Workers’ Compensation Fraud III – The Provider

Provider fraud occurs when an intentional misrepresentation of the facts of an injury are presented by the provider.  According to one survey, employers blame providers for workers’ compensation fraud about ten percent of the time.

Fraud can take many forms, but it generally falls into two basic categories.  First is billing fraud.  We have all heard of providers who take advantage of the workers’ compensation system.  Intentionally increasing bills by adding services that were never rendered is clearly fraud.  Obviously, whenever these “additional” services are billed, thousands of dollars can literally be stolen from the insurer.   Most often, the worker does not even know billing fraud is taking place and is caught in the delays in care because of billing reviews.  In addition, insurers are forced to incur more claims costs due to the billing review process, case managers being attached to questionable claims and possible legal action being taken against a provider.

The second category of provider fraud is a little subtler, but is no less fraud.  When a medical provider deliberately documents that a worker has any type of disability that does not have any basis in fact, that provider is committing fraud.  This does not mean differing from different providers’ medical opinions regarding a condition, nor does it mean that an initial diagnosis cannot be ruled out with objective findings.  Here are some basic “red flags” for provider fraud that you should watch for, as provided by Ohio Bureau of Worker’s Compensation website.  None of these stands alone as fraud, but does give you a reason to ask questions.

  • Injured worker doesn’t recall having received the billed service
  • Provider’s medical reports read almost identically, even though they were submitted for different patients with different conditions
  • Frequency of treatments or duration of treatment is greater than expected for allowed injury type, especially for older (non-catastrophic) claims
  • Larger volume of prescription drugs billed than expected for the allowed injury type
  • No change in treatment given regimen or no measurable improvement after an extended period
  • Same provider(s) and attorney(s) are repeatedly associated with questionable claims
  • Provider services are billed (for non-emergency care) for dates of service on weekends or holidays or on dates when the patient was hospitalized
  • Provider bills for dates of service after the effective date for change of provider record
  • Documentation does not support service billed and/or is inconsistent with the services billed
  • Frequent delays in the submission of requested records
  • Provider is actively billing multiple claims for an injured worker; day or date of service is inconsistent with the type of provider