A Publication of WTVP

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 10 percent of the time.

Fraud can take many forms, but it generally falls into two basic categories. The 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 by the delays in care because of billing reviews. In addition, insurers are forced to incur more claim costs due to the billing review process, case managers are attached to questionable claims and possible legal action is taken against a provider.

The second category of provider fraud is a little subtler, but is no less fraudulent. When a medical provider deliberately documents that a worker has any type of disability that does not have a factual basis, 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. To clarify, 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 hasn’t received the billed service.
• Provider’s medical reports read almost identically, but they were submitted for different patients and 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 or no measurable improvement after an extended period.
• Same provider(s) and attorney(s) are repeatedly associated with questionable claims.
• Provider bills for dates of service after the effective date for change of provider of 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 injured worker.
• Date of service is inconsistent with the type of provider.

Many good medical providers get categorized with medical providers who have questionable practices. Did a competent person answer your questions? Communication with your provider can prevent these fraudulent practices. IBI