A Publication of WTVP

I’ve been skeptical about the recent changes in the workers’ compensation laws in our state. However, eliminating balance billing of patients for workers’ compensation medical bills and the fraud provision actually made good sense.

In the past, medical providers could charge any amount for medical services, and the insurance company would pay whatever they chose under their own reasonable and customary (U&C) provision. The remainder of the bill usually fell on the shoulder of the patient. The obvious implications were overcharged, underpaid, and unpaid medical bills that led to disgruntled employees seeking legal counsel.

Now that the balance billing provision has been joined with the medical fee schedule provision, the results should have some positive effects. Medical providers have defined charge levels, insurance carriers must reimburse these charges—no more U&C—in a defined timely manner, and employees won’t be left holding the proverbial bag. Hopefully, this will reduce some of the workers’ compensation litigation in the state.

The second change—a long time coming for all parties—is the fraud provision. While it’s my experience that most workers who seek care for a work-related injury are truly injured, in my 10-plus years of working in the comp arena, there have been some cases that were not only laughable and ridiculous, but were outright cases for insurance fraud. Until now, there were no fraud provisions in the workers’ compensation laws. The primary option was through the division of insurance, but the convoluted nature of the process made it difficult to win cases.

My most memorable example of what should have been prosecuted fraud was a 23-year-old gentleman who was scheduled for a functional capacity evaluation at one of my former employers. This gentleman used public transportation to get to his appointments. One day, the bus was late on its route. With the bus stop only a block away from the clinic, I could watch out the window and see the guy walk to the clinic. On this day, he did not walk to the clinic—he sprinted to the front doors. Upon entering the clinic, he suddenly developed a dramatic limp that wasn’t present when he was running. After the visit, he proceeded to limp out of the clinic, only to sprint back to the bus stop so he wouldn’t miss his ride.

The new provision states, “Any person violating [the fraud provision] is guilty of a Class 4 felony. Any person or entity convicted of any violation of this Section shall be ordered to pay complete restitution any person or entity so defrauded in addition to any fine or to sentence imposed as a result of the conviction…Any person convicted of fraud…shall be civilly liable to the payor of benefits…in an amount equal to 3 times the value of the benefits…plus reasonable attorney’s fees and expenses incurred by the payor[.]”

In short, running to the bus stop now can get you into trouble. IBI