Workers Comp Fraud

Leading the Fight on Fraud

The State Insurance Fund has been leading the fight on fraud with their arrest record nearing the 1,000 mark. State Insurance Fund’s special investigation unit, the Division of Confidential Investigations (DCI) is comprised of white collar crime investigators, most with over 20 years of law enforcement experience with top Law Enforcement Agencies. It is estimated that every dollar DCI uses to fight fraud returns $7 to $10 in savings through deterrence and restitution.

What is Workers' Compensation Fraud?

 Claim fraud can be broken down into two categories:
1. Claimant fraud
2. Provider fraud

Claimant Fraud


Claimant fraud occurs when a worker knowingly makes a false or misleading statement for the purpose of obtaining workers’ compensation benefits. The most common type of claimant fraud is when a worker exaggerates his condition in order to continue benefits relating to the work related accident they suffered.

Claim fraud can also occur when an employee files a claim for an accident that did not occur, injuries that do not exist or injuries that are not work related.

 

Types of Claimant Fraud to be aware of:

 

  • Malingering – when an injured worker recovers from their injuries, however, continues to receive benefits.
  • Receiving benefits while employed elsewhere – an employee who files a workers’ compensation claim and collects benefits while claiming they are unable to work and works another job without reporting income/work status.
  • Non-work related injury – when an employee claims he/she was injured at work, however the injury occurred while not engaged in work activities.
  • Non-injury claim – when an employee fakes an injury in order to collect workers’ compensation benefits. This often occurs after a layoff or plant closing announcement or rumor.
  • Multiple claims – an employee who files multiple workers’ compensation claims for the same injury.
  • Prescription drugs – when prescriptions are misused for illegally resale.

 

Provider Fraud

 

Provider fraud occurs when doctors, medical practices or medical laboratories charge excessive fees for medical services performed or charges for work never performed. Provider fraud can also occur if the provider convinces the employee to file a workers’ compensation claim in lieu of unemployment benefits claiming the individual can make more money. A less obvious form of provider fraud could be unnecessary tests or treatment, even if the injury is legitimate and some form of treatment is needed.

 

Types of Provider Fraud to be aware of:

 

  • False billing – when a doctor, clinic or lab bills for services not performed.
  • Kickbacks – a medical provider who pays or receives compensation for a patient referral.
  • Self-referrals – a medical provider who inappropriately refers patients to clinic or laboratory in which the provider has a financial interest
  • Upcoding – a provider who bills for a more expensive treatment or service than what was performed.
  • Unbundling – a provider that performs a single service and bills it as a series of separate procedures.
  • Over-utilization – a provider administers and bills for unnecessary medical services.
  • Product switching – a provider or pharmacy that bills for one type of product but dispenses a cheaper version.

Fraud: These are some “Red Flag” indicators to be aware of.

Everyone plays a role in combating fraud. Being aware of some “red flags” will help prompt additional questions and/or investigations into these issues.

  • Accident occurs on a Monday morning or late on a Friday and is not reported until the following Monday. What occurred over the weekend or during days off?
  • The accident occurs just prior to a strike, plant closing, layoff, job termination or end of seasonal work..
  • Accident was unwitnessed by any fellow employees.
  • Injured worker has a history of prior claims.
  • Substantial delay between date of incident and date reported to supervisor.
  • Different descriptions between employer’s accident investigation and medical provider’s report.
  • Difficulties reaching injured worker at home during disability period.
  • Injured worker’s attorney or medical provider is known for being involved in suspect claims.
  • Injured worker switches medical providers frequently.
  • After receiving a release to return to work, injured worker switches physicians.
  • Injuries are minor (strain/sprain), but requires excessive treatment and lost time.
  • Date of services do not correlate with the date of injury.
  • Injured workers from the same insured are all using the same medical provider or attorney.

What Can You Do to Stop Fraud?

An employer is the first line of defense.  Fraud prevention should be an important function of your accident investigations process.  Below are some steps that can be added to your accident investigation to assist in preventing fraud:

 

§ Immediately following an accident or incident complete a full accident investigation.

 

§ Take statements from all witnesses.

 

§ Have the injured worker give a written statement in his/her own words, and include the “fraud warning language” on the statement form they sign. (see sample forms is located at the end of this document)

 

§ Keep disposable cameras available for supervisors.  Photos can be very helpful for subrogation issues, safety committee meetings and the carrier’s investigations.

 

If any type of fraud is suspected then immediately report it to the Division of Confidential Investigations:

 

Albany    (518) 437-8083
Buffalo   (716) 851-2111
Endicott   (607) 741-3997
Nassua &Suffolk   (631) 756-4006
New York City   (212) 312-7302
Rochester  (585) 258-2023
Syracuse  (315) 453-6651
White Plains  (914) 997-4905

 

Fraud can also be reported on-line by accessing the State Insurance Fund’s web site at www.NYSIF.com or by contacting us at (914)381-5511.

Why Should You care?
 

Every dollar paid out because of insurance fraud must be made up by a dollar in additional premium. Increases in workers' compensation premiums are passed on by companies in higher prices for goods and services. Additionally, the hidden costs of fraud discourage businesses from giving raises, hiring or expanding, and force some companies out of the state and others out of business.

New OSHA Recordkeeping Requirements

1. ALL EMPLOYERS must follow the serious injury rule and….
  • Contact OSHA within 8 hours of a work related fatality.
  • Contact OSHA within 24 hours of a work related in-patient hospitalization, amputation or loss of eye.

For more information on reporting a fatality or severe injury click here.

 
2. EMPLOYERS WITH 11 OR MORE EMPLOYEES must maintain OSHA recordkeeping forms….
  • OSHA 300 log along with a claim report must be kept in your OSHA records. If you are unsure an incident is OSHA recordable use OSHA Recordkeeping Advisor.
  • OSHA 300a must be posted for all employees to view from Feb 1 to April 30th of each year.
  • Only employers in exempt industries can be exempt from this portion of the recordkeeping regulation. (See Partially Exempt Industry list).
 
3. EMPLOYERS WITH 20 TO 249 EMPLOYEES in certain industries employers must also annually file the OSHA 300a through OSHA.gov….

In addition to the rules listed above, employers with 20-249 employees per establishment (see definitions below for establishment) and are in OSHA’s list of high risk industries are required to electronically file their OSHA 300a forms annually.  The high risk industry list includes construction, manufacturing, utilities, department stores, general merchandise stores, general freight trucking, warehouse and storage, waste management services, and other high risk industries.  A complete list of OHSA’s high risk industries can be found at this link: https://www.osha.gov/recordkeeping/NAICScodesforelectronicsubmission.html

2016 data in Form 300A must be submitted by July 1, 2017, and again by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.
 
4. EMPLOYERS WITH 250 OR MORE EMPLOYEES must electronically submit to OSHA injury and illness information from OSHA Forms 300, 300A, and 301 through OSHA
 
Form 300A must be submitted by July 1, 2017, and must submit information from all forms (300A, 300, and 301) by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.
Forms, instructional videos, incident rate calculators, and interactive tools can be found in the Recordkeeping section of the Keevily Portal to help answer your questions about this OSHA regulation.
Establishment: The electronic reporting requirements are based on the size of the establishment, not the firm. The OSHA injury and illness records are maintained at the establishment level. An establishment is defined as a single physical location where business is conducted or where services or industrial operations are performed. A firm may be comprised of one or more establishments. To determine if you need to provide OSHA with the required data for an establishment, you need to determine the establishment's peak employment during the last calendar year. Each individual employed in the establishment at any time during the calendar year counts as one employee, including full-time, part-time, seasonal, and temporary workers.
You have three options for reporting the serious event:
 By telephone to the OSHA Area Office nearest to the site of the work-related incident.

By telephone to the 24-hour OSHA hotline (1-800-321-OSHA or 1-800-321-6742).

Electronically, using the event reporting application that will be located on OSHA's public website.  

Your Responsibilities as an Employer

Reporting Injury and Illness

When a workplace injury or illness occurs, employers are required under Section 110 of the New York State Workers’ Compensation Law to report the incident to State Insurance Fund in a timely manner. Benefits of reporting cases immediately :

  • Allows the injured worker to receive treatment and benefits promptly,
  • Allows carrier ample time to investigate claim,
  • Has been shown to reduce the costs of a claim,
  • Avoid penalties for late filing,
  • Helps the insurer monitor and administer the claim, and
  • Ultimately leads to the injured worker returning to work faster.

How soon must employers report a workplace injury or illness?

  Employers should notify their insurer immediately if the injury or illness:

  • Caused (or will cause) the worker to lose time from regular duties beyond the working day or shift on which the injury occurred.
  • Required (or will require) the worker to receive medical treatment beyond ordinary first aid, or more than two minor medical treatments.

State Insurance Fund must file paperwork accepting or denying the claim on or before the 18th day after the workplace injury or illness occurred, or within 10 days after the employer learns of the event — whichever period is greater.

How do employers report a workplace injury or illness?

An online system has been implemented by the NYS Workers Compensation Board to process claims with more speed and efficiency. Faster resolution helps lower claim costs. This process starts with you, the employer, filing a new claim Electronic First Report of Injury (EFROI) with NYSIF.

Is there a penalty for untimely reporting?

  YES. Employers should notify State Insurance Fund immediately of a workplace injury or illness as penalties of up to $2,500 for late or missing reports are possible.

Can employers challenge a claim?

  YES. Add all facts and concerns to the additional info section in the Electronic First Report Of Injury. Cases are transmitted to Keevily and NYSIF at which point we will begin to manage the issues .

To learn more contact a member of your Keevily claims team:

Ivana Molinari, WC Claims Assistant (914) 269-9459 imolinari@keevily.com

Mary Dennis, WC Claims Assistant (914) 412-0511 mdennis@keevily.com

Demeika Wheeler, WC Claims Assistant/ERTW (914) 269-9441 dwheeler@keevily.com

Janice Robinson, Sr. WC Claims Specialist (914) 412-0572 jrobinson@keevily.com

Richard Whitehill, Sr. WC Actuarial Specialist (914)412-0509 rwhitehill@keevily.com

Genevieve Keller, WC Claims Manager (914) 412-0563 gkeller@keevily.com

Early Return to Work

Reasons to Consider Early Return to Work to reduce your Workers Comp claim costs.

Reduce Claim Costs up to 70 Percent:  Not only are lost-time days reduced, but studies show medical costs are also reduced.  Premiums are loss sensitive, and claims impact your future costs.

Increase the Chances of your Employee Returning to Work:  There is only a 50% chance that an injured employee will return to work after a six-month absence; this declines to a 25% chance following a one-year absence and is further reduced to a 1% chance after a two-year absence.

Faster Recovery Period:  A good early return to work program treats work as therapy to help the injured worker recover three times faster than if they stayed at home.

Reduce Award Costs:  The potential for an injured worker to become permanently disabled is greatly reduced.

Reduce Fraud: Early return to work programs demonstrate that getting injured doesn’t necessarily mean getting paid for being out of work.

Increase Employee Morale:  Early return to work programs send the message that employees are a valuable asset rather than a disposable resource.

Early Return to Work can result in significant savings

It  can be applied to any industry and be successful with any company with some creative thinking.  The efforts are worth the savings.  An example of a company taking advantage of early return to work is Roto-Rooter Services Co. with workers’ compensation costs ranging from $1.40 million to $1.85 million each year. In 1993, after the launch of their early return to work program, this figure dropped to $365,000.

The research showed that three steps have the most impact:

  1. Early employer/worker contact
  2. An offer of lesser duties
  3. Contact between the employer and the doctor

And Keevily can help you coordinate the modified duty offer process.

Keevily has a specialized program that coordinates early return to work.  We work directly with the doctor and your company to develop a modified duty position and obtain approval from the treating physician.  We will help you through all the steps of the program and continue working with you until the injured worker is released to full duty. 

FORM

If you have any cases you would like us to review for Early Return to Work, please complete the "Job Demand Summary” and provide the injured worker's name.