Combating Medical Fraud in Workers’ Compensation Claims

Managing Member Alan G. Brackett and Associate JoAnn Hymel are co-authors of the “Attorney Analysis” column for Reuters Legal News. Their most recent article, “Combating medical fraud in workers’ compensation claims,” was published on July 6, 2022. Following is an excerpt from the article, which you can continue reading on Reuters Legal News. You can also download a PDF of the entire article at the link below.

Combating medical fraud in workers’ compensation claims

Workers’ compensation is a “no-fault” insurance system that was established to provide benefits (medical care and lost wage benefits) to employees injured or who suffer illness or disease while in the course and scope of their employment. An employer, or more typically, its insurance carrier, pays benefits to the injured worker irrespective of who is found to be at fault in causing the injury. In exchange for coverage of expenses related to the work injury or illness, employers generally have immunity from personal injury lawsuits.

A large part of any workers’ compensation claim is the injured worker’s medical care. The employer’s insurance carrier will cover the employee’s medical expenses resulting from the work injury or illness, such as doctor’s visits and consultations, imaging, medications, therapy, medical devices, etc.

Most workers’ compensation systems — both state and federal — have their own fee schedules, where certain treatment may be billed at a reduced rate. In addition, medical benefits under workers’ compensation typically aren’t subject to deductibles, co-pays or other financial limits; however, some state laws might limit coverage of treatment based on certain medical-based guidelines, such as the number of therapy sessions or injections warranted.

What is medical fraud?

As with most insurance claims, workers’ compensation carriers are entitled to conduct investigations throughout the course of the claim to determine whether the injured employee might be committing fraud to obtain a financial gain. Yet, fraud can be committed by anyone in the workers’ compensation system — the injured worker, the employer, or medical providers attempting to defraud the system by capitalizing on the treatment of their patients.

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