What do you know about workers’ comp fraud? Our sleuths have questions – and answers!

By Melissa Vince, BWC Public Relations Manager

We’ve had a great time talking workers’ comp fraud this International Fraud Awareness Week. We enjoyed sharing what we do to detect, deter and put a stop to workers’ compensation fraud in Ohio.

Our fraud investigators especially look forward to participating every year because they want to raise awareness and encourage tips from the public, but also because they truly enjoy what they do.

And we appreciate them because they do a great job. So, in honor of them, we let them take a little break to have some fun putting together this quiz challenging your knowledge of workers’ compensation fraud.

So, fire up that brain and let’s get started. Just flip your monitor over for the answers listed at the bottom.

Thanks for following us this week! We’ll be back next year for Fraud Awareness Week, but don’t go away because we’re here all year long on our blog, Twitter and Facebook.

  1. True or false?
    Fraud and abuse are the same.
  2. True or false?
    Proving fraud requires evidence of “knowledge and intent”
  3. True or false?
    Abuse can be criminally prosecuted under the law.
  4. BWC has teams focused on investigating the following types of fraud:
    a) Claimant
    b) Employer
    c) Medical provider
    d) All of the above
  5. Which is an example of fraud?
    a) Billing for services not rendered (a doctor bills for procedures not performed)
    b) Classifying full-time employees as independent contractors/subcontractors.
    c) A claimant performing physical activity outside of his or her restrictions
    d) All of the above
  6. What are the two most common fraud allegations our investigators receive related to medical providers?
    a) Billing for services not rendered (a doctor bills for procedures not performed)
    b) Unlicensed provider (not licensed to practice medicine in the State of Ohio)
    c) Unbundling (charging separately for bundled services)
    d) Upcoding (billing for a more expensive service than the one provided to the claimant)
  7. What is the most common fraud allegation our investigators receive related to employers?
    a) No coverage
    b) Lapsed coverage
    c) Falsified certificate of premium coverage
    d) Underreporting payroll
  8. What is the most common fraud allegation our investigators receive related to claimants?
    a) Physical activity (performing physical activity outside of his or her restrictions; malingering)
    b) Work/Comp (working while receiving lost time benefits)
    c) False claim (staged accidents; false injuries)
    d) Altered documents

 

It’s not easy being Green: Cleveland florist convicted of work comp fraud

Green Thumb Florists owes BWC $32,000

The owner of a Cleveland flower shop owes the Ohio Bureau of Workers’ Compensation (BWC) nearly $32,000 in restitution after pleading guilty to workers’ compensation fraud in late September.

Mary Green, the owner of Green Thumb Florists, was ordered to pay BWC $31,562, sentenced to five years of community control and fined $315 after pleading guilty Sept. 27 to one fourth-degree felony count of workers compensation fraud in the Cuyahoga County Court of Common Pleas.

Acting on a tip, agents with BWC’s special investigations department (SID) discovered Green had altered a BWC certificate to make it appear her business had proper workers compensation coverage, as required by state law. Agents also discovered her actual policy had been in lapsed status since 2011.

“Our agents made multiple site visits, witnessed multiple employees and put Mary Green on notice to bring her BWC policy into compliance with the law,” said SID Director Jim Wernecke. “But when she wouldn’t cooperate, we brought her case to the county prosecutor and now she has a felony on her record. It didn’t have to go this far. We really need employers to reach out to BWC if they’re struggling to pay their premiums.”

To report suspected workers’ compensation fraud, call 1-800-644-6292 or visit bwc.ohio.gov.

Spotlight: Our college interns

By Jeff Baker, Program Administrator, BWC Special Investigations Department

In recognition of International Fraud Awareness Week 2017, we are highlighting careers in criminal investigations, especially those that commence with the study of criminology, criminal justice, law enforcement, digital forensics or data analytics.

History:  BWC’s Special Investigations Department (SID) created its college relations program in 1995 to promote the study and practice of criminology, criminal justice, law enforcement and public administration. On college and university campuses throughout Ohio (and beyond), SID staff members exchange insights with students, faculty and staff members on how to combat crime.

Since the program began 20 years ago, SID has recruited, selected and trained more than 300 paid interns and unpaid externs. Many have gone on to become law enforcement officers, criminal investigators, special agents, digital forensic analysts, assistant special agents in charge and special agents in charge. We currently employ in full time positions, thirteen graduates from our SID college internship program.

On Campus: BWC representatives travel to colleges and universities to meet with candidates. For example, on Nov. 14, BWC was represented at Bowling Green State University by SID Special Agent in Charge Craig Matthews and BWC Human Capital Management Analyst Megan Lentz.

They participated in a job fair specifically targeted toward criminal justice majors. Matthews described the internship program in the special investigations department at the Toledo service office and Lentz explained the application process.

Panel Discussion:  For two hours on Nov. 15, two investigative professionals, Taylor Scarberry and Paul Balzer, participated in our agency’s second panel event where five current permanent employees who started out at BWC as interns discussed their experiences with our current interns. Moderated by Megan Lentz, these successful professionals painted a picture of what it is like to permanently come on board with our agency.

The former SID interns described their success and career paths working in specialized units, including the intelligence and special investigations units (SIUs), as well the health care provider team and regional claimant SIU.

Megan Lentz, Kayla Michel, Luke Bogner, Nathan LaChappelle, Taylor Scarberry and Paul Balzer

They described their many important responsibilities as a college intern with SID. They also mentioned what they did not do, such as getting coffee or food for their co-workers, running any errand, or any other trivial activity.

Panelist Taylor Scarberry: Taylor started his career with BWC in November 2012 as an exemplary college intern with the Columbus SIU. On August 22, 2016, he commenced his permanent employment with BWC as a Criminal Investigator with the Southeast Regional Claimant SIU, assigned to the Cambridge service office. He reports to special agent in charge Scott Lape, a former SID college intern.

During today’s panel discussion, Taylor offered the following knowledge, understanding and wisdom:

“Following my experience as a college intern with the Special Investigations Department and obtaining my Bachelor’s degree in Criminology from The Ohio State University, it was important to me to find a career in criminal justice.  I discovered quickly during my internship that criminal justice was something I was passionate about and saw myself establishing a career in.  BWC provided me that opportunity and the team atmosphere within the SID is something I enjoy being a part of every day.”

Panelist Paul Balzer: Paul started his career with BWC in 2010 while a student at The Ohio State University. Following his internship, he joined BWC full-time as a criminal investigator with health care provider team (HCPT) in December 2011. On October 7, 2012, Paul was promoted to special agent with the HCPT. On Nov. 28, 2016, he was promoted to fraud analyst with the intelligence unit, a team supervised by a former SID college intern, special agent in charge Eric Brown.

As an experienced panelist who has already earned multiple promotions, Paul offered the following recollections and insights:

“I had no idea what this agency did or that it even existed. But the synopsis I read about the internship combined all three things I had wanted to do – work in health care, computer science and criminology. In my current position, I want to continue to make an impact. There are a lot of challenges in the criminal justice system, but we can still make an impact and improve the lives of others. I hope we continue to use critical resources in the most efficient manner possible to stop fraud, because fraud just drives up costs for the entire system.”

Reasons for Ongoing Success: The SID college relations program has been successful in hiring interns with a variety of backgrounds, majors and career goals who quickly become vital assets to BWC’s efforts to fight workers’ compensation fraud. We solicit and heed feedback from our interns to continually improve our program.

The Future: If you know of any students that would be a great fit in our program, please encourage them to submit an application via our Future Opportunities posting. We have an intern position that we are looking to fill right now and we are using the Future Opportunities posting to select our applications. Additionally, we have the specific intern positions posted:

Suspect fraud? Call our Fraud Hotline!

By Jeff Baker, Program Administrator, BWC Special Investigations Department

In recognition of International Fraud Awareness Week 2017, we are increasing awareness of fraud and the vigilance of everyday citizens to report suspected fraud committed against the Ohio workers’ compensation system.

A suspicion can be reported online, by email to our secure BWC Allegations@bwc.state.oh.us account, U.S. Postal Service or by calling our Fraud Hotline at 1-800-644-6292. Calling the BWC Fraud Hotline is the most interactive and direct way that you, our partners in fraud prevention and detection, can help.

We realize that such partnerships are necessary to achieve our fraud prevention goals. Since the creation of our Special Investigations Department (SID) in 1993, thousands of our closed, founded cases started with a call to our Fraud Hotline. For example, the conviction of Tim Tokles on August 30, 2017 was the result of just such a call.

You may suspect someone is working while receiving compensation, filed a false claim for an injury that did not happen or is committing another type of workers’ compensation fraud. Calling a fraud hotline may seem rather intimidating. We understand that it can be a nerve-wracking decision to make the call. The person you suspect of fraud could be a friend, a loved-one or even an immediate family member.

Above all, we realize the importance of personal security and safety to each caller.

When you call the SID Fraud Hotline, you will speak with a real person on the other end, one who is ready and willing to listen to your concerns and has years of investigative knowledge, skills and experience securing the essential information from sources like you. Whether your fraud hotline agent is Jake, Taylor, Karen, Connor, Jeff, or any of eight of our most experienced fraud analysts assigned to special investigations unit (SIUs) statewide, you will know within seconds that you have reached a committed, successful professional.

Your fraud hotline agent will know and promptly secure the information needed by our teams of 125 SID employees. Your identity will remain either anonymous or confidential, depending upon your preference. You do not need to have proven any facts; you do not even need to have 100 percent confidence in your suspicion. You need only to suspect that fraud may have occurred or continue to occur. We will conduct the investigation and determine the facts.    

The entire process entails as few as five minutes. Nonetheless, collecting the right information from a caller requires our SID Fraud Hotline professionals to devote as much time as the caller’s unique allegation merits.

When calling, please provide the information you have, including:

  • The name and address (if known) of the subject you’re reporting;
  • A description of the suspect’s behavior; and
  • Any other information that might pertain to the suspected fraudulent activity.

It is through the vigilance of citizens like you, that we are combatting workers’ compensation fraud in Ohio.

In pursuit of fairness – #FraudWeek 2017

By Jim Wernecke, Director, BWC Special Investigations Department

I have always appreciated the importance of fairness and integrity. I have used these virtues as a guide throughout my career, from early on when I supervised 15 employees at a small manufacturing company, to my 25 years with the Ohio State Highway Patrol and now as head of the Ohio Bureau of Workers’ Compensation’s Special Investigations Department.

I am privileged to lead 122 professionals who work to deter, detect and investigate workers’ compensation fraud in the state of Ohio. We pursue cases of claimant, medical provider and employer fraud.

What drives a claimant to file a false claim; an employer to purposely misclassify their workers; or a physician to fudge paperwork to secure higher service payments? We can debate the reasons, and they probably vary in each case, but my drive to halt wrongdoing comes from an appreciation for standards, rules and enforcement of the law that are conducted uniformly, fairly and systematically. In short, I want to know that others are following the same rules you and I follow.

It is easy to translate this philosophy into the world of workers’ compensation when you think about employer premiums, medical services and protection of our injured workers. Injured workers deserve a fair system that’s focused on their care and recovery. Employers want their competitors to play by the same rules, and they want assurance that any employee who attempts to gain undeserved benefits will be held accountable. And we all want truthful and professional physicians delivering our medical care.

These are among the many reasons I count fairness and integrity among the most important qualities you’ll find in a person. Treat people fairly, and treat them the way you want to be treated. Our integrity is on the line when we don’t accept the responsibility and tell the truth. Once trust is lost, it’s likely gone forever. I’m sure many of you feel the same.

We take great care to protect the dollars Ohio employers set aside to care for their injured workers. We’re not too shy to say we think we do a pretty good job, but we’re always seeking improvement. That’s why we enjoy taking part in International Fraud Awareness Week each year. We’re not only able to highlight our successes, but also engage and learn from our fraud-fighting peers across the country. This year will be no different.

Those of you who follow workers’ comp fraud in Ohio know we share our fraud news weekly on “Fraud Friday,” but we always take it to another level during IFAW. Please join us this week and all year long as we share new cases, tips for identifying and preventing fraud, insights from our investigators, and much more on our Facebook and Twitter pages.

Happy Fraud Awareness Week!

Make your business a falls-free zone!

September is Falls Prevention Awareness Month

Submitted by STEADY U Ohio, an initiative of the Ohio Department of Aging

Older adults probably play an important role in the success of your business, both as consumers and employees. That is, until they fall down.

One in three older adults will fall this year. Every five minutes, an older Ohioan is injured in a fall. When staff or customers fall in your business, it doesn’t just hurt them; it also hurts your reputation and your bottom line. A single fall can affect an older adult’s ability to remain independent and contribute to your continuing success.

Most falls in businesses can be prevented, and prevention can be achieved largely through staff and customer education and motivation. The STEADY U Ohio initiative is ready to help businesses create a safer environment for older adults and Ohioans of all ages who do business with them. Here are a few steps every business should take to prevent falls:

  • Create a falls prevention policy for your business and make sure your employees know and understand it.
  • Routinely identify issues with flooring, stairs, lighting and housekeeping that could cause accidents.
  • Post signs at your entrance and around the business advising customers to notify staff of slipping or tripping hazards.
  • Ensure that walkways are clean and clear of cords and obstructions. If you must use rugs or mats, ensure that they remain flat and that they do not move under foot.
  • Ensure that people can move freely around displays in the aisles without adjusting their gait. Avoid displays at the end of aisles that obscure a customer’s view of other customers and obstacles.
  • Have staff regularly monitor aisles for items that have fallen off shelves and are blocking.
  • Quickly clean up all spills (dry and wet). Provide supplies (i.e., towels, “wet floor” signs, trash cans) in convenient locations around your business.
  • Provide seating around your business, particularly in areas where customers may have to wait during busy times (e.g., near checkout lines, the service desk, the pharmacy, restrooms and exits).
  • When it’s snowy or icy, extend sales or offer shopping options for older customers (e.g., delivery or rain checks by phone) so they don’t have to risk falling to get a good deal.
  • Educate staff on proper lifting and carrying techniques and equipment, and instruct them to help customers carry large or bulky objects and bags.
  • If someone falls, document the incident and examine the cause so that you can prevent future accidents. Use our incident report template to get started.
  • Empower staff to offer assistance to customers who appear to be having trouble getting around.

Find tools to help your business prevent falls at our website, www.steadyu.ohio.gov. Resources include a sample falls prevention policy, a hazard checklist, an incident report template, tip sheets and a falls risk self-assessment. Educate yourself, your staff and your consumers, and make your business a falls-free zone!

Have you ever wondered how BWC calculates your workers’ compensation insurance premium rate?

By Christopher S. Carlson, FCAS, MAAA, BWC Chief Actuarial Officer

It all comes down to an equation:

     Modified premium rate
+   Administrative cost rate
+   Disabled Workers’ Relief Funds assessments
=   Blended insurance rate per $100 of payroll

With the definitions in the sidebar as reference, let’s break down the formula:

All employers have a base rate determined by their manual classifications.

Larger businesses also have an experience modifier, a projection of expected future claims costs (based on past claims experience).

Multiplying the base rate and experience modifier (if you have one) results in the modified premium rate (MPR).

BWC factors in an administrative cost rate, used to run BWC and the Industrial Commission, and then adds assessments for two Disabled Workers’ Relief Funds that provide cost of living increases for disabled workers.

The result is your blended premium rate, the amount you pay per $100 of payroll

So there you have it, a quick lesson in BWC Premium Rate Development 101. This YouTube video provides even more detail on how BWC calculates your Ohio workers’ compensation premiums.

Remember, the best way to keep premiums low is to provide a safe workplace. Safer workplaces reduce accidents, reduce costs, and in the end, reduce your premiums.