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OhioBWC - Basics: (Policy library) - File

Fraud policy

Policy Name:

Fraud/Special Investigations

Policy #:

CP-06-01

Code/Rule Reference:

R.C. 4123.511(K); R.C. 2913.48

Effective Date:

11/28/12

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance

Origin:

Claims Policy

Supersedes:

All policies and procedures regarding fraud and special investigations that predate the effective date of this policy

History:

New 11/28/12

Review date:

11/28/17

 

 

I. POLICY PURPOSE

 

The 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.

 

II. APPLICABILITY

 

This policy applies to all BWC staff.

 

III. DEFINITIONS

 

Shell Company: 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.

 

Special 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.

 

Workers’ compensation fraud: 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 the following:

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 BWC;

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 self-insuring employer;

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’ compensation benefits;

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.

 

IV. POLICY

 

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.

 


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