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Medical Fraud and Workers’ Compensation

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Posted By DAM Firm | July 11 2016 | Workers' Compensation

California has a widespread problem with medical fraud in the state’s workers’ compensation system. Health care providers are racking up tens of thousands of dollars in unnecessary tests, procedures, and treatments – exploiting the system to make millions on the backs of workers who suffer injuries on the job. The holes in California’s workers’ compensation system make siphoning money from that system almost too easy.

Exploring California’s Workers’ Compensation System

State rules for workers’ compensation are loose in California, leading to plenty of opportunity for fraud. Anyone can pretend to be a medical provider by simply sending a letter to the state, without the need for any proof. Real providers can run meaningless tests and bill the system, knowing they won’t get caught because injured workers don’t see the bill. The weaknesses in the system make it impossible for the state to validate medical provider claims.

There is a great division of power within California’s workers’ compensation system. The system spreads one job across multiple departments, leading to gaps in communication and dropped responsibilities. The state’s Department of Industrial Relations is in charge of administering workers’ compensation benefits, while medical boards oversee physicians. Hundreds of insurers and self-insured employers decide which medical bills to pay.

Many states’ fraud strategies stop paying medical providers if a Medicaid agency determines there is reason to suspect fraud. Unfortunately, California has no such law. Medical providers are free to continue performing questionable surgeries, doling out complicated treatment advice, and otherwise exploiting the system at the expense of injured workers – most of which only speak Spanish. There is nothing to prevent this type of fraud from continuing, even if agencies suspect the worst.

Federal laws have taken steps toward preventing “sham” medical facilities from cropping up. Now, Medicare uses data to check on medical offices and verify their authenticity. Medical officials visit providers when they open, three to five years after they open, and if they receive any complaints. This system dissuades fraudsters from opening false clinics, stealing patient data, and falsifying medical invoices. Once again, however, California has no data reviews or in-person checks that occur on a regular basis.

The Risk to Injured Workers

Workers’ compensation fraud hurts more than just the system. Criminal medical providers are getting rich at the expense of injured workers, who undergo unnecessary tests and even surgeries so the provider can make money. Many targeted workers don’t realize they are victims since they never see their medical bills. They trust the opinions of doctors when they say a patient needs surgery – unaware that nurses who get paid for their involvement may tamper with MRI results to encourage this diagnosis.

Medical fraud also effects employers who pay for workers’ compensation insurance. If an employer is public, it’s the taxpayers who foot the bills for fake charges. In the fraud scheme involving California’s workers’ compensation system, nobody wins except the masterminds. These schemes are far from victim-less crimes. If you’ve been at the tail end of a medical fraud scheme involving workers’ compensation an attorney can help.

Your Riverside Workers’ Compensation Attorneys

Workers’ compensation fraud isn’t a new crime, but it’s one that’s currently breaking records in our state. Until lawmakers revise California’s workers’ compensation system to include anti-fraud strategies, injured workers and their employers are still suffering the costs. If you’ve been affected by a medical fraud scheme, get in touch with our workers’ compensation attorneys. We can help you sue fraudulent health care providers for your pain, suffering, and mental anguish.

If you’re an employer whose business paid the price for a medical provider’s fraud, our attorneys can help you obtain financial compensation for your losses and damages. Nobody should suffer from the criminal activity of others. Contact our Riverside office for a free consultation today.

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