FRAUD AND ABUSE
CAN ADVERSELY AFFECT
YOUR BUDGET
YOU HAVE THE RIGHT TO KNOW
THE ACTIVITIES OF YOUR DISABLED EMPLOYEES
AND CONFIRM THE VALIDITY OF EVERY CLAIM
An employee out on disability (lower back) documented in the conduct of his own carpeting business.
What We Do
At very low cost to you, our investigators objectively document the activities of claimants to confirm the validity of FECA claims made. If needed, the Department of Labor, Office of Workers Comp Programs has granted our company written access to their files.
Our Services
This is often the first service requested. Various database checks are made to confirm the claimant's provided information and document his current profit or non-profit employment. Physical checks can be made to confirm the claimant's physical activities. A full captioned report is returned to the requesting authority within 14 days. The results of these checks may show the case warrants further investigation. The cost is $60.73 per hour. You should budget about $500 for this service.
This is the full investigation with video documentation of the physical abilities of the claimant. Other employment is fully documented. Three copies of all VHS videos are provided for your use. We can present video to medical providers and at any hearings. A full captioned report is returned to the requesting authority within 14 days with status reports every 30 days. We will stay with the case through to final resolution. Cost is $60.73 per hour. You should budget about $2,500 for this service.
BRIEF IN-PERSON CLAIMANT INTERVIEW:
Three attempts would be made during normal working hours to find the claimant at his stated home address. If home, he is interviewed briefly and a report on the claimant's current condition is returned to the requesting authority. If the claimant is not present, further investigation may be warranted. This service is of use to executives with claimants who have been off work for some years. Cost is $60.73 per hour. You should budget about $250 for this service.
COMPENSABILITY INVESTIGATION:
An on-scene inquiry is begun as soon as possible after notification of a work-related injury. Recorded or written statements can be obtained from the employee, supervisors, co-workers, witnesses or involved third parties. Matters such as subrogation, concurrent employment and apportionment are factually documented. Official reports are gathered and summarized. Full captioned report is returned to the requesting authority within 14 days. We work with health and safety departments in the execution of the investigation. Cost is $60.73 per hour. You should budget about $600 for this service.
Your best defense against any abuse of the benefit system is knowledge of how abuse can occur. Our trained and experienced investigators will come to your office, meeting or conference. We deliver multi-media training showing lots of actual examples. The presentation is very entertaining but is also enlightening to all personnel involved in the claims process. Topics include current fraud and abuse MO's, effective subrogation investigations and collections, as well as subjects tailored to your needs. Cost for a full day of training is $608 and $304 for a halfday seminar.
Our investigator is dispatched to your offices where all questionable claims will be personably reviewed with you. Recommendations for further action will be presented and explained. Many questions about cases can be resolved on the spot. Cost is $60.73 per hour.
If there is any subrogation possible, we will document the claim and collect and return all funds owed. There is no hourly fee for this service. We charge only a small percentage of monies actually collected.
The Difference Between Fraud and Abuse
Inspector General, Fraud Investigations
NYS Workers' Compensation Board
What is fraud? What is abuse? What is the difference between them? Because abuse is a very broad term, it is easy to confuse the two.
Workers' compensation abuse is any practice that uses the workers' compensation system in a way that is contrary to either the intended purpose of the system or the law. This includes some behavior that is not criminal and some that is, most significantly, fraud.
In the simplest terms, insurance fraud occurs when someone knowingly and with intent to defraud, presents or causes to be presented, any written statement that is materially false and misleading to obtain some benefit or advantage, or to cause some benefit that is due to be denied. If there is no material, written lie, there may be abuse, but it is not fraud. However, workers' compensation fraud may be committed by a false statement, which could be verbal.
Merely filing a claim that is not warranted or violating the rules of the workers' compensation system, in the absence of fraud (a lie) or kickbacks, may be abuse, but it is not criminal. The specific elements of fraud must be present. Similarly, over-treatment by a physician might represent a difference in opinion; although it could appear excessive and possibly abusive, it does not necessarily constitute fraud. Typical abuses of the system also include magnification of complaints or disability that fall short of an outright lie, or an over utilization of benefits. For example, soft tissue injuries give rise to subjective complaints that they cannot either prove or disprove.
An employee with disabling knee injuries documented in the conduct of his own air conditioning business
The presence or absence of a specific, provable lie is the deciding factor. To separate fraud from abuse, it is necessary to look for the material, written lie that was presented or caused to be presented to or by an insurer. (State) Penal Law punishes written fraud only; the Workers' Compensation Law also prohibits oral fraud, in addition to written fraud.
For example, returning to work while receiving temporary disability payments might be abuse, or it might be An employee with disabling knee injuries documented in the conduct of his own air conditioning business.
fraud, depending upon the circumstances. If temporary disability benefits continue when the claimant has returned to work, and no one ever asks the claimant "are you working?", there is an abuse of temporary disability benefits, but there is no written lie and therefore no insurance fraud.
However, using the same example, if someone, such as the adjuster or the doctor, specifically asks the claimant "are you currently working?" - and the claimant replies "no" and thus lies, and that lie is transcribed in a written instrument (e.g., doctor's report or employer's claim form) there is insurance fraud and a possible action under the Workers' Compensation Law and Penal Law, if the lie is relied upon to determine the amount and payment of temporary disability.
The Workers' Compensation Reform Act of 1996 has made it easier for prosecutors to establish fraud cases. Under an amendment to Section 132 of the Workers' Compensation Law, every check issued directly to a benefit recipient or health care provider must contain a statement directly beneath the endorsement line indicating that in endorsing the check, the signatory certifies that s(he) is entitled to such payment and that the circumstances which would affect entitlement to payment have not changed. Thus, with every check that is presented, prosecutors potentially have the basis for the "written lie" that is essential to a fraud case.
Though not legally a fraud, offering or accepting kickbacks for the referral or settlement of cases is a reportable and prosecutable crime. Kickbacks indirectly feed the problem of fraud and as a result, cause damage to our society and our economy. Consequently, the legislature has determined that paying and receiving kickbacks can contribute to fraud and are punishable criminal acts.
In separating criminal insurance fraud from abuse, remember these key elements:
• There is always a false representation - the lie
• The lie must be intentional or knowingly made
• The lie must be made for the purpose of obtaining a benefit the claimant is not due, denying a benefit that is due, or obtaining insurance at less than the proper rate
• The lie must be material, that is, it must make a difference: If the truth had been told, would you have done anything differently?
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