New Jersey Telemedicine Restrictions Face 3rd Circuit Challenge in 2025
August 14, 2025 | JacobiJournal.com — A coalition of doctors and cancer patients is taking their fight against New Jersey telemedicine restrictions to the U.S. Court of Appeals for the Third Circuit, arguing the state’s licensing rule violates multiple constitutional rights and jeopardizes access to life-saving care. Rule Limits Out-of-State Specialists The appeal follows a lower court’s dismissal of their lawsuit challenging a New Jersey law requiring out-of-state physicians to obtain a state license before treating Garden State patients via telehealth. Plaintiffs say the rule unfairly limits medical options for those with rare and complex conditions, who often rely on specialists outside New Jersey. First Amendment and Patient Rights at Issue Drs. Shannon MacDonald and Paul Gardner, along with two cancer patients, contend the restrictions infringe on the First Amendment by preventing discussions between certain doctors and patients about treatment options. Their brief argues these conversations constitute protected speech and that the state’s policy imposes content- and speaker-based limits that should face strict scrutiny. Broader Constitutional Concerns The plaintiffs also assert that the rule violates the dormant commerce clause by restricting interstate medical services, the privileges and immunities clause by imposing burdensome licensing requirements, and the 14th Amendment by limiting patients’ ability to direct their own medical care. Attorneys Urge 3rd Circuit to Act “The distinction between medical treatment and preliminary consultations via telemedicine is critical,” the appeal notes, accusing the lower court of sidestepping this issue. Jack E. Brown of the Pacific Legal Foundation, representing the plaintiffs, expressed optimism that the Third Circuit will overturn the dismissal, forcing New Jersey to defend what he called an “outdated and potentially deadly rule.” The New Jersey Attorney General’s Office has declined to comment on the case. For more on telehealth policy trends, visit the American Telemedicine Association. FAQs: About New Jersey Telemedicine Restrictions What do New Jersey telemedicine restrictions require? They mandate that out-of-state doctors obtain a New Jersey medical license before providing telehealth services to patients in the state. Why are these restrictions being challenged in court? Plaintiffs argue the law violates constitutional rights, including free speech, interstate commerce protections, and patient autonomy under the 14th Amendment. What is at stake in the 3rd Circuit appeal? The ruling could set a precedent for how states regulate telemedicine, potentially expanding or limiting access to out-of-state medical specialists. What penalties could doctors face for violating New Jersey’s telemedicine restrictions? Physicians who provide telehealth services without a valid New Jersey medical license could face fines, disciplinary action, or legal enforcement by the state medical board. How might the 3rd Circuit decision impact telemedicine across the U.S.? If the court strikes down New Jersey’s licensing requirement, it could weaken similar restrictions in other states, potentially opening the door to broader interstate telehealth access. What arguments support the telemedicine restrictions? Supporters claim the licensing rule protects patient safety, ensures quality of care, and allows the state to regulate physicians practicing on its residents. Subscribe to JacobiJournal.com for in-depth coverage of cases like the telemedicine restrictions challenge, and get expert analysis on the future of patient rights and interstate medical care. 🔎 Read More from JacobiJournal.com:
California Insurance Commissioner Sues Over FAIR Plan’s Smoke Damage Claim Denials
August 4, 2025 | JacobiJournal.com – California Insurance Commissioner Ricardo Lara has filed a lawsuit against the California FAIR Plan Association, accusing the state’s insurer of last resort of improperly denying homeowner claims related to wildfire smoke damage. The legal action, announced on August 1, 2025, shines a spotlight on FAIR Plan smoke claims, raising concerns about how these cases are evaluated and denied amidst California’s intensifying fire seasons. The lawsuit alleges that FAIR Plan has routinely denied valid claims for smoke-related damage, despite policyholders having coverage under their insurance agreements. These FAIR Plan smoke claims often involve residual damage such as soot infiltration, lingering odors, or compromised air systems—issues that may not be immediately visible but still impact habitability. Commissioner Lara emphasized that California homeowners deserve full and fair compensation when their properties are affected by wildfire smoke, not just direct fire damage. Regulators argue that improperly denied FAIR Plan smoke claims not only violate the spirit of the coverage but also undermine public trust in a system meant to serve as a safety net for high-risk regions. This legal challenge seeks to clarify insurer responsibilities and ensure more consistent outcomes for affected policyholders across the state. FAIR Plan Smoke Claims Spark Regulatory Scrutiny The Department of Insurance opened its investigation after receiving numerous complaints from homeowners who reported property damage due to smoke infiltration. These FAIR Plan smoke claims ranged from soot-covered interiors to HVAC system contamination and long-term air quality concerns—issues that often go overlooked in standard fire loss assessments. In many cases, FAIR Plan reportedly denied these smoke claims outright or offered partial settlements, citing a lack of visible structural damage. Lara’s office argues that this practice is inconsistent with the language of the policies and violates California’s insurance regulations. As the volume of FAIR Plan smoke claims continues to rise in the aftermath of increasingly severe wildfire seasons, state regulators are intensifying their oversight to ensure proper claims handling and policyholder protections. Consumer Protections and Legal Ramifications “This is about holding insurers accountable,” said Lara. “Wildfire survivors should not be left fighting for coverage that they are clearly owed. FAIR Plan’s role is to protect high-risk homeowners—not sidestep their responsibilities.” Legal experts believe the case could set precedent for how smoke damage is evaluated and covered under California policies moving forward. If successful, the lawsuit may compel FAIR Plan to revise its claims handling protocols and reassess prior denials. What This Means for Policyholders With wildfire season in full swing and home insurance availability shrinking in high-risk areas, the Commissioner’s legal challenge sends a strong message. As traditional carriers pull back from fire-prone regions, more Californians are forced onto the FAIR Plan—a system now under fire for failing to meet its obligations. The surge in FAIR Plan smoke claims highlights systemic issues in how these policies are interpreted and executed. Homeowners relying on FAIR Plan coverage often face uncertainty when filing for smoke-related damages, despite having paid into policies designed to protect them. The outcome of this case could have ripple effects across the state, influencing future legislative reforms, regulatory scrutiny, and insurer accountability. A favorable ruling for policyholders could also establish clearer standards for processing FAIR Plan smoke claims, giving homeowners more confidence that legitimate damages—particularly from smoke exposure—will be covered fully and fairly. Read more in the official press release from the California Department of Insurance. FAQs: FAIR Plan Smoke Claim Denials Why Is California Suing the FAIR Plan Over Smoke Damage Claims? California’s Insurance Commissioner filed a lawsuit claiming the FAIR Plan improperly denied valid smoke damage claims. The legal action seeks to ensure homeowners receive full benefits under their policies. How Can Homeowners Affected by Wildfire Smoke File a FAIR Plan Claim? Homeowners should document all visible damage, obtain air quality tests if possible, and file their claims promptly. If denied, they can appeal or contact the Department of Insurance for assistance. What Could This Lawsuit Mean for Future Wildfire Coverage? If successful, the lawsuit may lead to stronger regulatory guidelines for smoke damage assessments and more comprehensive coverage obligations for insurers. For the latest updates on insurance disputes, regulatory enforcement, and wildfire-related claims in California, subscribe to JacobiJournal.com. 🔎 Read More from JacobiJournal.com:
Fourth Circuit Upholds 17-Year Sentence in $12M Medicaid Fraud Case
July 31, 2025 | JacobiJournal.com – In a decisive legal ruling, the U.S. Court of Appeals for the Fourth Circuit upheld the 17-year prison sentence of Donald Booker, a North Carolina lab owner convicted of running a large-scale Medicaid fraud case. The court affirmed both the conviction and sentence tied to a scheme involving over $12 million in false Medicaid billing. Booker operated United Youth Care Services and United Diagnostic Laboratories, where he orchestrated the submission of fraudulent drug testing claims. The conspiracy involved kickbacks to treatment centers and housing facilities, including “Do It 4 The Hood” and “Legacy Housing,” in exchange for patient referrals. Scheme Involved Routine Drug Tests and Kickbacks According to court documents, Booker billed Medicaid for unnecessary, repetitive drug screens, often performed twice weekly on patients without proper medical evaluation. These patients were referred by community organizations that received direct illegal payments in return. The case resulted in convictions for illegal remuneration, money laundering, and conspiracy to defraud the U.S. government. Over $1.6 million in illegal kickbacks were proven at trial. The court rejected all arguments for reversal, stating the evidence overwhelmingly supported the jury’s findings. Broader Relevance for Medicaid Providers This Medicaid fraud case is part of a growing trend of federal enforcement targeting diagnostic labs, addiction treatment providers, and telehealth schemes. The Fourth Circuit’s ruling reinforces the DOJ’s approach of pursuing not only fraud but also financial arrangements that jeopardize patient care and program integrity. Providers nationwide are urged to evaluate referral relationships and billing protocols. This ruling serves as a strong compliance reminder in the face of mounting scrutiny. For a full legal opinion, see the Fourth Circuit’s document in the U.S. Court of Appeals for the Fourth Circuit (PDF). FAQ: About the Medicaid Fraud Case Why did the Fourth Circuit uphold the 17-year sentence in this Medicaid fraud case? The court found no error in the jury’s verdict or sentencing process, citing substantial evidence of illegal kickbacks, false claims, and intent to defraud Medicaid. What industries should take note of this ruling? Diagnostic laboratories, behavioral health providers, and referral networks—especially those serving Medicaid populations—should examine the ruling’s implications for compliance enforcement. What does this case mean for future Medicaid fraud investigations? The ruling signals continued judicial support for aggressive prosecution of healthcare fraud, including complex schemes involving community partnerships and repeated billing abuse. Stay ahead of the latest enforcement trends. Subscribe to JacobiJournal.com for weekly fraud, labor, and healthcare compliance updates impacting professionals nationwide. 🔎 Read More from JacobiJournal.com:
DOJ Probes $1B UnitedHealth Medicare Advantage Fraud Over Coding Practices
July 18, 2025 | JacobiJournal.com – UnitedHealth Medicare Advantage fraud is at the center of a widening federal investigation. The Department of Justice (DOJ) has intensified its efforts to uncover the extent of the scheme involving UnitedHealth Group, focusing specifically on allegations of inflated diagnostic coding within its Medicare Advantage program. Alongside the FBI and the Department of Health and Human Services (HHS), the DOJ is scrutinizing UnitedHealth’s HouseCalls division, which conducts in-home health assessments for Medicare Advantage enrollees. Authorities suspect that these assessments may have been used to exaggerate patient conditions, leading to increased and potentially fraudulent Medicare reimbursements. Allegations of Upcoding in Medicare Adbvantage Investigators are examining whether UnitedHealth improperly coded diagnoses during HouseCalls visits to exaggerate patients’ health risks. This practice, known as upcoding, can result in higher Medicare reimbursements by portraying patients as sicker than they are. The probe follows earlier whistleblower lawsuits that alleged UnitedHealth and other insurers manipulated coding to secure billions in additional Medicare payments. This latest investigation suggests the DOJ is expanding its scrutiny of Medicare Advantage fraud, an area of growing concern given the program’s rapid expansion and high cost to taxpayers. Compliance Risks for Insurers The UnitedHealth Medicare Advantage fraud investigation underscores the need for health insurers to ensure coding accuracy and compliance with federal regulations. Coding errors or intentional misrepresentations not only inflate government costs but also expose insurers to False Claims Act liabilities and significant financial penalties. Healthcare compliance experts advise insurers to audit their risk adjustment coding processes, enhance provider training, and ensure oversight mechanisms are in place to prevent fraudulent activity. Regulatory Scrutiny on the Rise The DOJ’s focus on UnitedHealth reflects broader government efforts to control Medicare Advantage spending, which has ballooned in recent years. Regulators and lawmakers have increasingly criticized risk adjustment abuses and are considering stricter guidelines for diagnostic coding. Insurers operating in the Medicare Advantage space face mounting pressure to prove that their coding practices are not designed to game the system. As enforcement intensifies, companies must demonstrate a clear commitment to ethical billing and transparent reporting. For a general and legitimate information link on Medicare fraud, you can use this official source. What’s Next in the UnitedHealth Medicare Advantage Fraud Case As of July 2025, the DOJ has not announced formal charges, but sources suggest the investigation is active and could lead to legal action or settlements. The outcome may shape future enforcement strategies against similar Medicare Advantage fraud cases, setting compliance benchmarks for the entire industry. FAQs: Understanding UnitedHealth Medicare Advantage Fraud What is UnitedHealth Medicare Advantage fraud? UnitedHealth Medicare Advantage fraud refers to allegations that UnitedHealth inflated diagnostic codes within its Medicare Advantage program, specifically through its HouseCalls division. This practice, known as upcoding, can lead to higher payments from Medicare by making patients appear sicker than they are. Why is UnitedHealth Medicare Advantage fraud under investigation? The DOJ, along with the FBI and HHS, is investigating UnitedHealth Medicare Advantage fraud to determine if the company violated federal laws by manipulating diagnostic codes. The investigation aims to uncover whether these practices resulted in billions of dollars in improper Medicare payments. What are the consequences if UnitedHealth is found liable for Medicare Advantage fraud? If UnitedHealth is found liable, the company could face substantial penalties under the False Claims Act, including fines, repayment of funds, and potentially stricter regulatory oversight. This could also prompt broader audits of Medicare Advantage plans industry-wide. Where can I report suspected Medicare Advantage fraud? Anyone can report suspected Medicare Advantage fraud to the Office of Inspector General (OIG) here. Timely reporting helps authorities investigate and prevent further abuses within the system. Stay informed on healthcare fraud investigations and Medicare compliance updates. Subscribe to JacobiJournal.com for expert insights on regulatory actions, enforcement trends, and fraud prosecutions. 🔎 Read More from JacobiJournal.com:
Home Health Agency Owner Convicted for $400K in Medicare Fraud via Falsified Records
June 30, 2025 | JacobiJournal.com – A home health agency owner has been convicted in a $400,000 Medicare fraud scheme that involved falsified documentation to claim services never provided. This case adds to the growing list of healthcare fraud prosecutions, particularly in home-based care, a sector increasingly scrutinized by federal authorities. Fabricated Records, Real Consequences in Medicare Fraud The owner directed staff to forge patient records, including visit notes and certifications, to create the appearance of legitimate medical services. These fake claims were submitted to Medicare, resulting in substantial reimbursement for treatments that either never occurred or were medically unnecessary. Investigators found a pattern of deception dating back several years. Systemic Oversight Failure in Medicare Fraud This conviction underscores how documentation abuse remains a persistent vulnerability in the Medicare system. Home health agencies, while vital for aging populations, continue to face enforcement due to weak internal controls and high reimbursement incentives. Prosecutors noted that the scheme not only defrauded taxpayers but also undermined trust in care delivery. A Signal to the Industry Federal officials have reiterated that healthcare fraud—especially involving home health services—will remain a high-priority enforcement area. With billions allocated annually to Medicare, oversight agencies are ramping up audits and encouraging whistleblowers to report suspicious billing practices. Lessons from the Case Industry experts recommend stronger compliance protocols, regular chart audits, and better staff training to prevent similar schemes. Patients and families are also urged to stay informed about services billed under their names to spot potential abuse early. As federal crackdowns continue, the healthcare sector is reminded that cutting corners not only risks legal penalties—it puts patients and public trust on the line. For more information on Medicare fraud prevention, visit the official Medicare.gov Fraud Prevention page. FAQs: What is Home Health Medicare Fraud? Home Health Medicare Fraud involves false claims submitted by home health agencies for services that were never provided or medically unnecessary. This type of fraud undermines the integrity of Medicare funding and patient care. How can patients detect Home Health Medicare Fraud? Patients can review their Medicare statements regularly, ensuring all billed services were actually received. Discrepancies should be reported to Medicare immediately to prevent further fraud. What are the penalties for Home Health Medicare Fraud? Convictions for Home Health Medicare Fraud can lead to significant fines, restitution, and prison sentences, as seen in this case where the agency owner was convicted of defrauding Medicare of $400,000. Stay informed on healthcare fraud cases and compliance strategies. Subscribe to JacobiJournal.com for weekly updates on enforcement trends and industry risks. 🔎 Read More from JacobiJournal.com:
Pepperdine University and Janitorial Contractors Cited for Labor Violations
May 07, 2025 | JacobiJournal.com – The California Labor Commissioner’s Office has cited Pepperdine University and four janitorial contractors a combined $80,000 for violating state janitorial registration laws, raising concerns about labor compliance practices within higher education institutions. The Pepperdine labor violations case adds to a growing trend of enforcement actions targeting universities and large employers who fail to vet subcontractors properly. Labor advocates argue that unregistered janitorial firms often escape oversight, exposing workers to wage theft, unsafe conditions, and retaliation. California’s Labor Code Section 1432, enacted to address these very issues, plays a key role in maintaining accountability across contracted labor networks. This citation also reflects the Labor Commissioner’s continued focus on high-profile institutions, reinforcing that public image does not exempt employers from scrutiny. As universities increasingly rely on outsourced services, compliance with labor registration requirements is becoming a top priority for legal and risk departments across the state. Unregistered Contractors Trigger Citations The investigation revealed that Pepperdine hired unregistered janitorial companies, a direct violation of California Labor Code Section 1432, which mandates annual registration for all janitorial employers. As a result: Watchdog Referral Sparked Inquiry The Maintenance Cooperation Trust Fund, a watchdog organization that monitors janitorial labor practices, referred the case to state authorities. Their referral led to a deeper investigation into Pepperdine’s hiring practices. The Pepperdine labor violations case reflects a broader pattern observed in recent enforcement actions statewide, where institutions shift to lower-cost vendors without confirming regulatory compliance. Industry experts warn that failing to verify janitorial registration status can result in not only financial penalties but reputational harm—especially for universities expected to uphold high ethical standards. Labor advocates say such oversights enable exploitative working conditions to persist, particularly in sectors where immigrant and low-wage workers are overrepresented. Companies Operated Across Multiple States The cited contractors operated both in California and out of state, with locations in: The Labor Commissioner emphasized the importance of maintaining compliance not just within California, but also for companies working across state lines. For full details, refer to the California Department of Industrial Relations’ Janitorial Registration FAQs. Source FAQs: Pepperdine Labor Violations What laws did Pepperdine violate in the labor investigation? Pepperdine labor violations stemmed from hiring unregistered janitorial contractors, breaching California Labor Code Section 1432. The law requires janitorial employers to register annually with the state to protect workers from exploitation. Why were Pepperdine and the contractors fined $80,000? The Pepperdine labor violations resulted in a $40,000 fine for the university and $10,000 each for four janitorial vendors. These penalties address the use of unregistered service providers, which violates labor registration requirements. How do Pepperdine labor violations impact other institutions? Pepperdine labor violations could prompt more audits and stricter enforcement in higher education. Schools contracting with out-of-state vendors must ensure compliance with California labor laws. What is California Labor Code Section 1432, and why does it matter? Under California Labor Code Section 1432, all janitorial employers must register annually with the state to operate legally. This law aims to ensure employers meet basic compliance standards and uphold fair labor practices. The Pepperdine labor violations highlight the importance of this registration requirement in protecting vulnerable workers. What can universities do to avoid labor violations like Pepperdine’s? To avoid Pepperdine labor violations, universities must conduct due diligence when contracting service vendors. This includes verifying state registration, checking compliance history, and confirming that subcontractors meet all labor law requirements. Proactively reviewing vendor status through California’s labor enforcement portals can help prevent costly citations. For more updates on university labor law enforcement, compliance cases, and regulatory action across education and employment sectors, subscribe to JacobiJournal.com. 🔎 Read More from JacobiJournal.com:
Heritage Sues Adjuster for Libel Over ’60 Minutes’ Report
April 30, 2025 | JacobiJournal.com — Heritage sues adjuster: Heritage Property & Casualty Insurance Co. has filed a libel and defamation lawsuit against independent adjuster Jordan Lee, just weeks after his appearance on 60 Minutes accusing Heritage of manipulating hurricane damage reports. Lee’s attorney, John Tolley, fired back, calling the Heritage sues adjuster case a retaliatory strike against whistleblowers. “Jordan Lee acted courageously to shine a light on systemic misconduct,” Tolley said. “This lawsuit is an attack not just on him, but on every Floridian who relies on fair insurance practices after a disaster.” Lee’s Allegations: Altered Estimates and Silenced Voices In a September 2024 broadcast of 60 Minutes, Lee claimed that Heritage and other insurers routinely slashed independent adjusters’ damage estimates to minimize claim payouts after Hurricane Ian. “I handled 46 of them; 44 of them were changed,” Lee told CBS. Some claims, he said, were reduced by as much as 98%. The controversy began in late 2022 when Lee and two other adjusters testified before a Florida House committee, accusing insurers of altering their reports without consent. The revised reports made it appear as though the original adjusters had recommended the lower figures. Heritage’s Side: Inflated Claims and Alleged Misconduct Heritage responded by filing a complaint in Hillsborough County Circuit Court, alleging that Lee deliberately inflated estimates to increase his commission-based compensation. The suit also claims that Lee violated policy guidelines by favoring replacement costs over repairs and failing to document damage properly. According to Heritage’s complaint, “When his misconduct was uncovered and his estimates were corrected, Defendant did not receive the compensation he expected. Consequently, Defendant returned to Texas and began falsely and publicly alleging that Plaintiff intentionally reduced his estimates.” The insurer argues that a third-party administrator had to spend considerable time revising Lee’s reports to align them with actual damage, policy terms, and coverage limits. Legal Experts and Whistleblower Concerns Despite Heritage’s assertions, legal experts view the lawsuit with skepticism. Bob Jarvis, a law professor at Nova Southeastern University, said the suit likely aims to intimidate rather than win. “This lawsuit will bankrupt Jordan Lee, even if he wins,” Jarvis stated. “The message is clear: whistleblowers beware.” Tolley agreed, calling it a “blatant attempt to silence and punish not only Jordan but other potential whistleblowers for doing or attempting to do the right thing.” Financial Fallout and Ongoing Investigations Following the 60 Minutes segment, Heritage’s stock dipped sharply. However, it has since rebounded, reaching a nine-year high, according to Yahoo! Finance. In 2022, Florida’s then-Chief Financial Officer Jimmy Patronis promised an investigation into insurer practices related to Hurricane Ian claims. As of now, that investigation has not produced any public findings. Heritage CEO Ernie Garateix responded to the initial wave of allegations last fall, saying: “Third-party field adjusters, like Jordan Lee, always have to collaborate with those higher up. The company Lee worked for during Hurricane Ian is no longer in business.” He also clarified that some desk adjuster names were omitted from final reports due to software issues, and that some revised estimates actually increased, benefiting homeowners. What’s Next Attorney Gregory Kehoe of Greenberg Traurig is representing Heritage. He declined to comment on the pending litigation. Tolley has not yet filed a formal answer or motion to dismiss. The Heritage lawsuit accuses Lee of libel, slander, defamation, and fraud, and seeks monetary damages and legal fees. The amended complaint can be seen here. FAQs: Heritage Sues Adjuster Lawsuit What is the Heritage sues adjuster lawsuit about? The lawsuit centers on Heritage’s claim that Jordan Lee made false public statements on 60 Minutes, accusing the insurer of altering hurricane damage reports. Why is the Heritage sues adjuster case significant? The case highlights tensions between insurers and independent adjusters, raising broader concerns about whistleblower protections in Florida’s insurance industry. What could be the outcome of the Heritage sues adjuster case? If Heritage wins, Lee could face significant financial damages. If Lee prevails, it may strengthen whistleblower protections and increase scrutiny on insurer practices. For the latest updates on legal settlements, disaster recovery, and insurance fraud, visit JacobiJournal.com. 🔎 Read More from JacobiJournal.com:
Ohio BWC Recoups Nearly $4K After Fraud Investigation
April 10, 2025 | JacobiJournal.com — Ohio BWC fraud investigation efforts led to a recent guilty plea and restitution recovery in Columbus. On April 10, 2025, the Ohio Bureau of Workers’ Compensation (BWC) successfully recouped $3,816 after a woman admitted to working while collecting disability benefits. This outcome underscores how even smaller-scale fraud cases remain a priority for state investigators. While the restitution amount may seem modest compared to multimillion-dollar schemes, the Ohio BWC fraud investigation highlights the agency’s commitment to protecting the State Insurance Fund. Every fraudulent claim, no matter the size, has a direct impact on employers who pay into the system and on injured workers who rely on legitimate benefits to recover. The case also demonstrates the role of the BWC’s Special Investigations Department (SID), which frequently acts on community tips to uncover fraud. By leveraging tips, surveillance, and employer cooperation, the department ensures accountability and reinforces that fraudulent actions will be detected and prosecuted. Ultimately, this conviction sends a strong deterrent message: individuals attempting to exploit the workers’ compensation system risk not only financial penalties but also criminal records and potential jail time. For honest workers and employers, the vigilance of the BWC protects the integrity of Ohio’s workers’ compensation program. Investigation Begins After Tip The Ohio BWC fraud investigation started when the Special Investigations Department (SID) received a credible tip suggesting that the claimant was engaged in outside employment while continuing to collect disability benefits. Acting on the report, investigators launched a full review, which included checking payroll records, cross-referencing tax filings, and interviewing potential employers. SID investigators also conducted surveillance, a standard tool in workers’ compensation fraud cases, to verify whether the woman was actively working despite her claim of disability. This layered approach not only confirmed that she had worked for four different employers but also documented evidence strong enough to secure a guilty plea in court. By responding swiftly to community reports, the Ohio BWC demonstrates how proactive fraud detection safeguards the system. Each Ohio BWC fraud investigation ensures that funds remain available to support genuinely injured workers, rather than being drained by fraudulent claims. Woman Worked for Multiple Employers While Receiving Benefits The investigation revealed that the woman had worked for four different employers while collecting benefits she wasn’t entitled to. Evidence showed that she consistently earned wages across different job sites, all while continuing to receive disability payments from the BWC. This type of activity not only violated the terms of her benefits but also represented a clear example of workers’ compensation fraud. Investigators highlighted that cases involving multiple employers can be particularly concerning, since the claimant actively seeks out income opportunities while deliberately concealing employment status from the Bureau. Such actions create unfair strain on the system and undermine trust in the workers’ compensation process, ultimately driving up costs for honest workers and employers. Guilty Plea and Full Restitution Recovered Ohio BWC Recoups: On February 19, 2025, she pleaded guilty to a first-degree misdemeanor. The judge acknowledged that the BWC had already recovered the full restitution amount of $3,816. Protecting the State Insurance Fund SID, a criminal justice agency within the BWC, continues to pursue individuals who defraud the workers’ compensation system. By doing so, it protects the State Insurance Fund and ensures that benefits remain available for injured workers who genuinely need them. Source: Ohio BWC Newsroom – Fraud Investigation Restitution FAQs: Ohio BWC Fraud Investigation What triggered the Ohio BWC fraud investigation? The investigation began after the BWC’s Special Investigations Department (SID) received a tip that the woman was working while collecting disability benefits. How much was recovered in the Ohio BWC fraud investigation? The Ohio BWC fraud investigation resulted in the recovery of $3,816 in restitution after the woman’s guilty plea. What charges were filed in the Ohio BWC fraud investigation? The defendant pleaded guilty to one count of workers’ compensation fraud, classified as a first-degree misdemeanor in Ohio. Stay informed on the latest fraud cases, enforcement actions, and workers’ compensation updates. Subscribe to JacobiJournal.com today for weekly insights. Stay updated! 🔎 Read More from JacobiJournal.com:
Nautilus Insurance Sues Fleming After Murdaugh’s Conviction
Nautilus Insurance Sues Fleming: Days after a court ordered Alex Murdaugh to pay almost $15 million to Nautilus Insurance Co., his co-conspirator, Cory Fleming, is now on trial for his involvement in the fraudulent scheme. Murdaugh’s Fraud and Legal Consequences Alex Murdaugh, a prominent South Carolina attorney, drew global attention after he was convicted in 2023 for murdering his wife and son. Along with the murders, Murdaugh admitted to 27 counts of financial crimes, including defrauding insurance companies. Nautilus Insurance Sues Fleming Murdaugh and his friend Cory Fleming exploited an insurance settlement following the 2018 death of Murdaugh’s housekeeper, Gloria Satterfield. Murdaugh falsely claimed that his dogs caused her fall at the family’s hunting camp. He convinced Satterfield’s family to file a claim under his umbrella policy, and Nautilus Insurance paid $3.8 million. Instead of forwarding the settlement money, Murdaugh and Fleming allegedly diverted much of it for personal use. After Murdaugh’s confession, a court ordered him to pay $14.8 million in damages to Nautilus. Fleming, who helped with the fraud, now faces trial in a civil lawsuit for his role in the scheme. Fleming’s Trial and Legal Arguments Nautilus Insurance accuses Fleming of civil conspiracy and negligence, claiming that the fraud deceived and harmed the insurer. Fleming’s defense argues that Nautilus had ample time to investigate the claim and failed to uncover evidence of fraud. The Charleston Post and Courier reported that a Nautilus agent raised concerns about the Satterfield claim. Despite these warnings, the company proceeded with the settlement. After Murdaugh and Fleming’s criminal convictions, Nautilus gathered the evidence it needed and filed this civil suit. Fleming’s trial began on Monday and will likely conclude within the week. For more updates on this case, visit JacobiJournal.com. For further details, read the original article on Bloomberg.
Colorado Governor Proposes Privatization of State Workers’ Comp Carrier to Bolster Budget
In a strategic move to address Colorado’s budget shortfall, Governor Jared Polis has proposed privatizing Pinnacol Assurance, the state’s workers’ compensation carrier of last resort. By divesting the state’s interest in this quasi-governmental entity, Polis aims to generate additional revenue and ease fiscal pressure on Colorado’s general fund. Colorado Governor Privatization as a Financial Strategy Governor Polis’s proposal comes as Colorado faces significant budget challenges. According to a report by Colorado Politics, the plan could reduce the state’s general fund by approximately $630 million. This reduction is critical as Colorado confronts a projected budget gap of $672 million. If lawmakers allocate the mandated $350 million to a new law enforcement fund, the gap could exceed $1 billion. Privatizing Pinnacol Assurance could help the state bridge this gap. Polis believes the move will reclaim the state’s investment and redirect funds to cover pressing financial needs, as reported by the Denver Post. Historical Context and Legislative Considerations Privatizing Pinnacol Assurance is not a new idea. Over the past decade, similar proposals have surfaced, but lawmakers have not reached consensus. Current discussions indicate that legislators may require more detailed information to assess the plan’s feasibility and benefits. Pinnacol Assurance, established in 1915, provides workers’ compensation coverage to over 50,000 businesses in Colorado. However, its structure limits the company to selling policies only within the state and solely for workers’ compensation. This restriction has hindered Pinnacol’s growth and competitiveness, as noted by Colorado’s Sum & Substance publication. Future-Proofing Pinnacol Assurance Governor Polis believes that privatizing Pinnacol could allow the company to expand beyond state lines and diversify its services. This strategy could enhance Pinnacol’s financial stability and adaptability in a changing business environment. The governor’s plan includes drawing $100 million annually from Pinnacol for five years to support the transition and reform efforts. Polis emphasizes the importance of modernizing Pinnacol to better serve Colorado’s employers and employees. For more insights into Colorado’s policy changes and economic strategies, visit JacobiJournal.com. Additional details about Governor Polis’s proposal and its implications can be found in the original reporting by Colorado Politics.