Ohio Bureau of Workers Compensation (BWC) Administrator/CEO Steve Buehrer recently announced seven individuals were convicted of or pleaded guilty to charges related to defrauding Ohio's workers comp system during a 30-day period. The court actions are the result of investigations conducted by BWC's Special Investigations Department (SID), which works to deter, detect, investigate, and prosecute workers comp fraud.
The following is a sampling of cases that resulted in a guilty plea or a conviction.
Nancy Madewell, dba Bagel Cafe Inc. (Kettering, Montgomery County), pleaded guilty to three counts of failure to comply for operating her business without workers comp coverage. Numerous attempts were made by BWC's Employer Compliance Department to bring Madewell into compliance, but she continued to operate without proper workers comp coverage. Madewell failed to appear for trial and a warrant was issued. She then reported to Kettering Municipal Court in response to the warrant and entered a guilty plea. Madewell was sentenced to 60 days in jail suspended on the condition of not violating her three-year, unsupervised probation. [WCx]
Jose Ramirez (Cleveland, Cuyahoga County) was sentenced to one felony count of workers comp fraud for working while receiving benefits. SID opened an investigation after receiving an allegation that Ramirez was working on cars in his driveway. The investigation found that Ramirez was working for a transmission repair service while receiving temporary total disability benefits. Ramirez conducted various tasks, such as, sweeping the floors, cleaning the shop, delivering parts to customers, picking up parts from suppliers, supervising/assisting other mechanics with repairs, and driving business tow trucks to pick up vehicles. Ramirez worked up to four days per week and was paid in cash. Ramirez pleaded guilty in Franklin County Common Pleas Court and was convicted.
Mitchell Oakley (Harrod, Allen County) pleaded guilty to one count of workers comp fraud for filing a false claim. Oakley filed a claim indicating he was injured on his first day of work for an employer. However, SID found that Oakley was actually injured moving boxes at home prior to his employment. He was sentenced in Lima Municipal Court to 30 days suspended and must repay $150 in court costs.
Victoria Hall (Toledo, Lucas County) was sentenced to a felony count of workers comp fraud for working while receiving benefits. SID investigators obtained undercover surveillance video showing her working at a convenience store while receiving temporary total disability benefits. Hall was previously injured at the same gas station and returned to work there after the gas station was under a different name and owner. Hall admitted to wrongdoing during an interview and pleaded guilty. Hall was sentenced to three years of community control and ordered to pay restitution in the amount of $7,754.97 and investigative costs of $1,000. The conditions of her community control are to pay the restitution and maintain employment. If Hall violates her probation, the judge stated that he will send her to jail for a term of 12 months.
Nancy Palmer (Cleveland, Cuyahoga County) was sentenced on a felony count of workers comp fraud for working while receiving benefits. SID received an allegation that Palmer had been working at a local veterinary hospital. Investigators found she had returned to work as a veterinary assistant while receiving temporary total disability benefits. She was performing duties such as office work, assisting during surgeries, cleaning and taking care of animals. It was also found that Palmer was working as a telephone solicitor for a local charity. Palmer entered a guilty plea and the judge ordered her to pay $7,457.72 in restitution and $1,000 for investigative costs. She was also sentenced to seven months in prison suspended, for 18 months of community control. [WCx]
Randall Schornack (Austintown, Mahoning County) was sentenced on a felony count of workers comp fraud for working while receiving benefits. SID received an anonymous tip on the fraud hotline that Schornack was working as a disc jockey at area bars under the name "DJ Randy Stevens." SID's investigation determined that Schornack was working as a DJ for several bars in Mayfield and also for a professional DJ service in Girard while receiving temporary total disability benefits. The SID obtained video of Schornack unloading and carrying speakers and other equipment from his vehicle into different establishments on a weekly basis and performing work services as a DJ. Schornack was ordered to pay $27,202.62 in restitution He was also sentenced to 18 months in prison suspended, for five years of community control.
Information from Ohio BWC
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
From time to time employers are confronted with the dilemma of how to deal with a small, but fraudulent, workers compensation claim. The employer knows the claim is fraudulent. However the cost of contesting the claim, and the extra time that will be required of the risk manager or workers comp coordinator, makes it seem like a good idea to let the employee ‘get away with it’. Why spend $5,000 in legal fees on the workers comp claim, complete the investigation needed to defeat the claim, and risk a wrongful discharge claim, when the employee will be back at work in a couple of weeks?
If the ‘little fraud” is not contested, there will undoubtedly be more little frauds. And as the word spreads that the employer is an easy mark, employees will push the envelope with larger fraudulent claims. When the employer lets the minor, clearly fraudulent claim run its course, the other employees notice what is occurring. [WCx]
The workplace grapevine quickly shares the news that ‘good ole Joe’ is going to claim he hurt his back, so he can take his family on that extended vacation that he has promised them for years. When everyone in the shop knows that he is going to make a fraudulent workers comp claim, they all watch to see what develops. ‘Good ole Joe’s’ bogus workers comp claim is often the subject of discussion at lunch, or during breaks. The employees will wait and see if he gets away with it. When Joe stays off work for a month then returns to the job like nothing has happened, the dishonest employees may also plan “vacation on comp.”
The honest employees will continue to be honest, regardless of whether or not some co-workers get away with fraud. But, the favorable impression of the employer is diminished, as the employer should have done more to prevent the fraud. Plus, when the fraudulent employee gets light duty or a cushy job, while the honest employees have to pick up the fraudulent employee’s heavier tasks, resentment builds. This is not just towards bogus ‘good ole Joe’, but also at the employer for giving the honest employees an unfair share of the work. Morale declines among all the honest and good employees.
While management may be frustrated by a bogus workers comp claim, when nothing is done about it, the employees do not perceive it that way. The impression the employees will get is that management does not care about a little time off on comp. And, most employees think that workers' compensation is paid for by the insurance company, not their employer. Besides it is the big, rich insurance company that is paying for it, not the employer (in the mind of the dishonest employee). Hence, since management will turn a blind eye to the fraud, the discontents, the gripers, the poor performers and the troublemakers all see this as a turn to get something for nothing. The number of bogus claims then increases.
Many of the bogus claims will run a course in a month or two. However, for some employees the bogus claim is the solution to a long-term ailment. The pre-existing slip disc in the neck, or the torn knee ligament, can now be paid for by workers compensation. The employees saw that management took no action on ‘good ole Joe’s” claim; therefore, management does not care if the employees “fudge” a little bit, and claim the medical problem is related to work, when it is not.
The employee who turns in the bogus claim for a major medical problem does not think about the cost differential between his workers comp claim and ‘good ole Joe’ who just took some paid time off. Also, the bogus employee may be a little concerned that he will get caught in the fraud. The employee committing fraud is much more likely than the honest employee with a legitimate injury to hide behind the curtain of protection of a personal injury lawyer (who does not care if the workers compensation claim is bogus, as long as he gets his fee).
The culture of fraud will grow from the minor claims to major claims, plus the number of bogus workers compensation claims will increase significantly, all because management allowed “a little fraud” to save the cost of fighting it. [WCx]
The employer can prevent the bogus / fraudulent claims from spiraling out of control. The employees should know that every workers compensation claim is investigated thoroughly, and all questionable claims are vigorously defended. In addition, any proven case of fraud should be turned over to local law enforcement for prosecution. Every employee should know that the employer pays for all workers comp claims through the insurance premium, and that bogus claims are theft from the company. A culture where every legitimate claim gets prompt medical care and every questionable claim is contested will go a long ways toward preventing the ‘it is only a little fraud’ mentality.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
The Florida Department of Financial Services Division of Insurance Fraud reports that it has charged an Orlando man with workers compensation fraud and grand theft after an investigation claimed he fraudulently collected more than $115,000 in benefits.
According to the office of Florida Chief Financial Officer Jeff Atwater, Keith Jackson falsely reported that his injuries took place at the time of his employment as an Orange County corrections officer. Jackson could receive up to 30 years in prison if convicted.
“It is one of my missions as your CFO to root out fraud of all types,” CFO Atwater commented in a statement. “Those who are looking to game the system are ultimately putting the financial burden on all of Florida’s consumers. If you bilk the system, we will find you and put you behind bars.”
Atwater’s office reports that Jackson had claimed to have injured his back and foot while taking part in defense tactics training as an Orange County corrections officer.
“Jackson’s claim was initially deemed compensable; however, it was determined that Jackson made false statements and omitted material information about his medical conditions,” Atwater’s office reported. [WCx]
Anyone with information regarding suspected insurance fraud is asked to call 1-800-378-0445. Individuals who provide tips can remain anonymous and are eligible for a reward of up to $25,000 for information that directly leads to an arrest and conviction in an insurance fraud scheme.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
The fastest growing area of workers compensation fraud is narcotics abuse. The fake workers comp claim for the purpose of feeding a drug addiction, or for the purpose of obtaining narcotics for resale, is a fast growing problem. Employers and claim adjusters should proceed with caution when an employee has been given a narcotic prescription, especially when there has not been a recent surgery.
The term “pill mills” has been used by law enforcement to describe medical facilities where the primary purpose of the medical facility is to write prescriptions for painkillers. The U.S. Drug Enforcement Administration (DEA) has been raiding medical facilities in Florida, Georgia, Ohio and other states with mixed results. They close down one pill mill only to have another one pop up. (WCxKit)
Pill mills often try to camouflage the activity as pain management clinics. There is however some red flags that distinguish a pill mill operation from a legitimate pain management clinic. Included below are some characteristics of pill mills.
-The physician(s) have little training / background in pain management.
-The facility sees a high volume of patients daily.
-The facility provides scant patient examinations before prescribing narcotics.
-The facility both writes the prescription and fills the prescription.
-The facility writes prescriptions for amounts that exceed the manufacturer’s recommendation for maximum usage.
-The price of the prescription is inflated over what the same dosage would cost at a chain drug store.
-The facility operates on a cash-only basis.
-The patients often travel long distances to the facility, even from out of state.
-The facility is often located near an interstate highway for convenience of patients traveling long distances.
-The facility advertises its “services” on Craigslist or other similar Internet sites.
The abuse of narcotics has gotten so bad that, per the Associated Press, drug overdose deaths have surpassed traffic accidents as the top cause of accidental death in Ohio, Colorado, Massachusetts, New York, Oregon and 11 other states. According to the Center for Disease Control, 20,000 people a year die from prescription drug overdose.
Pill mills like the Greater Medical Advance Clinic in Wheelersburg, Ohio are at the center of this epidemic. According to the arrest documents, the clinic owner, George Marshall Adkins, wore a handgun in the clinic while dispensing tens of thousands of painkillers at inflated prices.
Employers in Florida should be especially cautious of prescription drug abuse on the workers compensation claims. According to Florida state officials, 85% of all oxycodone pills sold in the United States come from Florida, with the top 50 medical prescribers of such drugs being located in Florida.
Carlos Gonzales in South Florida was arrested for his black market business of selling narcotics. Gonzales was not an ordinary street level drug dealer. He was a doctor operating a “pain management center” with numerous workers compensation patients. He lived in a multi-million dollar home with a Mercedes, a Bentley and a Lamborghini parked in the driveway. The DEA estimated he was making from $13,000 to $20,000 a week writing thousands of prescriptions.
There are steps an employer can take to stop workers comp fraud / drug abuse through pill mills. Among the ways the employer can fight workers comp fraud / drug abuse include
-Operate a drug free workplace – if the employees knows that drug testing for hiring and random drug testing is performed, the employees inclined to abuse drugs (and to file bogus workers comp claims to obtain drugs) will go somewhere else to work until they pull the workers comp fraud.
-Drug screen after each injury – a drug screen on the day of the injury should be a part of the immediate medical treatment. In many states a failed drug screen can be grounds for the denial of the workers comp claim. In the states where the workers comp claim cannot be denied due to the failed drug screen, the employer will at least know what the employee’s drugs of choice are.
-In the states where the employer is allowed to select the medical provider, be sure to do so. Check the reputation of the medical provider with local defense counsel to eliminate doctors known for over prescribing medications or known for referring employees to questionable pain management clinics.
-Whenever pain becomes a significant part of the employee’s complaints following an injury, especially pain without visible trauma, a nurse case manager should be assigned to the claim to prevent narcotics abuse.
-All prescriptions for the injured employee should be filled through a pharmacy benefit manager (PBM). Any time the employee is exceeding the manufacturer’s recommended maximum dosage, the PBM can review the requested dosage with the medical provider. (WCxKit)
By taking the above steps, the employer can significantly reduce the number of bogus workers comp claims for the purpose of obtaining narcotics, either for drug abuse or for resale.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Texas Mutual Insurance Company reported recently that a Travis County district court sentenced Thomas Mikulenka of League City, Texas on workers compensation fraud-related charges.
The court sentenced Mikulenka to three years deferred adjudication and 100 hours of community service. Mikulenka was also ordered to pay $7,221 in restitution to Texas Mutual. (WCxKit)
Mikulenka reported a job-related injury while working as an electrician for IGC Construction, Inc. in Houston. He claimed he was unable to work as a result of the injury, and Texas Mutual began paying income benefits to him.
Meanwhile, Texas Mutual uncovered evidence that Mikulenka was working as a laborer while receiving income benefits.
Investigators call this type of scam double-dipping because claimants collect benefits for being too injured to work when, in fact, they are gainfully employed. Texas law requires claimants to contact their workers comp carrier when they return to work. (WCxKit)
Left unchecked, double-dipping and other workers comp fraud can lead to higher premiums for all Texas employers.
Maryland Woman Sentenced in Nevada Workers Comp Fraud Case
A Maryland woman has been sentenced to 2 ½ years in a Nevada state prison for attempting to defraud her employer’s workers compensation insurer of $20,000 while at a professional conference at the Las Vegas Hilton, according to Nevada Attorney General Catherine Cortez Masto’s office.
Tamara Thompson-Johnson, 45, was ordered to pay $20,000 in restitution, $4,000 in extradition costs and serve 2 ½ years in a Nevada prison after pleading guilty to making false statements to obtain workers comp benefits from her employer, officials say. (WCxKit)
According to officials, Thompson-Johnson claimed she was injured at the Las Vegas Hilton when a vase, dislodged by an intoxicated person, fell from its pedestal. Although she refused medical treatment at the scene, she reported to security that she had been struck by the vase and checked herself into a hospital.
The Nevada General Attorney’s office says Thompson-Johnson hired a lawyer and requested a claim for compensation from the Las Vegas Hilton. Her claim was turned down when surveillance footage of the incident surfaced showing that the vase narrowly missed Thompson-Johnson.
Although her lawyer ceased representing her Thompson-Johnson filed another claim through her employer’s workers comp carrier Travelers Insurance, claiming the vase hit her on the back of her head, neck and back, leaving her disabled. As a result she was paid $20,000 on her fraudulent claim.
According to the Nevada Attorney General’s office, Thompson-Johnson was extradited from Maryland when she did not appear for court hearings in Las Vegas.
She pleaded guilty to one felony count of making false statements or representations to garner benefits and was sentenced in November. (WCxKit)
Along with a 2 ½ year jail sentence, she was ordered to pay $20,435 in full restitution to Travelers Insurance, $4,005 in extradition costs and to reimburse the state $1,000 for costs in connection to the case and was ordered to disclose her conviction to present and future employers and insurers.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
A Corrections Officer from New York Mills is facing fraud charges after authorities say he wrongfully collected workers compensation benefits from the State, according to information from the New York State Police.
The police noted that Frank Caporale, 43, of New York Mills was charged with first-degree offering a false instrument for filing and fraudulent practices, both felonies.
Caporale, a New York State Corrections Officer at Midstate Correctional Facility, allegedly submitted written statements that contained materially false information to the New York State Insurance Fund as part of a claim for payment.
According to State Police, the statements indicated that Caporale was not employed, when he in fact was working a second job. As a result of these filings, the defendant did wrongfully collect $10,540 in workers comp benefits from the State Insurance Fund.
Caporale was subsequently given appearance tickets returnable in the Town of Marcy Justice Court.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Benjamin Lawsky, superintendent of the Financial Services, recently reported that 18 people in 13 New York counties have been arrested in the latest effort to save businesses money by cracking down on workers compensation fraud.
The arrests were the result of a series of joint investigations led by the Department of Financial Services (DFS). Joining DFS in the investigations were the Office of the Inspector General (OIG) of the New York State Workers Compensation Board, the New York State Insurance Fund (NYSIF) and other insurers. (WCxKit)
The 18 arrests included:
Albany County — Charles Foster, 48, of Hoosick Falls, collected $22,800 in benefits after hurting his leg when cutting down a tree while employed by the Village of Hoosick Falls in February 2010. However, investigators found that he was managing a storage facility and running a scrap metal business while collecting the benefits from NYSIF. He is charged with workers comp fraud.
Schenectady County — Lee Kittle, 49, of Scotia, collected $22,600 in compensation from NYSIF after suffering an injury while employed at a mill in 1993. He was found to be working at Schenectady County Community College as a tutor and the Saratoga Race Track as a teller. He gave authorities a written confession. He is charged with offering a false instrument for filing in the first degree and workers comp fraud.
Erie County – John Czechowski, 45, of West Seneca, collected $12,000 from NYSIF after he was classified as totally disabled for a back injury he suffered working as a roofer. However, investigators discovered he was working off the books for a contracting company while collecting the benefits. He is charged with third degree insurance fraud, grand larceny, offering a false instrument for filing and workers comp fraud.
Onondaga County — Kemberlei Senke, 44, of Liverpool, is accused of claimant fraud for collecting $26,000 in benefits issued by NYSIF between June 2009 and January 2011. She reported suffering a knee injury while employed by Artistry in Wood. The investigation disclosed that she falsified reports to the NYSIF to inflate her wages and employment status. She is charged with insurance fraud in the third degree, offering a false instrument for filing in the first degree and workers comp fraud.
Onondaga County — Cheryl LaQuay, 62, of Calcium, is accused of fraudulently collecting $53,000 in benefits from the NYSIF between Oct. 2006 and Sept. 2011, while working as a home health aide. She is charged with insurance fraud in the second degree, offering a false instrument for filing in the first degree and workers comp fraud.
Oneida County — Aaron McElhinney, 26, of Vernon, is accused of collecting $11,600 in benefits from Chartis Insurance Company after falsely reporting that he suffered a work-related injury. Investigators found that he told his girlfriend and her mother that he was going to fake the injury so he could go to Florida. Co-workers corroborated that he did not hurt himself. He is charged with insurance fraud in the third degree and workers comp fraud.
Oneida County — William Ellis, 43, of Utica, admitted working for a construction company from 2004 through 2007 doing roofing, siding, plumbing and masonry while collecting $15,000 in benefits from NYSIF for an injury he suffered while working for a paving and excavating company in 1993.
Oneida County – William O'Neil, 30, of Rome, is accused of collecting $1,790 in benefits from 21st Century North American Insurance Company while working for a moving company. He was collecting benefits after suffering an injury while working as a carpenter. He is also accused of giving false testimony at a workers compensation hearing and causing a false independent medical examination report to be prepared and filed as part of his claim. He is charged with perjury in the first degree and workers comp fraud.
Ulster County — Sergio Cortez, 37, of Rosendale, collected $6,800 in benefits from NYSIF after claiming he suffered a slip and fall injury while working as a carpenter for ABD Stratford LLC in September 2009. However, investigators found that he was working as a landscaper while collecting benefits. He is charged with insurance fraud in the third degree and workers comp fraud.
Ulster County — Willie Dixon, 47, of New Paltz, collected benefits from NYSIF for an injury he reportedly suffered while working for the New York State Office of Family and Children Services in May 2010. An investigation revealed he failed to disclose on work activity reports that he was employed as a coach while collecting $4,700 in benefits. He is charged with insurance fraud in the third degree and workers comp fraud.
Ulster County – James Roy, 51, Hyde Park, is accused of attempting to collect benefits after falsely reporting that he suffered a work-related injury while employed by a tool-making company. He claimed that the injury occurred when he slipped on ice in the company’s parking lot, but witnesses contradicted his claim. He never received compensation because his claim was discovered to be false before benefits were issued. He is charged with workers comp fraud.
Otsego County — Susan Gridley, 61, of Schuyler Lake, started collecting benefits after an injury she sustained while working at a horse farm in 1986. She later failed to disclose on work activity reports submitted to the NYSIF that she was working as horse boarder and trainer while collecting $4,700 in benefits.
Oswego County — Kimberly Harrington, 53, of Lacona, is accused of cashing her dead husband’s workers comp benefit checks totaling $2461.90. The checks were issued by the NYSIF. She is charged with grand larceny in the fourth degree.
Warren County — Jeffrey Hamblin, 45, of Glens Falls, reportedly suffered a knee injury while employed as a truck driver for HR Logic/Doberts Dairy in November 2001. An investigation revealed he was employed as a general contractor for Painters Plus and worked for a doctor while collecting $7,700 in benefits from Liberty Mutual Insurance Company. He is charged with falsifying business records in the first degree and insurance fraud in the third degree.
Chenango County – Patricia Wilcox, 60, of Oxford, started collecting benefits from NYSIF after claiming she suffered a broken ankle while working as a teacher’s aide at the Chenango County Head Start program. Investigators found that her injury actually occurred at her home. She fraudulently collected $12,900 in benefits. She is charged with falsifying business records in the first degree and workers comp fraud.
Tompkins County – Steven Odum, 65, of Ithaca, is accused of failing to disclose work activity as the lead guitarist with the “Steve Odum Trio” on reports he sent to the NYSIF while collecting $11,300 in benefits after suffering an injury in 1988 while working at a residential child care institution. He is charged with offering a false instrument for filing in the first degree and workers comp fraud.
Clinton County – Leonard Drown, 63, of Morrisonville, is accused of collecting $25,500 in benefits from Pennsylvania Manufacturers Association Insurance Company after claiming that he was not working because of an injury. Investigators found that he was, in fact, working while collecting the benefits. (WCxKit)
Broome County – Olga Shelestovsky, 43, of Johnson City, is accused of working as a waitress while collecting $2,200 in benefits from NYSIF and claiming that she was unable to do any physical work. She is charged with offering a false instrument for filing in the first degree and workers comp fraud.
All of the accused are innocent until proven guilty.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He recommends the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
The Clinton County (New York) District Attorney’s office recently announced an arrest associated with workers compensation and insurance fraud.
Robert Deyo, 34, of Plattsburgh was arrested and arraigned in Plattsburgh City Court before the Honorable Penelope Clute and charged with one count of Perjury in the First Degree and one count of Committing a Fraudulent Practice. (WCxKit)
The charges stem from allegations that Deyo was receiving workers comp benefits he was not entitled to by continuing to work as a contractor, and not reporting that fact to his employer or the insurance carrier.
“Workers compensation fraud takes hard-earned money from honest businesses, workers and consumers alike,” said New York State Insurance Fund Chief Executive Deputy Director Dennis Hayes. “Through the assistance of local law enforcement and cooperation with our partner agencies, NYSIF has and will continue to aggressively fight workers compensation fraud.”
Deyo was remanded to the Clinton County Jail in lieu of $2,000 bail – $4,000 bond.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
Recently addressing a group of 40 fraud directors from around the country, Massachusetts Attorney General Martha Coakley highlighted the importance of collaboration among law enforcement, employers, employees, and local fraud bureaus to prevent and prosecute cases of fraud across a variety of industries, according to a report from her office.
“The cost of corruption on businesses and taxpayers is significant,” AG Coakley said. “It undermines the level playing field for businesses, distorts the competitive marketplace, and costs taxpayers at a time when every dollar is crucial. It is in everyone’s interest – in both the public and private sector – to deter and prosecute cases of fraud, and we must all work together to do that effectively.” (WCxKit)
The Fraud Directors Conference, held in Chatham, was sponsored by the Insurance Fraud Bureau of Massachusetts. The Attorney General discussed the types of cases prosecuted by her office ranging from public corruption and Medicaid fraud matters to workers compensation and auto insurance schemes.
She highlighted examples in which public and private cooperation proved key factors in deterring cases of fraud. For instance, when the state was confronted with an uptick of cases of auto insurance fraud schemes, a collaborative effort between the Massachusetts Insurance Fraud Bureau, District Attorneys, federal and state law enforcement, and private insurance companies worked to combat these crimes and build strong criminal cases.
Coakley’s office has made the investigation and prosecution of cases of fraud and corruption a priority. For instance, in the last fiscal year, the Attorney General’s Office recovered $69 million in Medicaid fraud. (WCxKit)
Recently, she reported the indictments against 10 people in connection with four Medicaid Fraud cases.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
Every now and then one comes across a claimant who knows the
twists and turns of the workers compensation system. These claimants are mostly dependable and good workers. But when a potential subjective injury happens, they are the people to watch out for.
The insurance industry calls these people “career claimants.” When a background check is done, they have a list of prior claims a mile long. Having many prior claims does not necessarily mean they are bad workers; perhaps they are injury-prone. It is very interesting, however, when claims are filed, they are sneaky enough to do just enough to keep the wheels turning on their claim to remain out of work or on medical restrictions. Odd how that happens…
Adjusters can use their defensive tools to get these claimants off workers comp. Even when adjusters do IMEs, surveillance, and speak with the physicians providing the treatment, nothing seems to get this type of worker back to full duty.
When claimants know too much about how the workers comp system works, they use it to their advantage by:
1. Having the physician on their side
Physicians usually base opinions on medical evidence.
Tricky claimants know what to tell and what not to tell the doctor. They use the Internet as an information source. For example, if someone sustains a back strain, acceptable symptoms are researched to report without over-exaggerating the symptomology to cause the treating physician to see red flags.
Limited range of motion, muscle spasm, and bringing up pain complaints tell a doctor if the person is or is not hurt. The doctor proceeds presuming the patient is reporting honesty and may keep the patient on restrictions, on continuing treatment, and off work. This is where the independent medical examination (IME) comes into play. It is always good to have another opinion just in case the treating doctor is not being proactive in moving the patient along to full duty, especially if the subjective complaints do not match the objective evidence on examination.
2. Rescheduling doctor and physical therapy appointments
Everyone has a life outside of work. However, constant rescheduling of medical appointments is a
red flag for the
adjuster. Maybe now and then a physical therapy appointment is missed, especially when working light duty. But, it is important to remember legitimate injured workers want to get treatment in order to heal and return to full duty.
A typical lumbar strain does not necessarily prevent a person from being active or running errands, but if a trend arises of constant rescheduling — THINK — what else is going on besides the injured worker’s schedule. Surveillance is a handy tool to confirm suspicions. It is especially helpful if the injured worker is caught in a lie. If the worker reports to the adjuster therapy is missed even when off work, and surveillance shows the employee doing yard work instead of going to physical therapy, that is evidence to suspend the claim due to non-compliance with the treatment plan provided by the doctor.
Hot Tip: One therapy office has a policy of charging the patient the full amount of the missed appointment unless given 24-hour notice. They present patients with this written policy at the beginning of therapy and make them sign indicating they understand they will be charged and their insurance will not be billed.
3. The claimant knows the lingo
One thing jumping right into the adjuster’s face is a claimant knowledgeable about the injury in medical terms. The average person does not use words like radiculopathy, impingement, and stenosis or know what they mean.
Even more striking is when a worker discusses a settlement or redemption early on in the claim. This should lead the adjuster to believe the worker has been down the workers comp claim road before. Most times, when a background check is done it shows prior litigation experience with prior employers. These are all red flags indicating you really want to keep an eye on this claimant.
4. The claimant is off work and cannot be found
When a claimant has a legitimate injury and is off work for a while, it is good idea to do surveillance just to see what the worker is up to. After a few days, if the video only shows the worker poking a head out of the front door to retrieve the mail, it is always a red flag. The person may have a prior claim history, broke restrictions and the claim was denied or suspended.
Or even worse, when you go to do surveillance the worker cannot be found anywhere. The worker might be staying at another location or at another property. When you talk to the employee, excuses are made about how pain is so disabling all that can be done is to stay home and rest. However, something is awry if you go to do surveillance and the car is not in the driveway.
5. The worker misses a few therapy appointments every week
Remember, injured workers with legitimate injuries want treatment so they can heal and return to work. In a red flag claim when a person goes to some treatment, but not all and not all the time, this means they are doing just enough to keep the claim alive, but missing just enough treatments to not get better.
The unsaid rule in claims is the longer a person is off work, the harder it is to get them back to work. This is where a light-duty work program comes in handy. Light duty forces the worker to go to work. It also forces them to go to treatment, especially if one has to leave work to go to therapy and then return to work to finish the shift. (WcxKit)
Doing just enough to keep the adjuster from disputing the claim shows the claimant knows a little bit about how the claims system works. As an adjuster, if a person makes 75 percent of the medical appointments, is that really going to stand up in court if you pull the trigger and file a dispute or suspension?
Summary
Just one of these does not mean your employee is cheating your — and a claimant may be well-informed and quite honest. But, there are some smart claimants who know how to work the system. If, as the adjuster, you spot one of these claims, it is your role to stay on top of every aspect of the claim. Make sure if workers miss appointments they have some sort of documentation to support absences. The more pressure you put on them the better result you will have in defeating unethical claimants at their own game.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com .
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
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