OhioBWC - Basics: Fraud and Workers’ Compensation
Fraud and workers compensation
Workers Compensation fraud costs all of us!
Fraud is a hidden cost of workers' compensation insurance that impacts claimants, employers and the general public.
Claimants, employers and health-care providers can commit fraud, which is defined as an intentional act or series of acts resulting in payments or benefits
to a person or entity not entitled to receive those payments or benefits.
What does the law state about fraud?
Per ORC 2913.48, a person commits workers' compensation fraud when he or she:
BWC is serious about deterring, detecting and investigating workers' compensation fraud
- Receives workers' compensation benefits to which he or she is not entitled;
- Makes false or misleading statements with the purpose of securing goods or services under the Workers' Compensation Act;
- Alters, falsifies, destroys, conceals or removes records or documents necessary to establish the validity of a claim, or necessary to
establish the nature of goods and services for which reimbursement is requested in a claim;
- Enters into an agreement for conspiracy to defraud the BWC or a self-insuring employer by making false claims for disability benefits.
To protect claimants' benefits and keep employers' premiums down, BWC is aggressively attacking fraud. The BWC special investigations department is
committed to effectively and proactively preventing losses to the workers' compensation system by deterring, detecting, investigating and referring
fraud cases for prosecution.
From the inception of our fraud program in July 1993, through June 2015, the BWC's special investigations department achieved the following performance results:
Red flags to spot fraud
- Researched 114,538 allegations;
- Completed 62,465 investigations;
- Closed 25,534 founded cases;
- Identified $1.6 billion in savings;
- Identified $26,478 per closed case;
- Referred 4,672 subjects for prosecution;
- Secured 2,429 criminal convictions.
A red flag is a warning or a sense that something isn’t right and leads one to take a closer look. The lists below will help you to identify likely
fraudulent behaviors. Identification of any one of the following red flags does not mean that fraud exists. However, to submit a fraud allegation
to BWC, you need only have a suspicion that fraud may have been committed. Experienced investigative experts at BWC will carefully collect and
analyze the facts to determine whether fraud was committed.
Spotting claimant fraud
Spotting employer fraud
- Individuals never available to answer calls at home or have limited availability for exams and/or appointments
- Individuals who perform seasonal work that is about to end when they file a claim
- Individuals who are on disability compensation engage in physical activities inconsistent with the limitations they claim to have due to their injury
- Individuals who collect BWC total disability compensation benefits while working
- Individuals who divert their prescribed narcotics to others or deceive medical providers to obtain multiple prescriptions
Spotting health-care provider fraud
- Suspicion that a competitor can underbid contracts due to not paying for workers' compensation coverage
- Certificate of BWC coverage not visible or contains an outdated coverage period and/or incorrect name of the BWC Administrator
- Employer misreports the amount of payroll or shifts payroll to lower cost jobs to avoid paying its fair share
- Employer misclassifies employees as independent contractors/subcontractors
- Medical providers perform medically unnecessary treatments or diagnostics tests.
- Medical providers bill for services not provided or bill for more expensive procedures than were actually performed.
- An unlicensed medical provider bills for services.
- Medical providers give limited or no medical treatment while heavily furnishing prescriptions for narcotics.
If you suspect workers' compensation fraud, submit a Fraud Allegation Form or call 1-800-644-6292, and follow the options.
Whether you submit the online form or call the fraud hotline, we will ask you to confidentially provide all of the information you have pertaining to
the suspected fraud, including the following:
- Name and address of the person you suspect is committing fraud;
- Details about the improper or fraudulent activity you suspect;
- Other general information pertaining to the suspected fraudulent activity.