Workers Compensation Insurance Fraud

Transcription

1 Don t Let Your Business Become a Victim! Fight Workers Compensation Insurance Fraud Ranney P. Pageler V.P., Fraud Investigations Department

2 Copyright 2011 EMPLOYERS. All rights reserved. This presentation may contain confidential, material, and/or non-public information regarding Employers Holdings, Inc. and its subsidiaries ( EMPLOYERS ). The United States securities laws prohibit any person who has received material, non-public information from an issuer from purchasing or selling securities of such issuer or from communicating such information to any other person under circumstances in which it is reasonably foreseeable that such person is likely to purchase or sell securities. EMPLOYERS and America s small business insurance specialist are registered trademarks of Employers Insurance Company of Nevada. Employers Holdings, Inc. is a holding company with subsidiaries that are specialty providers of workers' compensation insurance and services focused on select, small businesses engaged in low-to-medium hazard industries. The company, through its subsidiaries, operates in 30 states and the District of Columbia from 12 office locations. Insurance is offered through Employers Insurance Company of Nevada, Employers Compensation Insurance Company, Employers Preferred Insurance Company and Employers Assurance Company, all rated A- (Excellent) by the A.M. Best Company. Coverage is not available in all jurisdictions and varies by company. See for coverage availability.

3 Meet Our Speaker Ranney P. Pageler V.P. Fraud Investigations Department EMPLOYERS Has successfully referred more than 600 criminal prosecutions in 23 states for workers compensation fraud related crimes. Anti-fraud program has been the subject of numerous news media articles and broadcasts. Member of numerous anti-fraud organizations and taskforces.

4 Criminal Workers Comp Fraud A Crime Workers compensation insurance fraud is a crime: Many states have specific workers compensation or general insurance fraud statutes. All states have general theft/larceny statutes that include theft by trick or device. Many states have dedicated insurance fraud programs within the Department of Insurance, the Attorney General s Office or with local prosecutorial agencies. All police/sheriff departments have property or financial crime units.

5 Criminal Workers Comp Fraud - Reporting Reporting suspected workers compensation fraud is the same as reporting any other crime: You would call the police if you saw someone suspiciously entering a residence by forcing a door or a window. You would call the police if you saw someone breaking into a vehicle or an ATM machine. You should call the police if you suspect someone is committing workers compensation fraud.

6 Criminal Workers Comp Fraud - Defined An intentional misrepresentation (lie) to gain a workers compensation benefit. Document the initial statements or representations To: The employer Vocational rehabilitation counselor Claim examiner Co-workers Medical provider Neighbors and family Through: Notes Claim forms Deposition/testimony Telephone messages Hospital records Recorded statements, etc

7 Criminal Workers Comp Fraud Defined (Con t) Material Statement: Representation relating to matter which is so substantial and important as to influence party to whom made -Black s Law Dictionary 'Additional workers compensation benefits paid because of the misrepresentation.

8 Criminal Workers Comp Fraud - Proving Prove the misrepresentations (lie): Evidence of misstatements or misrepresentations : Payroll/employment records, prior claims history, prior medical treatment records, witness statements, surveillance video, etc. Prove Materiality: If truth had been known, fewer benefits would have been extended to the claimant: The claim examiner would have paid less or nothing in benefits; medical provider would not have prescribed as much treatment or medication; claimant would have been released to return to work sooner, etc.

9 Totally Fraudulent vs. Partially Fraudulent Totally fraudulent claim: Evidence proves that the industrial injury never occurred Arising Out of Employment/Course of Employment (AOE/COE) Partially fraudulent claim: Evidence proves a misrepresentation to gain a benefit during the course of a claim, but does not prove that the industrial injury never occurred (surveillance) Impact on policyholder s experience rating Totally vs. partially fraudulent claims and their effect on experience rating

10 What a Policyholder Should See in an Insurer s Anti-fraud Program Many states mandate and regulate insurance carrier anti-fraud activities: A Special/Fraud Investigations Unit (SIU/FIU) An anti-fraud plan Investigation into cases of suspected fraud Anti-fraud training to insurance carrier staff Anti-fraud outreach to policyholders and producers Required anti-fraud warnings on claim forms and checks Communication with law enforcement, prosecutorial and other authorized governmental agencies Written anti-fraud procedures Even if NOT mandated in your state, these areas should be addressed and demonstrated by your insurance carrier.

11 What a Policyholder Should See in an Insurer s Anti-fraud Program Additional desirable anti-fraud program components: Identification Verification (SSN, ISO, etc.) Provider Enforcement OFAC Compliance Coordination with other insurer functions (Loss Control, Underwriting, Premium Audit) Participation in alternative prosecution strategies (Tax, Drug Diversion, Medicaid, advertising, etc.) The Special/Fraud Investigations Unit should contain sufficient law enforcement/prosecutorial experience and knowledge to be successful in the areas of criminal investigation, prosecution and the criminal judicial system.

12 What a Policyholder Should See in an Insurer s Anti-fraud Program Coordination and integration of fraud investigations with claims investigations. Your Special/Fraud Investigations Unit (SIU/FIU) should: Review newly incurred claims for appropriate initial claims investigations (AOE/COE, Subrogation, Statements) Review ISO claim search information Review large loss/catastrophic claims (discussion of cases ancillary claim tools) Review all surveillance investigation results Review all re-opened or expanded benefit claims Maintain oversight of claims investigation vendors (Surveillance, other outside investigations, recorded statements) Coordinate criminal prosecution with the claims administrative legal process A Good Test: Ask your claim handler how to contact his/her Special/Fraud Investigations Unit.

13 Deterring Workers Comp Fraud Some simple, proven steps that help prevent fraudulent workers compensation claims: Clearly and continuously convey to all employees a commitment to workplace safety and a zero tolerance of workers compensation fraud Use insurer anti-fraud materials (posters, payroll stuffers, etc) to reinforce this message Educate all employees to the adverse impact that workers compensation fraud can have directly on each of them and their individual positions Contact your insurance carrier s Special/Fraud Investigation Unit BEFORE a claim is filed if you believe a suspect claim may be coming Report all claims in a timely manner Communicate accident inconsistencies to the claim examiner.

14 When You Suspect Workers Comp Fraud What should you do if you suspect workers compensation fraud is being committed against you? 1. Immediately articulate your suspicion to the claim examiner. 2. Articulate your suspicion to the insurance carrier Special/Fraud Investigations Unit. 3. If you feel the need to go further with the referral of a suspected case of workers compensation fraud: Contact your Department of Insurance, your Attorney General s Office, your local prosecutor s office or local law enforcement agency, as appropriate, for your jurisdiction.

15 Valuable Resources The Coalition Against Insurance Fraud provides a wealth of state specific anti-fraud information relating to insurance fraud statutes, insurer requirements and contact information for government insurance fraud units at

16 Valuable Resources (con t) EMPLOYERS How to identify workers compensation fraud Top 10 warning signs (Anti-Fraud Posters/Stuffers)

17 You may contact Ranney P. Pageler directly at EMPLOYERS Fraud Investigations Department: (800) While we can only handle suspected fraudulent cases for EMPLOYERS policyholders, please feel free to contact us with general workers compensation fraud questions. We can also provide contact information to direct you to the appropriate government agency or insurance fraud unit for your jurisdiction.

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