Identifying And Preventing Provider Fraud In Workers Comp Cases

Claimant fraud and premium fraud are two of the most well-known types of workers compensation fraud.

In these cases, a worker may intentionally fake an injury (claimant fraud) or a business owner may misrepresent their employee headcount or incorrectly classify employees to obtain lower insurance premiums.

Now, a lesser-known type is occurring with greater frequency: provider fraud. Provider fraud occurs when a professional other than the injured worker or employer accepts a bribe or illegal kick-back in exchange for patient or client referrals. The circle of potential culprits includes lawyers, translators, doctors, chiropractors, nurses, and telehealth professionals.

Opportunity, incentive and rationalization -- the ‘fraud triangle’ -- are key factors that go into a person’s decision to commit insurance fraud. These factors have been exacerbated in recent years, due in large part to the pressures presented by the global pandemic and the growing reliance upon remote services.

Most schemes involve knowingly billing for medical goods and medical and legal services that are unnecessary or not provided at all.