On Wednesday, Rebecca participated in a Webinar for an Illinois Workers’ Compensation Association. She presented on the topic “Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting.” In front of an audience of case managers, attorneys, human resource personnel and other healthcare professionals, Rebecca had a lively discussion on many aspects of healthcare fraud in a Workers’ Compensation setting.

Some highlights include:
Overall numbers –
The Insurance Information Institute estimates that all property/casualty insurance fraud cost insurers $30 billion annually.

Workers’ Compensation fraud accounts for approximately 25% or $7.2 billion a year, according to the National Insurance Crime Bureau (NICB).

The NICB characterizes Workers’ Compensation fraud as the “fastest growing segment of insurance fraud” in the nation.

Most studies indicate that the three parties primarily driving the cost of workers’ comp fraud are employers, medical providers, and employees.

Tips on spotting fraud:
Worker Claim Fraud
• Number of days worked and amount of salary inconsistent with occupation
• Injured worker disputes average weekly wage due to additional income (i.e., per diem and/or 1099 income)
• Cross-outs, white-outs and erasures on documents
• Injured worker files for benefits in a state other than principle location of the alleged industrial injury or occupational disease
• Injured worker-listed occupation is inconsistent with employer’s stated business
Employer Fraud
• Business displays or presents a Certificate of Coverage that contains inaccurate data, such as an implausible period of coverage
• Cross-outs, white-outs and/or erasures on documents, such as the Application for Ohio Workers’ Compensation Coverage (U-3) or Payroll Report (DP-21)
• Business name is not consistent with type of work being performed
• Number of employees, classifications and payroll are inconsistent
Provider Fraud
• Injured worker does not recall having received the billed service
• Provider’s medical reports read almost identically even though they are for different patients with different conditions
• Much higher healthcare costs than expected for the allowed injury type
• Frequency of treatments or duration of treatment period is greater than expected for allowed injury type, especially for older (non-catastrophic) claims

When investigating workers’ compensation fraud, always request detailed medical records and records of the injury. If all the facts don’t add up – you might be looking at fraudulent activity.

Roughly 60 billion healthcare dollars are lost each year due to fraud, waste and abuse. How does this theft affect you the taxpayer and healthcare consumer?

The answer is surprisingly simply ­ it hits your wallet first. Insurance premiums are increasing at a staggering rate ­ 33% in the last five years. If this continues, most individuals will not be able to afford any type of insurance, costing taxpayers even more because they will be the ones footing the bill for the uninsured.

Insurance premium increases hit the employer even harder. Many times employers (especially small businesses) are forced to reduce their workforce to accommodate the rising costs or even cut healthcare benefits entirely.

Prescription drugs are an area that is greatly affected by fraud. Fraudsters are fans of selling counterfeit medication. Consumers ingesting this medication (many times laced with poison ­boric acid for example) can end up in the emergency room with complications costing thousands.

The recent passage of Healthcare Reform is also proving to be good news for fraudsters. Many consumers have little to no knowledge of the bill and scammers have found multiple ways to cheat the innocent out of their money.

Fraudsters prey on the fear and confusion brought about by the bill. Going door-to-door selling fake insurance, scammers advertise an “ObamaCare” plan and insisting consumers better act fast due to a “limited enrollment” period. These scams bilk consumers out of thousands of dollars and leave them without any real insurance, so if a medical emergency where to occur, they would be left footing the bill.

So, what can the consumer do to help combat healthcare fraud? First, understand exactly what you’re being charged for and always ask for clarification on any charges for services that you do not recognize. Second, know where your medical identification is and alert proper authorities when your insurance card has been stolen ­ medical identity theft crimes can leave you sorting out medical bills for the rest of your life. Finally, be a conscientious healthcare consumer. Be aware of current fraud schemes and check out the Food & Drug Administration website to ensure your medication is not on the counterfeit list.