How to protect yourself from rising medical provider and claimant
According to the National Insurance Crime Bureau (NICB), Workers’ Comp
fraud referrals were up by 2% in the first half of 2009. While premium
fraud decreased 21%, medical provider and claimant fraud have increased.
Frustrated employers often have suspicions about claimant fraud, recognizing
that an employee may be faking or exaggerating an injury. Yet, medical-provider
fraud is often the biggest cost driver.
Risk and Insurance is currently
producing an in-depth series on fraud by Steve Tuckey. In the October
2009 article, he notes that the California Fraud Assessment Commission
finds that only 20% of the arrests have to do with claimant fraud and
the balance is for medical provider and employer fraud. Medical provider
fraud can range from unnecessary surgeries, excessive office visits,
inflated billing, billing for services not rendered, etc.
To help combat fraud, here are some tips offered by the NICB.
- Advise injured employees to be wary of attorneys or people who allege
to be insurance representatives and immediately solicit treatment at
a medical facility.
- Check doctors’ and attorneys’ credentials. Contact
state medical licensing boards or bar associations for information.
for medical mills. Medical mills can include fraudulent physicians
who fabricate credentials, billing and provide no medical services,
while recruiting individuals with bogus injuries. It also includes
double-dipping doctors who do provide medical services but treatments
are excessive, redundant or unnecessary. It helps to seek a second
- Be aware of inflated billing. According
to NICB, “the
most common type of medical mill is a healthcare provider who purposely
miscodes diagnoses and inflates bills to receive more insurance
money.” Match bills to records of visits and medical treatments.
- Watch for referrals. Attorneys involved in medical mill
operations often insist that an injured employee seek medical advice
from a specific doctor.
to the tips from the NICB, employers can protect themselves by:
aware of fraudulent billing. According to an article in the Los
Angeles Times, some California employers, including Walt Disney Co., plan to
send notices to injured workers to check if they in fact received the
medical services that are being billed for. Criminals obtain data on
injured workers and set up fake medical labs then bill insurers for
treatment that never occurred.
- Monitor social media cautiously. Social
networking sites can be a useful tool in identifying employee fraud;
however, employers need to adhere to privacy laws and avoid spying
on private, non-public pages.
- Use evidence-based guidelines. Evidence-based guidelines
in determining medical treatments and procedures for Workers’ Compensation
injuries can offer protection against unneeded and costly medical
treatments. While certain types of fraud such as musculoskeletal
treatments may go undetected, the guidelines can slow the incidence
a helpful brochure by the National Insurance Crime Bureau.