(A) Insurance fraud.
(1) For the purpose of this division (A), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
DATA. Has the same meaning as in R.C. § 2913.01 and additionally includes any other representation of information, knowledge, facts, concepts, or instructions that are being or have been prepared in a formalized manner.
DECEPTIVE. Means that a statement, in whole or in part, would cause another to be deceived because it contains a misleading representation, withholds information, prevents the acquisition of information, or by any other conduct, act, or omission creates, confirms, or perpetuates a false impression, including, but not limited to, a false impression as to law, value, state of mind, or other objective or subjective fact.
INSURER. Means any person that is authorized to engage in the business of insurance in this state under R.C. Title 39, the Ohio Fair Plan Underwriting Association created under R.C. § 3929.43, any health insuring corporation, and any legal entity that is self-insured and provides benefits to its employees or members.
POLICY. Means a policy, certificate, contract, or plan that is issued by an insurer.
STATEMENT. Includes but is not limited to any notice, letter, or memorandum; proof of loss; bill of lading; receipt for payment; invoice, account, or other financial statement; estimate of property damage; bill for services; diagnosis or prognosis; prescription; hospital, medical, or dental chart or other record; x-ray, photograph, videotape, or movie film; test result; other evidence of loss, injury, or expense; computer-generated document; and data in any form.
(2) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall do either of the following:
(a) Present to, or cause to be presented to, an insurer any written or oral statement that is part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive;
(b) Assist, aid, abet, solicit, procure, or conspire with another to prepare or make any written or oral statement that is intended to be presented to an insurer as part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive.
(3) Whoever violates this division (A) is guilty of insurance fraud. Except as otherwise provided in this division, insurance fraud is a misdemeanor of the first degree. If the amount of the claim that is false or deceptive is $1,000 or more, insurance fraud is a felony to be prosecuted under appropriate state law.
(4) This division (A) shall not be construed to abrogate, waive, or modify R.C. § 2317.02(A).
(R.C. § 2913.47)
(B) Workers' compensation fraud.
(1) No person, with purpose to defraud or knowing that the person is facilitating a fraud shall do any of the following:
(a) Receive workers' compensation benefits to which the person is not entitled;
(b) Make or present or cause to be made or presented a false or misleading statement with the purpose to secure payment for goods or services rendered under R.C. Chapter 4121, 4123, 4127, or 4131 or to secure workers' compensation benefits;
(c) Alter, falsity, destroy, conceal, or remove any record or document that is necessary to fully establish the validity of any claim filed with, or necessary to establish the nature and validity of all goods and services for which reimbursement or payment was received or is requested from the Bureau of Workers' Compensation, or a self-insuring employer under R.C. Chapter 4121, 4123, 4127, or 4131;
(d) Enter into an agreement or conspiracy to defraud the Bureau or Workers' Compensation or a self-insuring employer by making or presenting or causing to be made or presented a false claim for workers' compensation benefits.
(e) Make or present or cause to be made or presented a false statement concerning manual codes, classification or employees, payroll, paid compensation, or number of personnel, when information of that nature is necessary to determine the actual workers’ compensation premium or assessment owed to the Bureau by an employer;
(f) Alter, forge, or create a workers’ compensation certificate or falsely show current or correct workers’ compensation coverage;
(g) Fail to secure or maintain workers’ compensation coverage as required by R.C. Chapter 4123 with the intent to defraud the Bureau of Workers’ Compensation.
(2) Whoever violates this division (B) is guilty of workers’ compensation fraud. Except as otherwise provided in this division, workers’ compensation fraud is a misdemeanor of the first degree. If the value of premiums and assessments unpaid pursuant to actions described in divisions (B)(1)(e), (B)(1)(f), or (B)(1)(g) of this section, or goods, services, property, or money stolen is
$1,000
or more, workers’ compensation fraud is a felony to be prosecuted under appropriate state law.
(3) Upon application of the governmental body that conducted the investigation and prosecution of a violation of this division (B), the court shall order the person who is convicted of the violation to pay the governmental body its costs of investigating and prosecuting the case. These costs are in addition to any other costs or penalty provided under federal, state or local law.
(4) The remedies and penalties provided in this division (B) are not exclusive remedies and penalties and do not preclude the use of any other criminal or civil remedy or penalty for any act that is in violation of this division (B).
(5) For the purpose of this division (B), the following definitions shall apply unless the context clearly indicates or requires a different meaning.
CLAIM. Means any attempt to cause the Bureau of Workers' Compensation, an independent third party with whom the administrator or an employer contracts under R.C. § 4121.44, or a self-insuring employer to make payment or reimbursement for workers' compensation benefits.
EMPLOYER, EMPLOYEE, and SELF-INSURING EMPLOYER. Have the same meanings as in R.C. § 4123.01.
EMPLOYMENT. Means participating in any trade, occupation, business, service, or profession for substantial gainful remuneration.
FALSE. Means wholly or partially untrue or deceptive.
GOODS. Includes but is not limited to medical supplies, appliances, rehabilitative equipment, and any other apparatus or furnishing provided or used in the care, treatment, or rehabilitation of a claimant for workers' compensation benefits.
RECORDS. Means any medical, professional, financial, or business record relating to the treatment or care of any person, to goods or services provided to any person, or to rates paid for goods or services provided to any person, or any record that the administrator of workers' compensation requires pursuant to rule.
REMUNERATION. Includes but is not limited to wages, commissions, rebates, and any other reward or consideration.
SERVICES. Includes but is not limited to any service provided by any health care provider to a claimant for workers’ compensation benefits and any and all services provided by the Bureau as part of workers’ compensation insurance coverage.
STATEMENT. Includes but is not limited to any oral, written, electronic, electronic impulse, or magnetic communication notice, letter, memorandum, receipt for payment, invoice, account, financial statement, bill for services; a diagnosis, prognosis, prescription, hospital, medical, or dental chart or other record; and a computer generated document.
WORKERS' COMPENSATION BENEFITS. Means any compensation or benefits payable under R.C. Chapter 4121, 4123, 4127, or 4131.
(R.C. § 2913.48) Penalty, see § 130.99