By definition, fraud is the intentional intent to use deceit, trickery, or other nefarious means to deprive another individual of their inherent money, property, or legal rights. The majority of injured individuals were legitimately injured while furthering their employer’s interests.
However, we all know that there are those individuals who feel they are entitled to something to which they are not, and as such will employ various tactics to pad or line their own pockets.
As noted by the National Insurance Crime Bureau, such efforts cost the economic system billions of dollars on an annual basis. A conservative estimate would be as much as $10 billion. This is just within the workers’ compensation system alone. To be clear, there are a variety of “types” of fraud. However, the most common efforts would include faking injury, exaggerating an injury, filing a claim when everyone knows it is false, and on the part of healthcare providers submitting invoices for services not actually provided. In some instances, collusion between two separate parties who believe “they will never know” would fall into this category.
Such efforts on the part of relatively few individuals cost us all. Clearly, the cost of workers’ compensation insurance will escalate when paying for these inappropriate fees. Higher workers’ compensation costs will mean higher prices for the end user, or perhaps lower wages or other economic effects. Additionally, when that legitimately injured individual attempts to pursue the system, these types of fraud could (and probably should) raise a level of suspicion and skepticism that might interfere with the judicious application of the system to those who truly deserve it.
Thus, the question becomes what can we do about it? There is a saying in medicine that common things happen commonly, and rare things happen rarely. If that injured individual trips and falls and sustains an abrasion into the knee, one does not treat this with a total knee arthroplasty (even though the TKR clinically might be indicated). The next question becomes, is the need for a total knee arthroplasty truly a function of the identified incident?
Those involved in the adjudication of files need to compare all of the clinical data available and apply common sense with the standards of evidence-based medicine to the determinations made. And, as with anything, if you do not know the answer, ask a question.
So, fighting fraud starts with the employer, maintaining as safe an environment as possible, the coworkers not supporting this individual in their efforts to make a few extra bucks, the individual handling the claim file reading each piece of medical information and correlating that with the clinical determinations made as well as the healthcare providers understanding there truly not helping their injured employees by amplifying or attempting to incorporate care not required to address the sequelae of the compensable event. It is said that it takes a village to raise a child; however, it takes all participants in the workers’ compensation system to prevail against these fraudulent efforts.
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