Category Archives: doctors

Employer Fraud in Workers’ Compensation

Legislatures around the country (including ours in Wisconsin) seem to be preoccupied with employee fraud in workers’ compensation, despite overwhelming evidence that employee fraud is virtually nonexistent. 

Employer fraud, however, continues to plague the industry.  Over the last decade, my friend and colleague Len Jernigan has published a Top 10 Workers’ Comp Fraud Claims.  The list from 2015 can be found at this link.

None of the Top Ten includes only an injured worker.  The top six of the Top Ten stem from California claims.  Others are from New York, Washington, Utah, and Massachusetts. 

This year’s dollar amounts were particularly substantial, with nearly $850 million in total frauds, the largest being a $580 million kickback scheme out of California.  The California kickback scheme involved surgeons and the owner of a hospital.  The other California claims included FedEx mislabeling their drivers as Independent Contractors in order to avoid insurance, and the owners of a translation service fraudulently billing the workers’ compensation system.  Additional mislabeling involved California truck drivers from Pacer Cartage, which owed over $2 million to seven truckers, due to unlawful payroll deductions and misclassifications as Independent Contractors.

The single case involving a worker is a professional football player from the New York Giants who colluded with a claims adjuster, providing fictitious invoices and statements for more than $1.5 million.  The New York, Washington, and Utah claims also involved misclassification in which no workers’ compensation insurance was paid for actual employees.

Another popular theme is the under-reporting of earners in order to be granted lower insurance premiums.  That scheme was uncovered in Massachusetts, avoiding more than a half million dollars in insurance premiums.

The workers’ compensation insurance industry has done a marvelous job in diverting attention from the real culprits (employers, medical providers, and insurers) to the very rare, but sometimes spectacular claims involving employee fraud.  (A worker claiming permanent and total disability climbing around on rocks is far sexier than a financial officer mischaracterizing his employees in a closed office.)

Official Disabilities Guidelines Now Covers Diabetes

Today’s post comes from guest author Paul J. McAndrew, Jr. from Paul McAndrew Law Firm.

While diabetes is not a work injury or illness, it can have a serious impact on the rate at which an injured worker recovers. For instance, people with diabetes may have a much harder time healing from a foot or leg injury. The latest edition of the annual Official Disabilities Guidelines (ODG) has been released, including the latest ODG volume on treating patients. ODG Treatment is the nationally recognized standard for medicine in determining the scope and duration of medical treatment in workers’ compensation.

For the first time this year, ODG Treatment includes a chapter on diabetes. According to the American Diabetes Association, there are nearly 26 million people in the United States who have been diagnosed with diabetes, and an estimated 7 million more people suffering who have not yet been diagnosed. Clearly, the implications of diabetes on workers’ compensation are significant.

Can I Be Reimbursed For Medical Bills I've Already Paid?

Last week we posted on what to do about medical bills and workers’ compensation. We learned that the, in general, you don’t have to pay medical bills while on workers’ comp, with some exceptions. But what about medical bills you’ve already paid? 

Question: My private health insurance paid while my workers’ compensation claim was in dispute. I have been making payments to my doctor’s office, too, for co-pay and other charges. Can I be reimbursed? What about my prescription costs?

Answer: Yes, you can be reimbursed for your expenses!

Many employee claims for medical expenses will be paid by health insurers, even if the injuries are work-related and should be paid by the worker’s compensation insurance carrier. In some instances, the health insurer pays because it does not realize the accident or disease was work-related, and in other cases, the claims will be paid by the health insurer because the worker’s compensation carrier disputes that the injury was work-related (or the employer directs the employee to file the claim under the health insurance policy). In either case, the health insurer has the right to recoup the payments, because health insurance policies exclude payments of medical expenses covered by the worker’s compensation carrier.  While the group health carrier is prohibited from intervening in worker’s compensation proceedings, the department may direct reimbursement by the worker’s compensation insurer for payments made by health insurance carriers, when the department finds a work-related injury.

Additionally, if an injured worker pays for any work-related treatment of out of their own pocket (co-pays, prescriptions, mileages), they absolutely are entitled to be reimbursed if the claim (and resulting treatment) is deemed work-related.  An application for hearing, with the assistance of an attorney, generally is necessary. Reimbursement can occur through either a settlement or prevailing at a court hearing.

As medical expenses now eclipse indemnity (or actual compensation dollar) benefits in Wisconsin worker’s compensation claims, reimbursement for past medical expenses can be a significant issue—and drive the need for many cases and the need for representation.

I’m Getting Medical Bills, But I Have A Workers’ Compensation Claim

Question: I’m Getting Medical Bills, but I have a Workers’ Compensation Claim – Do I have to Pay Them?

Answer: No! Well, maybe…

If you have an accepted Wisconsin worker’s compensation claim, the worker’s compensation insurance carrier should be paying all of your medical bills, including prescription expenses.  Under the law, the carrier has to pay for medical treatment that is “reasonably required to cure and relieve from the effects of the injury.”   Therefore, if your claim has not been denied,  you have the right to get your medical expenses and bills paid without a deductible, including prescriptions, physical therapy, occupation therapy, diagnostic testing, office visits, psychological counseling, etc.  You also have the right to have your expenses covered for mileage driving to and from doctor appointments (which is reimbursed at 48.5 cents/mile). 

If you are receiving medical bills after a work injury, you should contact your doctors or medical providers and make sure they bill the worker’s compensation insurance carrier.  You can also forward any bills to your claims adjuster to request immediate processing and payment.  While this can become burdensome in dealing with medical bills and the worker’s compensation carrier, you need to be aggressive and not let bills pile up.  Make sure the adjuster and the medical provider are in communication so that all bills are paid promptly.

From a practical note, you should also make sure that your medical providers also list your own private group health insurance as the secondary payer (list the worker’s compensation carrier as primary).  If the worker’s compensation insurance carrier denies the claim or delays payment, the medical provider can submit the claim to your group health insurance.  While this may not be “fair,” it is far better to have your health insurance company pay the bill now versus having a large outstanding medical bill go into collections.  As part of an application for hearing, you can request reimbursement to your group health insurance and repayment for any out of pocket expenses (stayed tuned for more information).

To find out what to do if you have already paid a medical bill for an on-the-job injury, check in next week for part 2 of this series.