‘Records told the story’ in fraud case: Northeast Ohio Business Overbills Agency; Owner Found Guilty of Workers’ Comp Fraud
Cleveland,OH (WorkersCompensation.com) - The bills coming from a Northeast Ohio health care facility to the Ohio Bureau of Workers' Compensation (BWC) looked suspicious.
Too many, it seemed, were for treatment to a company co-owner and others closely connected to the business. Our agency had paid more than $110,000 for claims on one of those cases alone and $27,000 for treatment provided to co-owner Jeffrey L. Guerin. So, in late winter of 2013, our special investigations department decided to take a closer look at PT Plus LLC of Willoughby Hills, a provider of physical therapy and massage therapy about 20 miles northeast of Cleveland.
After a preliminary investigation by our Health Care Provider Team, we used an undercover agent posing as an injured worker to get an inside look at the practice. In roughly 23 visits over three months our agent observed — and records later proved — PT Plus billed BWC for services that weren't rendered to patients. In one case, our agent witnessed an injured worker refuse treatment, but PT Plus billed BWC anyhow, using spurious treatment notes to support the claim.
Our agents subsequently interviewed three former PT Plus employees, all of whom alleged co-owner Guerin committed health care fraud out of the business. Specifically, they claimed Guerin billed BWC and other third-party payers for treatment not rendered to patients. They said Guerin managed the day-to-day operations of the business and had total control over the billing process. They said he altered the units of service recorded on fee sheets and the patient's in/out time recorded on treatment notes to correspond with the amount of treatment billed to BWC.
As we were investigating, PT Plus went out of business around July 2014. Our agents learned the business records and patient charts were stored at Guerin's business partner's residence. We conducted a search warrant and interviewed the co-owner, who denied any involvement in the company's day-to-day operations and billing responsibilities. That was Guerin's role, he said.
Our agents interviewed Guerin, who admitted sole responsibility for billing and overseeing his company's daily operations. He told our agents that beginning in 2009 he had auditors review his businesses records to look for discrepancies. He said they found that he had actually under-billed BWC about 60 percent of the time, thus shorting his business money. For the audits that revealed overbilling, it didn't amount to much money, he said. Taken collectively, it was all a wash and that's why he didn't inform BWC or any other third-party payer, he explained. But that's not what our agents found.
During the interview, Guerin retrieved the audit worksheets from his basement and surrendered them to the agents. The agents conducted a cursory review and discovered the majority of the 2014 audit worksheets recorded overbilling. “He offered bizarre justifications and excuses for the records,” one agent told me. “He was cooperative, but we could tell he wasn't truthful. I think he felt he could explain his way out of it, but the records told the story.
Back at the office, the health care provider team conducted its own audit. The methodology entailed comparing the type, amount (Units of Service) and length (In/Out Times) of treatment that the therapists recorded on the billing and treatment records with the bills Guerin sent to BWC. The audit revealed more than 170 instances where Guerin altered data so he could bill and receive reimbursement for more treatment than was rendered.
On May 18, 2018, Guerin pleaded guilty to one count of workers' compensation fraud, a first- degree misdemeanor, in Franklin County Municipal Court. He paid BWC restitution in the amount of $7,154 on the same day.
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