For workers who have been hurt on the job and are unable to work, workers’ compensation insurance will pay for medical bills, injuries and partially or fully replace lost income.
Because workers’ compensation insurance is a no-fault insurance, meaning that no injury must be proven prior to receiving benefits, the system is vulnerable to fraud by workers, employers, and healthcare providers.
What Does Workers’ Compensation Fraud Look Like?
California makes knowingly submitting a false workers’ compensation claim a crime and in California, fraud of this system occurs when a person:
- Knowingly makes or presents false or fraudulent statements or material in order to obtain or deny someone else workers’ compensation benefits
- Makes a fraudulent statement regarding eligibility for benefits to discourage a worker who has been injured from making a workers’ compensation claim
- Knowingly aids and abets or participates in a conspiracy to commit workers’ compensation fraud
- Prepares or submits multiple claims for health care benefits covered by workers’ compensation insurance for the same injury
- Submits a health care benefit claim which is covered by workers’ compensation insurance that was not used
- Solicits or refers or accepts business from a person knowing they intend to commit workers’ compensation insurance fraud
A health care provider might trigger a charge of fraud by falsifying services or billing statements. Some of the ways a medical provider can create an alarm of fraud or be accused of fraud include:
- Submit a claim for services that were not rendered
- Bill at a higher level of service than provided; upcoding or unbundling
- Prescribe medicine that is unnecessary
- Provide medically unnecessary procedures or tests
Upcoding is knowingly submitting inaccurate billing codes to the workers’ compensation insurance company in order to obtain a higher reimbursement. Unbundling is submitting multiple CPT codes (Current Procedural Terminology Codes) instead of one code which is inclusive of a procedure. Multiple codes for the same procedure results in a higher reimbursement rate and is considered fraudulent.
Employees and health care providers are not the only people who can commit workers’ compensation insurance fraud. Employers in many instances have been investigated on suspicion of committing fraud or convicted of fraud. The ways in which fraud is committed by employers can include such acts as:
- Intentionally fail to purchase insurance for their employees
- Misclassify their workforce and the nature of work done by their employees in order to obtain reduced premiums
- Prematurely return an injured worker to work
- Lay off an employee once an insurance claim is filed
- Give managers incentives to deny workers’ claims or to settle for unreasonable amounts
- Provide ghost policies (policies that do not exist) to independent contractors who are actually employees
What Are The Penalties For Committing Fraud In California?
Fraud in California can be charged as a misdemeanor or a felony and the penalties depend on all the facts involved in the case, the monetary value of the fraud, and the defendant’s criminal history among other factors. A misdemeanor fraud charge can carry a sentence of up to 1 months in jail and a felony fraud charge can carry up to a 5-year prison sentence along with severe fines.
There are many ways to commit workers compensation fraud and penalties to fit the crime of fraud. Some examples of the types of fraud and their penalties are:
- Premium Fraud
Employers who lie to reduce their insurance premium: punishable by up to 5 years in prison and a $50,000 fine.
- Employer Fraud
Employers who wrongfully deny a worker their entitled benefits or discourage an employee from pursuing a claim: punishable by up to 5 years in prison and a $150,000 fine
- Uninsured Employers
Employers who fail to maintain workers’ compensation insurance for their employees as required by law: punishable by up to 1 year in jail and a $10,000 fine
- Worker/Applicant Fraud
An employee who lies in order to receive benefits by reporting false information or making false statements: punishable by up to 5 years in prison and a $150,000 fine
- Provider Fraud
Medical providers who falsify information or are guilty of knowingly providing services not rendered, billing for service not rendered, other falsification of services or upcoding and unbundling: punishable by up to 5 years in prison and a $50,000 fine
Do I Have A Defense?
If you’ve been charged with workers’ compensation fraud in Los Angeles, you will need a criminal defense lawyer. After knowing all the facts and elements of your case, your lawyer can create a defense strategy that can save you from possible prison time and severe fines. Only after knowing all the facts of your individual case, is an attorney able to advise you on the line of defense against your charges.
A lawyer can defend you in several ways and the following is always considered:
Lack of Intent
Submitting a false claim without establishing an intent to defraud. A provider may have provided a service or procedure that they believed was medically necessary and in good faith. A worker may have unknowingly submitted incorrect information or were given misinformation that they used to submit a claim.
Mistake of Fact
A false or duplicate claim was submitted by mistake. Honest mistakes have been made in billing insurance companies for wrong services or a worker has filed a duplicate claim believing they had not yet completed the full filing process and filed again.
If you are facing the charge of workers ‘ compensation insurance in Los Angeles, contact an experienced attorney.