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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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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.

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.

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

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.

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.