Weekly Fraud Blotter from Lexis/Nexis: October 1, 2009 Fact: Workers’ Compensation Insurance is a type of “property and casualty” business insurance required in all states, except Texas where an employer may opt out. It is referred to as a “line” of insurance coverage and is purchased from an insurance agent or broker. In a serious, seven-year legal criminal case, court documents claim a prominent medical management systems company filed over $70 million in medical bills in a complex “pay to play” cross-referral network of physicians preying upon unsuspecting injured workers to submit unlawful fraudulent bills for services never rendered. The firm is charged with unlawfully practicing medicine, engaging in illegal fee sharing, illegally referring business and fabricating medical charges. The Los Angeles District Attorney’s Office executed a search warrant on the company and discovered widespread unlawful patient capping and referrals to multiple Southern California workers’ compensation lawyers. As part of an agreement to resolve criminal charges a judge issued a consent order dismissing an estimated $70 million of medical bills the defendant previously submitted for payment to workers’ compensation insurance carriers. The company submitted several thousand allegedly fraudulent bills to the workers’ compensation insurance companies for services supposedly provided by more than 130 affiliated physicians and clinics. The dismissal of these bills culminates seven years of investigation and litigation spearheaded by lead defense attorney Clifford D. Sweet, III of Heggeness, Sweet, and Simington & Patrico, a Southern California law firm representing employers and their insurance companies since 1974 in workers’ compensation cases. Sweet, long recognized as a leading opponent of fraud in the workers’ compensation system, said “organized criminal enterprises profiteering from the workers’ compensation system are especially egregious as they rack up tens of thousands of dollars of bills for bogus medical treatment for simple sprains, they adversely affect the lives of hundreds of innocent injured workers enmeshed in their scheme.” (workersxzcompxzkit) He commented further on the long-term commit employers and insurance companies must be prepared to take to fight fraud, saying this is exactly the type of result contemplated by the Legislature when it mandated that workers’ compensation carriers earmark funds for fighting workers’ compensation fraud. Source: Heggeness, Sweet, Simington & Patrico Note: Documents in this case will be posted in the FREE DOWNLOAD section of the Lexis/Nexis web center. Reposted with Permission Visit LexisNexis for more information and full reports. The latest workers’ comp fraud blotter see http://law.lexisnexis.com/practiceareas/Workers-Compensation-Law-Blog/workers-compensation-fraud-/Workers-Comp-Fraud-Blotter-9252009—Recent-Arrests-Charges–Convictions WC Calculator: www.reduceyourworkerscomp.com/calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workman’s comp issues.
