4123.511(K); R.C. 2913.48
Percy, Chief of Operational Policy, Analytics & Compliance
policies and procedures regarding fraud and special investigations that
predate the effective date of this policy
purpose of this policy is to ensure that allegations of workers’ compensation fraud
are investigated, and when appropriate, prosecuted, and that any funds due to
BWC are recovered by any and all legal means, including, but not limited to,
establishing payment plans and filing liens.
policy applies to all BWC staff.
A company without active business operations or significant assets. Shell
companies are not necessarily illegal or illegitimate when utilized for
potential startup companies. Used illegally, shell companies may be utilized to
avoid paying taxes, workers’ compensation premiums and unemployment benefits
for a legitimate or illegitimate business, or to run false claims through the
system to gain workers’ compensation benefits.
Investigations Department (SID): The BWC division comprised of teams
dedicated to the prevention, detection, investigation, and prosecution of
workers’ compensation fraud.
Special Investigations Unit (SIU): A team
within the SID, located in BWC Claims Service Offices, that
investigates allegations of fraudulent behavior committed by injured workers,
health care providers, employers, and attorneys.
A criminal offense per O.R.C. 2913.48, that states that no person with purpose
to defraud or knowing that the person is facilitating a fraud shall do any of
A. Receive workers’
compensation benefits to which the person is not entitled;
B. Make, present,
or cause to be made or presented a false or misleading statement, with the
purpose to secure payment for goods or services, or to receive benefits from
C. Alter, falsify,
destroy, conceal, or remove any record or document that is necessary to fully
establish the validity of any claim filed with BWC or a self-insuring employer,
or necessary to establish the validity of goods and services for which
reimbursement or payment was received or is requested from BWC or a
D. Enter into an
agreement or conspiracy to defraud BWC or a self-insuring employer by making or
presenting, or causing to be made or presented a false claim for workers’
E. Make or present,
or cause to be made or presented, a false statement concerning information
necessary to determine the actual workers’ compensation premium or assessment
owed to BWC by an employer;
F. Alter, forge, or
create a workers’ compensation certificate to falsely show current or correct
workers’ compensation coverage;
G. Fail to secure
or maintain workers’ compensation coverage as required by O.R.C. 4123, with the
intent to defraud BWC.
It is the policy of BWC and the Special Investigations Department
to aggressively pursue cases of workers’ compensation claims fraud, medical
provider fraud, and premium fraud, and to declare overpayments, identify savings,
disallow claims, pursue prosecutions and recover dollars in order to improve the
effectiveness of BWC operations and decrease premium costs.