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?

    • January 29, 2015 at 4:03 am
      Cecilia Watt says:
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      Please share all or any information that you have on workers comp insurance carrier fraud on “Crimes Against Injured Workers” on Facebook! It is long overdue to out the fraud and corruption that is facilitated by the insurance carrier, their attorneys and the employer that is beset on the injured worker. The workers comp system is a cesspool of fraud and those so called WC professionals who participate in it are the garbage!

  • January 29, 2015 at 4:09 am
    Cecilia Watt says:
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    Watt vs Metropolitan Home Mortgage & Employers Compensation Insurance – Nevada; CA WCAB ADJ8329606: What is an injured worker to do when the defense repeated commits crimes against the injured worker? My employer falsely informed Employers Compensation Insurance Carrier that I was not hurt at work, thus, I have been the target of many crimes including having been maliciously maimed by the insurance carrier’s “network of medical providers”. I am an injured worker who has been deliberately & intentionally maimed and battered by the medical provider(s) in the workers compensation insurance carrier’s “network of medical providers”. After filing a workers comp claim, injured workers seek treatment. Unfortunately, some injured workers are maimed and battered by the very medical provider(s) that they are sent to. In my case as in many other WC cases, medical forms, surgery reports are altered and/or falsified. Documents changed over and above the injured workers signature.
    I was forced under anesthesia for simple lumbar epidurals. Just prior to the 2nd lumbar ESI procedure, while in pre-op, for, I objected to anesthesia. I was told I had no choice, that it was the policy of the surgery center that all patients must undergo anesthesia. I awakened from that with severe neck pain and slight left arm pain. My Doctor had injected my person from my neck, down the left side of my spine and my entire left leg with some sort of chemical that tingled and popped like Alka Seltzer. The tingling – popping sensation was also present in the frontal lobe area of my head. The procedure that I was there for was to receive an epidural steroid injection in the lumbar area and “trigger point shots” to the left side area of my lumbar spine. There should not have been any other injections.
    The next epidural procedure, I made it clear I that I did not want to be placed under anesthesia not only on the phone a day prior to the procedure, but also before the procedure in pre-op. I re-stated the same in the operating room for everyone there to hear. I said that I was to get a local pain blocker. (just as I had during the first lumbar epidural). Instead, my Doctor abruptly shoved the needle into my back without any pain blocker whatsoever. I could feel the needle going through the different textures of my back (not precisely in the lumbar disk area between the vertebrae). The injection was slightly to the left of the spine. My head flew up as I screamed “Wait!” or “Stop!”. He would not relent! As my head went down to the operating table (where a towel and prop to lay my head was), he moved the needle inside me to the nerve in my back next to my spine and held it against the nerve! The pain was so excruciating that I bit into the towel that was for my head to rest on and screamed with the towel in my mouth. Pure agony! He would not stop! Clearly, I had no choice once again but to give into anesthesia. When I awakened, I thought to myself, Oh my God, they didn’t! I could feel the injuries from being maimed throughout my back, neck, shoulders and arm, from my neck down to my tailbone. I could feel the nerves firing all over my back and next to both sides of my spine from the injections of some sort of chemical (the Alka Seltzer feeling again) that over the coming months, burned and corroded the ligaments in my spine, tendons and muscles, nerves in my back. It felt as though I was being burned from the inside out. PAIN from burning and maiming! I can now & back then could feel that some of the tissue/muscles were pushed away from my spine creating the feeling of divots or holes on both sides of my spine. I could feel what seemed to be a muscle pushed away and hanging down on to the right mid side of my person. The ligaments that are in my neck and run up into my skull feel damaged, sore. My spine felt “chiseled” in specific areas most prominently in the top of my back and neck and the bottom near the lumbar sacrum area. For 7 months, I had positional vertigo. The vertigo recently re-occurred for several weeks. I now have instability in my spinal column. I can feel the vertebrae in my spinal column moving not in sync with the other vertebrae. There is much more damage that I could continue to describe but will refrain.
    In order to get treatment, I had to see the AME “agreed upon medical examiner” (paid by the WC insurance carrier) designated for my WC case. I demanded to see him. Efforts to delay that ensued. Eventually, I was able to see him on August 12, 2013, more than 2 months after the procedure described above after my insistent efforts to move the date up from what I was originally informed was the earliest available date of September 9, 2013. I contacted the AME’s office and spoke to the appointment desk myself, I was told that there were dates available in July and August however, the insurance carrier and MY attorney agreed that I wasn’t to see the AME any sooner than August 26, 2013. Odd? My attorney’s initially moved the appointment from September 9, 2013 to August 26, 2013. Then they finally conceded to allow me to see the AME on August 12, 2013. After seeing the AME on 2 occasions and describing to him and his historian what happened to me verbally and via color sketches and in a 5 page written description, his report indicates, Yes, my neck was damaged during the procedure(s) however, the pain, the holes and more that I describe in my back and spine are “medically improbable”! Interestingly, the AME rendered an opinion of how my neck could have been accidentally damaged. That is NOT his job! He has also diagnosed me with degenerative disk disease. However, approximately 8-9 months prior to the 3rd epidural procedure, he specifically told me there was no sign of “DDD”.
    COOPERATION OF MEDICAL PROVIDERS: Not only was the Ortho Surgeon involved. It was also the surgery centers and the anesthesiologists and others that have been involved. After informing my then attorney via e-mail and via several cell phone conversations, the attorney who runs the WC division in that law office, called me on the phone and begged me not to file a grievance with the California Medical Board and allow himself and the AME to handle this! Later he called me again and told me to file for permanent disability right away! My attempts to get help through other means have been stalled. What has been done to me and the continued efforts to interfere as I try to seek treatment even outside of the WC system, has been a well-orchestrated effort. Through injured workers associations, I have come to find out that what has happened to me has happened to many other patients through the years but is being ignored due to the outrageous and maliciousness of the crime. To think that a field of medical professionals would participate in the maiming and battery of patients is something out of a movie, but it does exist! It is a strategic tactic.
    AWARENESS IS KEY: I’m trying to prevent what has happened to me from happening to others. Join me and other injured workers to 1. Create a mandated disclosure law in all workers comp cases that reveals the danger of injured workers being targeted for “battery” and “maiming”!. I should have been warned. Injured worker should be presented with a disclosure indicating something to the effect of: “Some injured workers have reported having been harmed, maimed or battered while receiving treatment for their injury. The injured worker is advised to report any occurrence of injury or suspected intentional harm to the proper governing authorities in the state in which their WC case is filed. I am told that only a few states have a medical battery laws. 2. Support a Medical Battery Law so that these crimes can be reported to the police department and/or the District Attorney’s office. 3. Injured workers should have the right to require a patient advocate to be present (NOT AN ADVOCATE FROM THE INSURANCE CARRIER’S MEDICAL PROVIDER NETWORK & WITHOUT THE APPROVAL OF THE EMPLOYER, INSURANCE CARRIER AND/OR DEFENSE ATTORNEY) should the need for anesthesia arise. I wish I had known that I had the right to remain awake during the 2nd epidural. I have since found out that most lumbar ESI procedures are done with just the local anesthesia pain blocker, just as I had requested. The third epidural wherein I was forced brutally to accept anesthesia, I don’t know what I could have done differently. I couldn’t scream loud enough that he (the Doctor) would stop pressing the needle against the nerve in my back! I couldn’t get off the table with the needle in my back either. My body is prolifically maimed. 4. A disclosure should be signed by the injured worker that indicates that “Some injured workers have reported having had documents altered / changed over and above their signature, medical reports falsified, surgery reports falsified, deceitful methods of marking documents one way on the top page, however, having documents marked differently on the flow through attached copies 5. Injured workers should have the right to have their treatments / surgeries / procedures, consults, appointments with any Doctor or medical staff including visits with a Primary Treating Physician, QME, AME, IMR, IME or other examiner, video and/or audio taped. At my procedures, I was asked to sign off on video and audio taping, but have since been told that no video or audio taping of the ESI was done. I find that interesting.
    I’m told that fraud against the injured worker has been going on for 20 plus years. Why aren’t injured workers advised / warned in advance of the various criminal activities targeted against the injured workers.
    NEVER ENDING PURSUIT FOR JUSTICE: I have gone to law enforcement 5 times wanting to file a complaint against the Doctor, Anesthesiologist, surgery centers etc. I have been told that I cannot report the crimes of falsified documents and maiming & battery as there is nothing in the penal code. All 5 instances, I was sent away without the benefit of being able to report the crimes perpetrated against me. I have contacted the FBI several times – I am told that they cannot do anything either. The OC DAs response to the maiming and battery, falsified surgery reports, documents changed over and above my signature and much more was “Unfortunately, your case is not unique”. This week (September 8, 2014), I was told that I can’t file charges or complaints with at the District Attorney’s office either. I am referred to the California Medical Board to file a complaint. Clearly, this is why crimes in the workers comp system are systematically committed against the injured worker.
    Fraud & battery has been facilitated on the part of the defense. “Creating the look of a condition(s). I had demanded to see the AME because I had been forced under anesthesia, maimed and battered! The AME knew this so out of concern for himself, he had his “office manager” present during the 2 office visits after the 3rd epidural! In his final report, he does not mention that I informed all parties including his office historian, that I had been forced under anesthesia and maimed. The “legal” staff member in his office told me that they removed the 5 page letter that I wrote to the AME which set forth some of the chain of events that had occurred since I filed the WC claim including the maiming, and more. She said that it was removed for my benefit as it was “Ex parte”. I believe that is was removed because the AME had an obligation to report the crimes that have been committed against me which would in turn jeopardize any future referrals to his office from this insurance carrier and / or defense attorney. I can see that the AME was not acting as a neutral party and he certainly wasn’t acting in my favor. His report, to me, reads biased in favor of the defense by virtue of statements that he included, that I am told is NOT his job – for example, lending an opinion for how I was hurt, rather than stating that the applicant (me) reports that she was forced under anesthesia, and awakened with injuries and injections throughout her body. Additionally, he indicates that my complaints of other pain, maiming, is medically improbable rather than doing the proper studies. The insurance adjuster told me herself, that they were not allowing any further studies including an MRI of thoracic region to investigate. Which is probably why the AME wouldn’t do one back in August 2013. During my visit with the AME, I brought a family member with me to act as my “patient advocate” at the AME appointments, however, the AME objected and said that he would not proceed with the office visit unless my family member / patient advocate left the examination room. The partner in the law firm that represented me back then (September 2013) told me to file for permanent disability right away. So, he must know what they have done to me. During my last attempt to file charges or a complaint against the “Ortho Surgeon” and others, the police officer told me that my attorney should have reported the incidents. I e-mailed the partner in the law firm asking if he reported the wrongdoing in my case. He said that he wasn’t present during my epidurals so he didn’t have to report it.
    ATTEMPTS TO GET TREATMENT OUTSIDE OF THE WORKERS COMP SYSTEM: I have tried to get help outside of WC. I have been met with bizarre situations and the Doctors through Medi-cal “doctoring” my medical record by not including the fact that I informed them of the maiming and pain throughout my body, instead, some mention only “lumbar pain”. Why would they do that! The most recent Doctor told me that if I accuse another Doctor of having maimed & battered me, that he will not take me as a patient! I refused to comply with his requirement, so he said, “Then, I can’t help you.”
    POWER / GREED: I am amazed at the power that the defense has over medical staff, surgery centers, etc. But I’ve been told that this has been going on for years. If you are an injured worker with a back injury, you, as I am, may be a target of maiming and battery to create the look of a condition, so that later the case can be litigated and the “condition” can be added and considered as apportionment which may reduce or eliminate the employer’s and the insurance carrier’s liability. There are likely many other strategic reasons.
    WC FRAUD: The most prevalent fraud in the worker’s comp system is facilitated by the defense and their “minions” including corrupt attorneys, Doctors, medical staff, surgery centers, hospitals, and insurance carriers and vindictive employers. Why isn’t this a well-known fact? Why aren’t injured workers warned? The insurance carrier’s often shine a light on the fraud perpetrated by injured workers, which is minuscule compared to the fraud perpetrated by the defense themselves.
    A former defense attorney who writes about workers compensation, and is still active in the industry, wrote an article wherein he asked of the people who were attending a workers compensation conference geared towards industry professionals, “How many of you, if you were hurt at work, would file a workers comp claim?” In response to his question, 1 person of the 400, raised their hand. Speaks for itself, doesn’t it.



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