Report on California Workers’ Comp Looks at Medical Provider Fraud

December 4, 2019

The Workers’ Compensation Insurance Rating Bureau of California in a follow-up analysis to its 2018 study that evaluated the potential impact of medical provider fraud enforcement shows indicted providers treated significantly more injured workers and rendered more services per injured worker.

The WCIRB report, Treatment Patterns of Medical Providers Indicted for Fraud in California Workers’ Compensation, reflects changes in Senate Bill No. 863 and subsequent legislation that led to reduction in medical costs, anti-fraud measures by various stakeholders also contributed.

The WCIRB’s findings include:

  • The average total medical paid per indicted provider was 10 times higher than other providers between 2013 and 2018, largely because indicted providers treated significantly more injured workers and rendered more services per injured worker.
  • The shares of medical payments for medical-legal and medical liens of indicted providers were two to three times higher than other providers. Indicted providers were also paid a significantly higher share for complex office visits and ML evaluations.
  • Indicted providers in the Los Angeles Basin accounted for about half of indicted providers linked to WCIRB data, but they received more than 90 percent of the medical payments made to these indicted providers. The share of indemnity claims involving CT within the LA Basin was consistently higher for indicted providers between 2013 and 2015, yet the pattern did not hold in 2016.

The WCIRB’s new research brief compares the treatment patterns and types of services rendered by indicted/suspended providers to non-indicted/suspended providers as well as the regional variations and differences in treatment levels on cumulative trauma claims.

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