Workers’ Compensation Fraud and the Insurance Producer

By Stephanie K. Jones | March 24, 2014

  • March 25, 2014 at 12:36 pm
    Perplexed says:
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    This article lists two categories of WC fraud, but overlooks a third: medical provider fraud. This may occur without any involvement of the worker or employer, through overcharging or overtreatment. If you follow the California news, you should be aware of the recent arrest of a state senator in a case involving unnecessary and overbilled spinal surgeries, and the huge system of bribes and kickbacks that facilitated this scheme.

  • March 25, 2014 at 8:14 pm
    Erwin C. Hizon says:
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    There is yet another element of WC fraud: The collusion of insurance regulators.

  • March 26, 2014 at 4:59 pm
    jadefox3 says:
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    What about the agent that begs a company to “negotiate” a 1.50 experience mod to 1.00 so his custorm can bid jobs! What about companies that go along with it!

    • March 28, 2014 at 3:51 pm
      Libby says:
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      Since when can you negotiate a mod down?

      • March 31, 2014 at 12:58 pm
        Jadefox says:
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        TX permits it

        • March 31, 2014 at 1:43 pm
          Libby says:
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          Only in TX.

  • March 27, 2014 at 3:25 am
    Per Simon Voldsgaard says:
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    Fraud is unacceptable –

    Having direct contact with customers, thereby valuating the moral habitues and evaluating manageable risk IS KEY in insurance.

    Be aware of the distance you as an organisation create by its own behavior like:
    Provisions
    Bonus

    It is always easier to change your own behavior!!!

    STILL: All the best wishes to those ho want to change others to the better ,o)

  • March 27, 2014 at 7:40 am
    Robb Holmes says:
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    Is there a law / statute that forces a WC insurer to pay a claim for injuries if they don’t want to? This would be besides a claim denial. Thank you.

    • March 28, 2014 at 3:53 pm
      Libby says:
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      WC benefits are statutory, so yes, the law outlines very specifically what they have to pay for.

  • March 27, 2014 at 10:32 am
    anton says:
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    In my opinion: in insurance fraud can occur when the system or Standard Operational Procedures shall be implemented in a working system. SOP Why can not walk? this can happen due to several things including:
    1. Staffing structure is not yet complete.
    Where in some staffing structure held by one person
    2. weak oversight
    Capacity Internal Affair unfavorable
    3. Placement employee who does not comply with requirements. (Right men / women in the right place)
    4. The moral hazard of prospective employees.
    conclusion: fraud in an insurance company can be minimized to meet the standard requirements of a good staffing structure. and mental coaching employees to provide good welfare.

    • March 28, 2014 at 3:55 pm
      Libby says:
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      How do you mentally coach someone out of committing fraud? You can put SOP in place to identify when it’s happening and the knowledge of those SOP in place may deter someone for fear of getting caught, but someone intent on committing fraud is going to do it if they think they can get away with it.

  • April 23, 2014 at 3:53 pm
    Kerwin Tschetter says:
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    Ah, Come on Ranney Pageler

    There is a third type of fraud that you have not mentioned – INSURANCE COMPANY FRAUD!

    In fact Mr. Pageler,

    Two former employees Bret Grove and Richard La Combe of the Fremont insurance company were charged with insurance fraud

    Isn’t it true that your former employer Fremont Compensation was also accused of fraud by the State of California and then seized and liquidated and the book of Fremont’s business was sold to your present employer, Employers Insurance Company of Nevada, for the grand sum of $1?

    Isn’t it also true that Fremont Comp, a/k/a Fremont Indemnity, engaged in a “price war” through the fraudulent use of net line underwriting that left Fremont’s reinsurers and the State Insurance Guarantee Associations or Funds “holding the bag” for $2.245 Billion dollars in accepted, but unfunded workers compensation claims, including $60 Million in Alaska?

    http://www.legis.state.ak.us/basis/get_jrn_page.asp?session=23&bill=HB403&jrn=2415&hse=H

    See Page 8 — $2.245 Billion dollar Deficiency
    http://www.caclo.org/perl/index.pl?document_id=5eed19c3b991f2fa0f18fd524ac95b3a

    08/04/2005 – Third Amended Complaint, Intentional Misrepresentation, Concealment, Promissory Fraud – Fremont
    http://www.caclo.org/perl/index.pl?document_id=b442802cf6079bc3bcd3af71b98be646

    Need I go on?

    My question to you Mr. Pageler,
    Is why weren’t more Fremont employees tried and put in Jail for Insurance Fraud?



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