Workers' Compensation Fraud

Every year millions of dollars are paid in falsified workers' compensation claims in Ohio. These fraudulent benefits paid out ultimately effect all employers, injured workers and the general public, in terms of hidden costs. Fraud is defined as an intentional act or serious of actions resulting in payments or benefits to a person or group that is not entitled to the payments or benefits. Fraud is committed when one or more of the following happens:

• A person receives knowingly benefits that he/she is not entitled to by law
• A person makes false and/or misleading statements with the intention of receiving money and/or services
• A person is involved in a plan to defraud the Ohio State Insurance Fund or Self-Insuring Employers under the Workers' Compensation Act

Workers' Compensation fraud can be committed by Injured Workers, Healthcare Providers and Employers. Below are Red Flag Indicators that can help in spotting potentially fraudulent activity.

Red Flag Indicators

Injured Worker Fraud

• Excessive cross-outs, white-outs and erasures on documents
• Injured Worker is difficult to contact. He/She is never home or is said to be sleeping or unavailable when others answer the phone.
• Evidence that the Injured Worker has been working or engaging in strenuous activities. (ie: calluses on hands, grease under fingernails)
• Injured Worker moves out of state shortly after the claim is filed.
• The accident/injury occurs just before completion of job, termination, plant closing or relocation, layoff or strike.
• Injured Worker is not cooperative with scheduling and/or attending diagnostic procedures to confirm injury.
• Injury is not consistent with nature of business.
• Date, time and place of incident is unknown
• Injured Worker cannot recall specific details regarding the incident.
• There are no witnesses to the incident.
• Co-workers have suggested that the incident is false.

Healthcare Provider Fraud

• There are much higher healthcare costs than expected for the allowed injury.
• Frequency and/or duration of treatments are greater than expected for allowed injury. (especially for older, non-catastrophic, injury)
• There is frequent billing in older (non-catastrophic) claims
• Provider submits bills for a large volume of prescription drugs for the type of injury allowed.
• The same Doctors and Attorneys are continually associated with questionable claims.
• Providers billing and payment levels suddenly increase.
• Provider bills date-of-service are questionable and/or inconsistent. (ie: weekends, holidays, effective dates)
• The medical documentation does not support or is inconsistent with the services billed. There are significant delays in recieving records to support the bills.
• Billed procedures are conflicting with allowed conditions or industrial conditions.
• Billed procedures are for evaluation and management codes only
• Multiple claims are being billed for one Injured Worker.
• There are bills for services that have likely not been preformed.

Spotting Employer Fraud

• Business's Certificate of Coverage contains inaccurate data
• Excessive cross-outs, white-outs and erasures on documents
• Business name and type of work being preformed are conflicting.
• Business's number or employee, classifications and payroll are inconsistent.
• The business is new and has multiple state exposures.
• Business paid a large deposit premium to avoid interim audits.
• Business requires new employees to complete 1099 forms to assert themselves as independent contractors.
• Business engages in under-reporting of payroll.
• Principal business location is a PO Box, suite or room number.

If you suspect fraud, submit a Fraud Allegations Form, or call the fraud hotline at 1-800-OHIOBWC.