month of July.

 Charles Watson (Toledo, Lucas County) pleaded guilty to one count of deception to obtain dangerous drugs for fraudulently receiving BWC paid narcotic prescriptions from two different physicians.  Watson was traveling from one physician in Toledo to another physician in Dover (Tuscarawas County) to obtain similar narcotics.  Neither physician knew Watson received narcotics from prescriptions written by the other physician.  Watson was sentenced nine months suspended incarceration and was placed on community control for two years.  As a condition of community control, Watson was ordered to pay restitution of $930.24 and court costs.  The court also suspended his driver’s license for six months. 

Misti Marshall (Elyria, Lorain County) entered a plea of guilty to one count of workers’ compensation fraud for working while receiving benefits. BWC’s Automated Detection and Intelligence unit noted a cross match with the Ohio Department of Job and Family Services (ODJFS) indicating potential fraud.  Investigators found Marshall was receiving wages from Assured Home Health, Rono Investments, Industrial Plastics and Kelly Services while she was collecting Temporary Total Disability and Living Maintenance benefits. Marshall must pay restitution of $18,177.15 and an additional $3,000 for investigative costs. Her sentencing is scheduled for September 22.

Benton Crist (Delphos, Allen County) pleaded guilty to one count of workers’ compensation fraud for working while receiving benefits.  Crist failed to inform BWC that he was working as a truck driver for Martin Transportation Systems, in Byron Center, Michigan (formerly Topline Express out of Lima, Ohio) during the time he was applying for and collecting Non-Working Wage Loss benefits.  The investigation began after a BWC claims service specialist recognized signs of possible fraud in his claim documents. Crist was sentenced to five years of community control and ordered to pay court costs and restitution of $ 42,876.34.  He was also sentenced to 12 months suspended incarceration.

Donald Fisher (Clermont County) pleaded guilty in Clermont County to one count of deception to obtain a dangerous drug, a fourth degree felony. Investigators found that Fisher was having his granddaughter use and sell narcotics prescribed by his BWC physician.  Between May 2010 to March 2011, Fisher gave his adult granddaughter 10 Opana and 10 Percocet pills each week to traffic on the street in exchange for sexual favors. Rebecca Fisher sold the Opana for $50 per pill and the Percocet for $12 per pill and split her profits with Fisher.  Both confessed to selling the BWC prescribed narcotics during the same period Fisher received Permanent Total Disability benefits. Fisher’s sentencing is pending.

http://www.ohiobwc.com/home/current/releases/2011/081211.asp

To report fraud online, please visit: http://bit.ly/reportfraud.
To speak with a fraud hotline agent, please call: 1-800-OHIOBWC.