Only You Can Prevent Fraud & Penalties! A guide for insurers and employers to avoid common penalty scenarios and reduce fraudulent claims practices.

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Elinor Cole
8 years ago
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1 Only You Can Prevent Fraud & Penalties! A guide for insurers and employers to avoid common penalty scenarios and reduce fraudulent claims practices.

2 Investigations and Sanctions Unit Sanctions Program Compensation penalties Civil penalties Benefit suspensions IME location appeals

3 Suspensions Injured worker failure to cooperate ORS (14) Missed IMEs Injurious practices

4 Investigations and Sanctions Unit Investigations Program Inducement Accepting Notice Directing Treatment Claims Handling Practices General Rule Violations

5 Authority The Law ORS = Oregon Revised Statutes Chapter 656 = Workers Comp Law Example: ORS

6 Authority Administrative Rules OAR = Oregon Administrative Rules Chapter 436 Division 60 covers claims handling by insurers and employers Return-to-work issues in Div 105, 110 & 120

7 Worker Fraud Insurer Special Investigations Unit (SIU) See ORS DA referral WCD cooperates

8 Fraud Investigations Insurer must investigate before they can issue a claim denial.

9 Fraud Investigations Employer is required to cooperate with claim investigation.

10 It s Not Always Fraud Insurers also need to know that. 85% of disabling claims are accepted. Misstatements cause delays and could Misstatements cause delays and could cost $$$.

11 What Can Employers Do? Consider red flags Pay attention Write it down Call your insurer

12 Red Flags Concurrent employment Un-witnessed accident Accident timing Worker history

13 Pay Attention! Know your workers Hobbies and skills Work ethic Family

14 Write It Down It may be months before action It may be months before action is taken.

15 Call Your Insurer Details = $$$ Physical description Vehicles Dwelling Housemates Avocations

16 What Can Workers Do? The truth, and nothing but the truth Insurer Employer Doctors Attorneys Judges

17 Investigations Issues worker complaints Inducement to not file ORS Up to $2,000 penalty

18 Investigations Issues worker complaints Employers often misunderstand the small claims provisions ORS (5) Currently $1,600

19 Investigations Issues worker complaints First aid OAR (4)

20 Investigations Issues worker complaints Bonus programs WCD supports bonus programs but Inducement to not file = up to $2000 penalty See ORS

21 Investigations Issues more worker complaints Accepting notice of claim ORS OAR (1) Note: There is a difference between notice of claim and notice of injury

22 Investigations Issues more worker complaints A signed Form 827 is a claim! ORS OAR (2) These complaints also come from providers

23 Investigations Issues insurer complaints Premium fraud Provider billing fraud

24 BEST PRACTICES

26 Best Practices - employers Display current compliance notices Get it from your insurer or from WCD It s the law! ORS

27 Best Practices - employers Keep an incident log available for review for 5 years OAR (4)

28 Best Practices - employers Employers must accept all notices of claim and provide receipt at once

29 Best Practices - employers Instruct workers that they have choice of physician Even if there is a drug-test policy

30 Best Practices - insurers Educate! Correct reporting procedures Immediate access to first injury report forms (Form 801)

31 Best Practices Promptly return phone messages from employers, insurers, and WCD. Avoid civil penalties for nonresponse, or for late response!

32 Penalties and Actions Non-response is typically $350, then $700, then $1,000 Then the claims manager gets a call from Bob Late response typically $50 per day up to $350

33 Penalties and Actions Other penalties as prescribed by law Up to $2,000 per violation. ORS

34 DCBS is here to help For assistance with coverage issues or other employer-related questions, call the Office of the Ombudsman for Small Business

35 DCBS is Here to Help For assistance with how to proceed with a claim, call the Ombudsman for Injured Workers

36 WCD is Here to Help For questions about laws and rules call our Benefit Consultants at Or ask for Investigations and Sanctions Unit Leah Bingham, Investigator, Bob Hamre, Manager

37 QUESTIONS?

WILLIAMSON COUNTY, TENNESSEE WORKERS COMPENSATION ANTI-FRAUD PLAN

WILLIAMSON COUNTY, TENNESSEE WORKERS COMPENSATION ANTI-FRAUD PLAN I. Provisions for the prevention, detection and investigation of workers compensation fraud. Williamson County Government will take all