Over the last couple of weeks, we have discussed issues in both employee and employer workers’ comp fraud. The main premise that stands out is that workers’ compensation fraud is expensive at around $7.2 billion a year, and despite the incorrect public perception that employees are the main culprit, it is actually the employers and healthcare providers committing crimes that drive up the cost of premiums. Today, we will discuss healthcare provider’s role in workers’ comp fraud.

Medical Provider Fraud

The Georgia State Board of Workers’ Compensation Enforcement Division (O.C.G.A. 34-9-24), has specific guidelines on workers’ compensation fraud. If a medical provider is found guilty of “knowingly and intentionally making any false or misleading statement or misrepresentation for obtaining or denying workers’ compensation” they face up to one year in jail and up to $10,000 in fines. If a medical provider is found guilty of fraudulent receipt of benefits they face the same sentence.

Medical provider fraud is an intentional deceptive claim that a provider makesthat might result in that person receiving a payment. Importantly, even if the perpetrator does not receive payment, the fraudulent claim is still a punishable crime.The provider may submit deceptive charges, manipulate billing codes, or excessively treat a claimant intentionally.

Claim Mills

One of the primary medical providers who commits the crime of workers’ compensation fraud are the claim mills. This is also where a doctor conspires with plaintiff lawyers to come up with an over inflated claim. Basically, what happens is the worker will be examined by the physician who will conjure up an excessive list of problems that will require many tests, procedures, and treatments. Medical mills are staffed by criminals that likely have no medical degree and exist for one reason: to over bill the insurance companies and line their pockets.

For example, a medical mill might draw one set of laboratories to diagnose a condition but then bill the insurance for four sets. The “provider” may perform unneeded tests to create a “condition” on paper, just so they can bill for a problem that never existed. When this happens, most of the time the worker is unaware of the scam and will likely never see a medical bill.

Solo Medical Provider Fraud

Sometimes it is a lone medical provider guilty of workers’ comp fraud. These individuals try to minimize their chances of getting apprehended by keeping everyone else in the dark. Some examples of medical care provider fraud include:

•     Unusual duration of appointment or increased frequency.
•     Medical documentation doesn’t match the billed service.
•     Billing for services never received.
•     Referring a worker for treatment to a facility where the provider has a hidden, vested interest.
•     Upcoding by charging multiple times for one service.
•     Miscoding by using a random billing code unrelated to the service performed.
•     Getting payment based on a referral provide.
•     Handing out generic drugs while billing for more expensive, brand name medications.
•     Multiple claims are billed for the worker.
•     The provider submits identical medical reports for different employees.
•     The cost of the healthcare is much higher than expected with no reason.
•     The worker doesn’t remember being treated for the billed service.
•     The only procedures billed are for management codes only.

Any time a medical provider knowingly submits false information it is medical provider fraud. These cases are complicated and usually involve large amounts of evidence. If convicted, medical providers face serious consequences including incarceration, significant fines, and medical license revocation. If you are an injured worker and feel you are a victim of medical provider fraud, consult with an experienced workers’ comp attorney to help you understand the process and your rights.

Workers’ compensation fraud is a felony that hurts everyone. People often think of it as a victimless crime, but it affects employers, employees, and drives up insurance cost for the entire state’s economy. Fighting fraud is truly a team effort and should be taken seriously by everyone.