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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.
California makes knowingly submitting a false workers’ compensation claim a crime and in California, fraud of this system occurs when a person:
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:
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:
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:
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.