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Thread Title: Fraud
Created On Monday May 23, 2005 4:47 AM

Hammer
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Monday May 23, 2005 4:47 AM

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Has anyone noticed that lately all the news about fraud pretains to ICs going after employers who try not to pay the "proper" premiums for wc coverage?

Joe-No.1

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majones
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Tuesday May 24, 2005 7:54 AM

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Joe,
Isn't it better that they go after the big guns like examiners, employers and doctors than the injured workers? I honestly believe it's the DOI and DA's office focusing on that direction. When we refer a claimant for fraud, it will be months and months before we even get a return call from the DA's office. However, if it's an employer or medical group, we get almost immediate responses. We had a case where the claimant alleged serious injury after a cart "fell on her" when the video of the entire incident showed the cart fell and she merely had one hand on the cart and it fell away from her. The DA and DOI didn't even look at the video for over a year. The examiner reporting the fraud will probably be retired before it ever gets prosecuted.

Makes no sense to me!

M

sfex
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Tuesday May 24, 2005 10:16 PM

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The DA goes after the deep pockets.

Employer premium fraud accounts for the higher premiums paid by ALL insured employers more so than each individual
injured worker's case with fraud amounting to less than $100,000 on average if prosecuted successfully.

It's easier to prosecute ER fraud because there is less ambiguity about intent vs. employee fraud where perhaps the injured worker was confused due to the medication he/she was taking and did or said something they shouldn't have. Prove it was intentional or there is no fraud.

I handled an account once where the ER claimed a payroll of only $100,000 which seemed pretty low since there were several employees covered under the policy. Then we received a claim in for the vice president of the company, who was included in the workers comp policy. When I asked for wage info, turned out this VP made close to $90,000 a year, leaving his employees with only $10,000 between the 3 of them.

Something doesn't sound right there.

Hammer
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Wednesday May 25, 2005 6:19 AM

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My point was that the IC are usually the ones that call the shots and purse IWs for fraud. Now with SB 899 and the amt of money the Ic's are making it is interesting to see that the IC have turned their attention away from the little guy. ICs and are now focusing on the employers.

I had previously mentioned that it was about time for Arnie to get the media machine grinding about fraud by the IWs, AA & medical providers as he is about to start his initative drive. I noticed in WCC news today that the city of San Diego's DA's office has commenced a new program, created for the purpose of going after IWs, AA & medical provders for fraud. BIG NEWS I hate to say "I told you so" This is merely the first and by no means the last we are going to be seeing in the news about those big bad, awful AA, medical providers and IWs.

Joe- No.1

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sfex
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Wednesday May 25, 2005 6:45 PM

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I tend to agree with Majones though that by the time the DA prosecutes one of my fraud cases, I'll be in retirement or perhaps beyond.

Got some really good cases too, with written documentation from the injured worker's own handlwriting (and signed) stating what the issue was, then surveillance tape on 3 occasions showing otherwise. Subpoenaed records that prove our point, and injured worker refuting those records again in writing.

I don't get it either...

laesquire
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Wednesday May 25, 2005 6:54 PM

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The carriers are running things. They are drunk with financial power. Who will go after them? Arnold? The insurance commissioner?

The carriers are charging outragous rates and want to make sure as many Employers as possible pay the full unregulated premium.

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Any posting herein is NOT legal advice. It also does NOT create and attorney-client- relationship.

majones
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Thursday May 26, 2005 8:18 AM

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I agree that the rates need to be regulated. However, excuse my ignorance, but maybe someone can explain how the IC's can drastically reduce their rates NOW when the new laws just took effect and they're still paying out so much on the old cases. Who knows how the new laws are going to play out, especially with AA's litigating every issue of the new laws and trying to get them overturned? If they get overturned or repealed, then the IC's will lose a tremendous amount of money if the employers have paid much lower premiums?

Again, I apologize for my ignorance, but I may be looking at this wrong.

M

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