Posts Tagged ‘Strategies’

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, or visit


Apple App Stores. Available from: or; 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: /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: /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:; 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.” Available from:; 2012 [accessed 06.26.12]

Ohio BWC Web. [accessed 06.26.12]

Savitz, E. “5 ways mobile apps will transform healthcare.” Forbes. Available from:; 2012 [accessed 06.26.12]

Simpson, A. “As more workers go mobile, workers’ compensation exposure grows.” Insurance Journal. Available from: /news/national/2011/06/01/200720.htm; 2012 [accessed 06.26.12]

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 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 or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

SID Annual Report for Fiscal Year 2011

FY11 Annual Report CoverWe published our fiscal year (FY) 2011 fraud results, ongoing trends and future strategies. View our FY 2011 Annual Report.

SID concluded FY 2011 by exceeding our operational goals. We increased effectiveness during FY 2011, referring 245 subjects for criminal prosecution or 20.8 percent of all founded, closed cases. Our prosecution referrals generated 276 convictions during FY 2010 and FY 2011 – the highest level of performance on this measure during any two-year period. We increased efficiency during FY 2011, reducing the average lag days from date allegation received to date case closed by fully 27 days or 10 percent. These results contribute to the agency’s priorities — improving operations and providing better service and care for customers.

During the last 12 months, we focused on improving our investigation and prosecution of medical provider and employer premium fraud. The FY 2011 fraud report includes information about these efforts and the condition of workers’ compensation fraud in Ohio. The report reviews results since our department’s inception in 1993 – including that we have closed more than 54,000 cases and identified $1.4 billion in savings to the Ohio workers’ compensation system. The report highlights our achievements during fiscal year 2011, including performance against goals measured via key indicators and summaries of noteworthy cases investigated and/or prosecuted. The report also identifies fraud trends by subject type and highlights future strategies as specified in our department’s five-year strategic plan.

To report fraud online, please visit:
To speak with a fraud hotline agent, please call: 1-800-OHIOBWC.

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