The ongoing efforts of the Ohio Bureau of Workers’ Compensation (BWC) to detect, investigate and prosecute fraud are paying off. The agency's most recent report to its board of directors reveals that its Special Investigations Department (SID) identified more than $55 million in savings for the state insurance fund for the fiscal year ending June 30, 2013.
According to Jennifer Saunders, the interim director of SID, the department closed more than 2,000 cases involving claimants, employers and medical providers last year. As Saunders explained to the committee, this included 140 criminal convictions and 236 referrals for prosecution. Additionally, an administrative review of 915 cases either uncovered fraudulent activity, or identified additional savings for Ohio employers paying into the state fund.
The department has organized strategic teams, each focusing on investigating a specific type of workers' compensation fraud. Their results are listed below:
- The employer fraud team, which investigates fraud committed by employers, closed 226 cases, generating $3,535,468 in savings. The team achieved 43 indictments and 33 convictions during FY 2013.
- Regional claimant fraud teams closed 1,353 cases, and identified $30,179,976 in savings. These teams secured 100 convictions, or 23.5 percent more than the 81 claimant subject convictions secured during FY 2012.
- The Health Care Provider Team, which investigates fraud committed by providers, pharmacies, and managed care organizations, closed 68 cases, or 83 percent more than in the previous year. The team identified $11,874,978 in savings to the workers’ compensation system and secured seven convictions.
Like other states, Ohio contends with rising prescription drug costs and related crimes. In response, it employs significant resources to combat prescription fraud. In 2013, the Ohio BWC's Intelligence Unit requested drug utilization reviews in cases where there was a question as to whether BWC-paid prescriptions were medically necessary. Those reviews resulted in the termination of drugs in 171 cases where the prescriptions were not necessary, generating $9,467,735 in savings. Drug complaints represented 22.8 percent of all complaints investigated by SID, second only to working while receiving benefits, which represented 28.9 percent of all complaints investigated during the last 12 months.
Following the report, Rick Gregory was appointed Director of BWC’s SID. Gregory most recently served as the Chief of Police in Provo, Utah and then formerly for the Florida Highway Patrol for more than 20 years.