Fraud, waste, and abuse continue to drive up the cost of administering workers’ compensation programs. Workers’ compensation fraud, which accounts for approximately one-quarter of all insurance fraud, comes in all forms: injury while off work, multiple claims, injury concurrent with termination, and many more.
Workers comp insurance fraud is a crime. Tens of billions of dollars in false claims and unpaid premiums are stolen every year. Scams are increasing the cost of insurance premiums — draining business profits and costing honest workers their pay and their jobs. In addition, these increasing costs are being passed on to you as a consumer with higher prices at the cash register.
Medical Records Investigations: Cost Effective Sleuthing to Cut Workers Comp Insurance Costs
Aggressive pursuit and investigation of fraud can help lower the financial impact of workers’ compensation on businesses. If you’re willing to do a little sleuthing, there is one interesting method of reducing workers’ compensation fraud in your business - the use of medical records for investigation. This method is often more cost-effective and less expensive than many of the more formal investigative tools.
Where should you look?
There are a few things to consider if you decide to use medical records to investigate a workers’ compensation insurance claim.
- Start at the beginning. Using this investigative technique at the onset of a claim allows you to better monitor treatment trends and develop a better understanding of the case. It’s important that you get ahead of the case before it becomes too complicated.
- Start with primary care providers. Records from a primary care provider will often provide a good overview of a person’s health, including yearly physicals.
- Don’t overlook urgent care clinics. In addition to checking the records of your local emergency rooms, you should also take a look at urgent care facilities in the vicinity of where the claimant both lives and works. Urgent care facilities are on the rise. They provide a more affordable option to health care for people who don’t have medical insurance, and they offer access to medical treatment for injuries that occur after hours or on the weekend.
- Look at other medical facilities. In today’s health care environment, proper treatment often requires a visit to a specialist. Specialists can also provide information about underlying conditions.
What should you look for?
Here are a few of the “red flags” you should look for in an investigation of medical records:
- If a claimant receives medical care and/or treatment at more than one facility in one day.
- If a claimant sought medical treatment on a Monday morning or after a holiday, it could indicate that an injury took place over the weekend or during a holiday – and not in the workplace.
- If a claimant received treatment and/or referrals from providers that share common waiting rooms or are located in adjoining buildings.
- If a claimant has a medical appointment while he or she is out of town or on vacation.
- If a claimant receives medical care on a weekend, holiday, or during inclement weather.
- Look for evidence that the medical records have been changed or altered, or if they aren’t consistent with what the primary doctor is recommending.
Be Proactive and Increase the Odds of Cutting Your Workers Comp Insurance Costs!
Today, you need to be proactive if you want to limit the amount of fraud, waste, and abuse within your business’s workers’ compensation programs, and medical record investigation may be one method to consider for your business.
For additional methods to reduce the cost of workers’ compensation, including getting the best rate on quality workers comp insurance, contact us at (800) 947-1270 or (610) 775-3848. We're independent agents with the power to lower your worker's comp insurance costs by offering policies from multiple competing insurance providers, so you'll get the best insurance at the best price.
