Presented by:Shawn Miller, Fraud Analyst

Investigative Staff Statewide23 Fraud Analysts55 Special Agents

Safety Violations Investigative UnitIntelligence Unit

Digital Forensics Unit

BWC Security Services

Special Investigations Unit (SIU)

Health Care Fraud Team

Employer Fraud Team

Claimant Fraud

Working while receiving benefits: TT, PTD, LM, NWWL

Physical activity: Activity that is inconsistent with medical reports. Using deceptive behavior during medical appointments to deceive physicians

False Claims: No real injury, mechanism of injury inconsistent

Drug Deception: selling narcotics, using deceptive means to obtain narcotics from various providers

Claimant Fraud

Allegations come from multiple sources

Claimant Fraud - Allegations

Allegations come in many forms

Founded

Administrative Criminal

Referral to AG

Referral to IC

Claimant Fraud

Workers Compensation Fraud

ORC 2913.48 – Workers’ Compensation Fraud

A) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall

1. Receive workers’ compensation benefits to which the person is not entitled

2. Make or present a false or misleading statement with the purpose to secure payment

3. Alter, falsify, destroy, conceal, or remove any record or document necessary to validate a claim

4. Enter into an agreement or conspiracy to defraud the bureau or a self-insuring employer by filing a false claim

Excessive use or misuse of workers’ compensation benefits.

Abuse cannot be criminally prosecuted under the law.

Dealt with by effective case/claims management and civil/administrative remedies.

AbuseOvert Act (misrepresentation)

Intentional omission

Requires “knowledge and intent”

Punishable by law

Fraud

Fraud vs. Abuse

How do we prove intent?

Documents

Witness statements

IW statements

Intent Documents

•FROI•Warrants/Direct-Deposit forms•TT Entitlement Letters •C84 application

Intent Documents

•FROI (first report of injury)

•Warrants

•TT Entitlement Letters

•C-84 application

•PTD contact letters

Intent Documents

•FROI

•Warrants

•TT Entitlement Letters

•C-84 application

•PTD contact letterss

Intent Documents

•FROI

•Warrants

•TT Entitlement Letters

•C-84 application

•PTD contact letterss

Self-Insured vs. State Fund

Things to Consider:

Add warning language to:compensation checks, direct deposit forms, etc.

Draft & Implement new forms:TT letter, contact letter, acknowledgement form, etc.

Case Study - Allegation

ALLEGATION

An allegation was received that reported MIECZKOWSKIwas involved in physical activity outside of her medicalrestrictions and was possibly working while receiving BWCdisability benefits.

Case Study – review of medical

“intolerable pain, can’t walk, need elevated foot, tingling, sharp pain”

“She states she is worse. The pain is radiating up into her hip. . . Pain level is 11/10 today.”

“Per IW it is hard for her to walk without a lot of pain, so she has to walk on her right heel. . . Not able to walk on forefoot at this point. Using a cane for steadiness.”

“Per IW nothing has changed with her right foot pain. She states that she still cannot walk with her foot has to walk on heel.”

“When I even get close to trying to touch her foot, she is very resistant to this because she knows it will cause pain.”

“. . .she stated she is unable to put her foot down on the floor as there is jarring sensation with tingling and severe dysesthesias in the foot, ankle and now into the leg. . .As a result of these symptoms, she is unable to attend to her day-to-day duties. Her pain is graded at a 10/10 in intensity. She states that her pain is constant 8/10, it is continuous, coughing increases it, touching, wind air, water, pressure, shoes, cold everything hurts, nothing gives her relief.”

“unable to put weight on her right leg, her gait was very slow, and she used a cane. It was noted that without a sock, she was unable to put her right foot on the ground”

Case Study - Surveillance

Case Study – Witness Interviews

Willoughby stated that she had never seen MIECZKOWSKI use a cane or crutches. Both classes met for 3 hours, 5 days per week and

consisted of a 30 minute lecture and a 2 ½ hour lab.

Gussett indicated the class met for 15 minute of lecture and a 2 hour, 45 minute lab, 5 days per week. Gussett stated that he never witnessed

MIECZKOWSKI using a cane, crutches, or wearing a boot to aid her standing or walking.

Case Study – Physician Interviews

Dr. Steiman stated that based on the school records and video, it appeared MIECZKOWSKI deceived him during her IME exam. He specifically pointed out in the exam report the "Activities of Daily Living Assessment" wherein he had noted MIECZKOWSKI reported needing assistance to perform activities such as

standing, walking, climbing stairs, carrying groceries, and ironically, preparing meals. Dr. Steiman stated he could no longer believe what MIECZKOWSKI had

reported in regards to her daily living limitations.

Dr. Bridger stated he did not know MIECZKOWSKI was attending the Culinary Institute; nor did he know that she was able to perform the activities captured on the

video. Dr. Bridger stated it was his understanding, based on visits with and statements made by MIECZKOWSKI; that she had to use a cane or a walking

boot for ambulation……he would not have certified the C84/Medco-14 forms dated between 10-26-2012 and 06-28-2013

Case Study – Industrial Commission

Administrative Savings:

TT Overpayment: $6,252TT Reserve Savings: $40,000

Vacated RSD Savings: $139,908

Total Savings: $186,160

Case Study – Criminal Conviction

Brooklynn MieczkowskiPlead Guilty Workers’ Compensation FraudMisdemeanor of the 1st degree

Sentenced to 60 days jail; suspended and ordered to repay $6,252 in restitution and $4,000 in investigative costs.

ACTIVITIES OF DAILY LIVING:

• Grocery shopping• Driving • Laundry• Mowing the yard• Lifting up and carrying children• Gardening• House cleaning

Physical Activity

Founded

Civil Criminal

Referral to AG

Referral to IC

Investigation Process

SI

PITFALLS

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Shawn Miller, Fraud Analyst(614) 752-5834Shawn.Miller@ohiobwc.com

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