Types of Fraud Investigated by the Office of the Inspector General
In addressing fraud within the workers' compensation system, the Office of the Inspector General conducts investigations into the following types of fraudulent conduct:
1. Employee Fraud
Occurs when an employee knowingly and intentionally misrepresents, or causes another to misrepresent a material fact about an injury for the purpose of obtaining, or helping another obtain workers' compensation benefits to which they are not otherwise entitled. The misrepresentation must be knowingly made as an inadvertent or unintentional misstatement is not fraud. The misrepresentation must have been made for the purpose of obtaining or denying benefits, and important enough to impact upon receipt of those benefits. For example, a misrepresentation by an employee that they were 25 years of age when, in fact, they were 22 years of age would not be a material misrepresentation constituting fraud unless the age difference was somehow significant to the claimed injury and to the determination of workers' compensation benefits.
Examples of Employee Fraud
- Filing a claim for an injury that did not occur on, or has no relation to the job.
- Lying about work status when questioned directly, such as at a deposition or a hearing, while receiving temporary disability benefits.
- Misrepresenting the severity of a claimed injury.
2. Employer Fraud
Occurs when an employer knowingly misrepresents facts about its employees in order to obtain a workers' compensation coverage for a premium price that is less than what the employer would otherwise be obligated to pay if all the facts about its employees were known to the issuer of the policy. Also occurs when an employer knowingly misrepresents facts to avoid, deny or obtain compensation on behalf of employees, or knowingly lies about entitlement to benefits to discourage an injured employee from pursuing a claim.
Examples of Employer Fraud
- Under-reporting the number of employees
- Misclassifying employees as independent contractors
- Misrepresenting the nature of the work performed by the employee
- Misrepresenting past loss experience
- Misrepresenting the company ownership
- Falsely informing an employee that workers' compensation benefits are only available if he or she has been employed for six months or more.
3. Health Care Provider Fraud
Occurs when a health care provider knowingly and intentionally submits a material misrepresentation about medical treatment afforded a workers' compensation claimant in a bill or invoice that the health care provider presents to the Board or to the insurance carrier for payment. Health care fraud includes frauds committed by any provider in the workers' compensation system, such as doctors, rehabilitation counselors, pharmacists, or chiropractors.
Examples of Provider Fraud
- Billing for exams of patients who were never examined
- Billing for treatment of patients who were never treated
- Duplicate billing in order to receive payment from different insurance carriers for the same medical treatment
- Billing follow-up exams as "first exams" to receive greater payment from the carrier
- Bundling unnecessary medical services with necessary services
- Misrepresenting the true code for the medical treatment provided