National Fraud Awareness Week is November 11 thru 17
Plain and simple, workers’ compensation fraud hurts everyone. It’s one of the cost drivers resulting in high insurance premium rates, businesses leaving the state and closing or scaling down operations. And if that isn’t enough, according to the Department of Insurance (DOI) fraud is a $500 yearly cost to every Californian. State Fund has earned a reputation as an industry leader in combating fraud. The core of our program is our 26-member Special Investigation Unit (SIU) supported by a 16-member Special Litigation Unit and more than 78 Investigative Liaisons throughout State Fund.
We all can make a concerted effort to stop fraud in its tracks. The National Fraud Awareness Week campaign highlights State Fund’s TIP reporting as our internal way to report and combat fraud. SIU established the Fraud Hotline (888-STOP FRAUD) as a way for employers, providers and vendors to report suspected fraudulent activity. Dedicated SIU investigators review all reports of suspected activity and report their findings to the California Department of Insurance and local district attorneys offices.
State Fund continues its efforts by fighting all types of workers’ compensation fraud, including premium, claims, and provider (medical, legal, and other service providers). Warning flags of suspicious activities can help us do are job by investigating reports in more detail. We listed several ‘red flag’ warnings that can be helpful in our fraud fight.
Claimant Fraud
- The claimant took unexplained or excessive time off prior to the claimed injury.
- "Monday morning" injury or a late Friday injury not reported until Monday morning.
- Applicant frequently changes physicians.
- Applicant refuses diagnostic procedures to confirm injury, or refuses to attend a scheduled defense medical exam.
- After being released to work applicant introduces new symptoms.
Medical Fraud
- Treatment dates appear on holidays or other days that facilities would not normally be open.
- Doctor ordered diagnostic testing that is not necessary to determine extent of applicant's injury or diagnostic testing is performed, yet there is no request by doctor in medical files.
- Medical bills submitted are photocopies of originals.
- Post Office Box is used as a medical provider address and/or the physician cannot be located at address shown on documentation.
- Doctor who may be working outside of specialty.
Policy Fraud
- Claims filed under a class code that has no reported payroll.
- Contractor working without a valid license.
- Employee reports wages were paid in cash or by personal check and/or employee provides 1099 as proof of earnings.
- Unusual ratio of clerical and non-clerical for type of business.
- Injury count doesn't match the number of employees and/or amount of payroll being reported.
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