Workers Comp Fraud in California and Ohio

California Fraud Case

Manuel Perales, 50
, of Fontana, Calif., has been charged with two counts of workers compensation insurance fraud, according to the San Bernardino County District Attorney's Office.
Recently, members of the DA’s Office, Workers Compensation Fraud Prosecution Unit, began an investigation into allegations of possible insurance fraud involving Perales. (WCxKit)
Perales reportedly sustained an industrial injury, while working for a local company. During the workers comp process, Perales withdrew his claim after being confronted with evidence that supported the incident was not true.
Although Perales withdrew his claim; he subsequently filed a second workers comp claim alleging that he sustained the same injuries, along with other industrial injuries, over a specific period of time, not including his original date of injury.
During this investigation evidence revealed that the allegations of workers comp insurance fraud were substantiated. As a result, an arrest warrant showing a bail amount of $100,000.00 was issued, charging Perales with insurance fraud. (WCxKit)
Later, Perales was located and arrested pursuant to the arrest warrant. He was transported, booked and housed at the San Bernardino County Sheriff’s West Valley Detention Center to await trial in this matter. Perales is scheduled for arraignment some time in 2012.

Ohio Fraud Case

A Cleveland (Cuyahoga County) woman was sentenced recently for fraud after Ohio Bureau of Workers Compensation (BWC) investigators found she was working for a veterinary hospital and a local charity while receiving benefits for a workplace injury. Nancy Palmer pleaded guilty and must repay more than $8,000.


BWC's Special Investigations Department (SID) reports it received an allegation that Palmer had been working at a local veterinary hospital. Investigators found she had returned to work as a veterinary assistant while receiving Temporary Total Disability benefits.(WCxKit)


According to the report, Palmer was performing duties such as office work, assisting during surgeries, cleaning and taking care of animals. It was also found that Palmer was working as a telephone solicitor for a local charity.


Palmer entered a guilty plea recently to a felony count of workers comp fraud. The judge ordered Palmer to pay $7,457.72 in restitution and $1,000 for investigative costs. She was also sentenced to seven months in prison, suspended for 18 months of community control.(WCxKit)

Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:






Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at:

An Adjuster Pinpoints Eight Medical Provider Red Flags of Over Treatment

Back again with the final part of the series on medical provider red flags.  This could be 50 red flags, but these are some of the most common. This is to provide continued awareness that not all medical clinics are on your side.  The caveat again is that this is not the norm. This article is just meant to raise awareness.  Because these issues, while uncommon, really do happen. That is about as politically correct as I can make it.  Here are the physician red flags you should be watching for. This article is summarized from an interview with an adjuster I met recently.



  1. The medical records are “template” style, or barely exist at all. Out of all of the red flag issues we discuss, this one does not indicate a shady doctor.  It could just be that the doctor is very poor at note taking.  But the two go hand in hand.  Great doctors do great analysis, and back up opinions with objective medical facts.  They arrive at this point by walking through the medical records, and creating a great conclusive medical report.  Doctors that get by by pairing up subjective history from a patient’s mouth are another story. (WCxKit)


  1. Missing dates of service, or no date labels on the medical notes.  
    I suppose if the “template”style medical record, is paired with one that is similar to a fill-in the-blank system (Patient came in with complaints of _______ which they attribute to work causing them _____ pain out of 10, with 10 being the worst pain imaginable) and pair it up without a date of service, I guess you could use that medical record for every date of service you ever have.  If anyone is watching, a physician will not get far by doing this.  But, if nobody is paying attention, thousands of dollars could be paid and for who knows what.  Make sure the notes are clearly labeled, dated, and legible.  If not, you need to contact the physician’s office right away.
    3. Different handwriting or inks on same dates of service.  Granted again, that may be the nurse or the medical assistant jotting some notes down before the doctor jots the notes down, but if you get the feeling that something is not adding up, then call them.  Their patient may be contacting them and coaching them what to put in the record, which we all know is not OK.
    4. The medical provider office will not send medical records or state that they do not keep a medical “record”.  I cannot think of one legit company that does not keep a note or record of some sort, for whatever reason.  Even the most trivial of companies store records of some sort.  So using that as a comparison, the medical record is very important.  And for a clinic to say they do not keep a record is unbelievable.  As a matter of fact, you should not pay any bill ever without a medical record attached to it.  How do you know what is being paid and for what?  If a doctor’s office ever tells you that they do not keep a record on a patient, my advice is to alert your counsel and have them step in right away.
    5. The medical notes showed continued high levels of pain. I have never broken my arm, but I anticipate that it hurts quite a bit.  Enough to be uncomfortable anyway.  So if it is 2 months later and you still have “10 out of 10” pain, that is just not correct.  If the pain is so unbearable, and you have treated with this doctor for 2 months, why go back there?  And how is the worker driving to these appointments?  And how can the worker go to the bank and cash your check, all with “10 out of 10” pain that has not lessened?  The doctor should be stating in the medical notes that the objective indicators for pain do not match the subjective complaints of “10 out of 10” pain.  If the physician is not doing anything about it, or the person is no better, then you have to find out what is going on medically and get that person to a specialist or set up an IME to address these ongoing complaints.


  1. Consistent improper billing practices.  Your Carrier/TPA usually cannot process a payment off of an invoice.  Usually the bill has to be printed on an HCFA-1500 form so the Carrier/TPA can process it.  This is standard.  A lot of offices that handle any type of insurance work know this.  So if they keep trying to submit their bills improperly, something is going on.  Why are they doing this?  Have any others had this sort of problem with this provider? Coding errors, print errors, ICD-9 code errors, etc. should be correct and correlate to the claim.  A few errors are to be expected.  But if it is constantly going on and on and on, you have to dig a little deeper.
    7. Conflicting medical reports or conflicting subjective complaints that are not addressed.  Let us say you are the adjuster and you are reviewing a stack of medical records on your claimant.  One day your claimant states they are in very bad pain, 8 out of 10.  It is hard to bend, and walk.  The next day they show up for therapy and they tell the therapist they are doing great, and they think treatment is really helping them.  2 days later they go back to the doctor and say they feel the same, about 7-8/10 pain. Then the same day they have therapy and tell the therapist they feel great, and are looking back to getting back to work.   I believe in the fact that people have good days and bad days.  But if you are hurt, and in legit pain, your symptoms should not yo-yo up and down like that.  Therapy can flare pain up a bit, but over the course of a few weeks the pain should be gradually lessened.  If you start to notice yo-yo pain complaints and pain out of proportion to the injury, think about getting your IME in order because the claimant is trying to extend their time out of work.


  1. Consistent excessive referrals or quick referrals to physical therapy where it may not be needed.  I know of a very popular occupational clinic.  A very large one. And I have handled a ton of claims where the clinic is the treating provider.  And over the course of a year or 2, I wager to say that everyone that walks through their doors with a comp case had a referral to go to the same physical therapy facility after the first or second visit. These were strains, sprains, lacerations, contusions, etc.  Every injury you could think of and they were all sent for therapy.  We had to call and talk to the doctor to find out the rationale.  This took a lot of time, but after a while they go the point and started to go by the medical norm for a referral for physical therapy.   This is meant to be a very loose example, but a lot of times personal doctors or practices also own therapy companies or diagnostic laboratories, or they have partial ownership in them, so they get to make money twice; once when you go to see them, and again when you go to their therapy facility.  So trust your instinct.  If you think a referral is questionable, call and talk to the doctor.  Make that doctor defend their decision and ask them questions.  After all they have a service to provide to you, and you have rights too in these work comp scenarios. Depending on your jurisdiction anyway. NOTE:  Make sure your company is aligned with a high-quality independent physical therapy network, perhaps even a national network, and put that in the account handling instructions, then monitor compliance and make sure the adjuster is helping monitor compliance.




Again this is not every doctor, at every clinic, attempting to get extra.  These questionable doctors are few and far between. But they are out there, and your adjuster and counsel know of some of them.  Physicians will say that they can only treat what the patient is telling them, and if the patient states they are in pain, then no matter what doctors are going to do what they can to help them.  So part of this problem is on the doctor, and part is on the claimant or patient. However, all of it can be questioned by you in a workers comp scenario.  Keep names of doctors and group practices that you had trouble with in the past.  If something does not seem right call and talk to the doctor about it and share your concerns. Remember the doctors or practices that caused you problems–chances are you will cross paths with them again.  Continue to stay proactive, and trust those instincts.


Your responsibility as an employer is to establish procedures, select vendors, and make sure you are actively involved in who treats your employees and the results they get from treatment, assuming this is allowed in your state. Working with a good TPA is important; ask them how they control these issues and learn what they are doing to prevent over treatment.



Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.comContact:








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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact


Medical Fraud in Workers Comp: You Might be Part of the Problem

Doctors and other providers who defraud the system for their own financial benefit are few, amounting to less than 4 percent. Yet, these few account for millions of dollars spent unnecessarily and without improved outcomes. Moreover, you could be helping these doctors defraud the system.
Fraudulent providers use tactics such as increasing the frequency and duration of medical services, billing at the highest levels regardless of state fee schedules, and billing repeatedly hoping to generate duplicate payments. Even more subversive are those who add multiple diagnoses to their exaggerated billing to avoid exposure by bill review systems. Such perpetrators also shrewdly submit bills using slightly altered names and addresses so their excesses are not easily noticed by electronic systems.
Modifying names and addresses is an easy and effective way to obfuscate data. Computer systems are literal, meaning they accept the data as it is. Consequently, adding a comma, reversing first and last names as they appear in one field, and adding or omitting a suite number, and abbreviating are all common ways to cause the system to create multiple records. Each iteration of the information is treated as unique by most computer systems so each becomes a separate record representing the same person or entity. While providers are sometimes dedicated perpetrators of these data deceptions, payers often contribute to the problem.
1.      Data quality is a people problem
Data quality in the provider demographic record in a computer system is critical to analyzing provider performance. How can individual provider performance be evaluated using analytics when multiple records representing the same person are present in the data? How can individual providers be identified when several hide behind the same TaxID number? Some providers use different names for the same office location or claim different specialties. Differentiating the good and bad is challenging.
Accurate data entry is critical to data quality, yet little attention is paid to this basic operational process. Good and bad doctors, as well as payers, are all guilty. A policy requiring names and addresses be pulled from a drop-down list of providers would prevent creating multiple entries caused by name reversals, misspellings, and key entry errors. This is basic software design. For those unable to create a hard-coded list from which the data entry person can select, a copy and paste policy should be established and enforced.
Manually typing information for each bill guarantees errors, record duplication, and confusion. Aggressive process management will significantly reduce the data entry problem.
Developing software interpretive rules to automatically correct and combine multiple records is fraught with uncertainties. For instance, a software rule might be written to interpret name reversals by looking for a comma indicating the last name is first. However, a comma is often not present, so even more confusion is created. Commas and periods, present or not, in names and address are a common issue of data quality and impossible to correct programmatically. It is a people problem.
2.      Unique identifier
Still, the best way to resolve the problem, whether it results from provider billing practices or data entry at the payer level, is to require unique provider identifiers such as NPI or state license numbers. NPI (National Provider Identifier) is a system required by CMS (Centers for Medicare and Medicaid Services). Individual providers must have an NPI number to be reimbursed by Medicare. Workers compensation payers should require the number on bills, a simple way to clarify provider identity. Of course, the same data entry rules must apply — either choose providers from drop down lists displaying NPI numbers or use the copy paste method to avoid inaccurate NPI number entry.
Most medical providers currently have NPI numbers because they want to be reimbursed by CMS for non-workers comp services. NPI numbers in the bill and in payers computer systems would eliminate the disguise offered by deliberate or unintended data duplication.
3.      Fighting medical fraud
Fighting medical fraud is more than challenging. But it is not only providers who contribute to the problem. Clean and complete provider records where the data are entered exactly the same way for every bill received from a provider will go a long way to correcting the problem. Duplicate records would be avoided and individual performance more accurately and fairly analyzed.
Evaluating provider performance and rating providers analytically depends on correct individual identification. Multiple records in the data for the same provider generated by sloppy data entry practices simply perpetuate and exaggerate the problem.

Author Karen Wolfe, BSN, MA, MBA, President/CEO, MedMetrics®, LLC.   Karen is founder and president of MedMetrics® LLC, an Internet-based Workers Compensation medical analytics company. She applies her medical knowledge to gathering, understanding and applying Workers Compensation data to the operational process. MedMetrics imports, integrates, and analyzes its clients’ medical billing and claims level data. MedMetrics uses several tools such as Predictive Intelligence Profiling and Medical Provider Performance Assessment to gather and analyze data. Contact: Phone: 541-390-1680;;

Our Workers Compensation Reduction Book:
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Louisiana Woman Arrested in Alleged Fake Billing Scheme

Following an investigation into alleged altered medical documents, troopers assigned to the Louisiana State Police Insurance Fraud Unit arrested Hollis Kagler, 43, and charged her with one count of insurance fraud.
According to State Police, the investigation stemmed from a complaint made by the National Teachers Associates Life Insurance Company (NTALIC) alleging that Kagler had submitted fraudulent medical invoices to support an injury claim. NTALIC specializes in offering supplemental health and life insurance programs to employees of the educational community, government agencies, and private businesses throughout the United States.(WCxKit)
May of 2010, Kagler claimed to have injured her back while moving furniture and submitted a hospital bill in the amount of $57,462 to Teachers for reimbursement. After Teachers questioned the validity of the bill, Kagler resubmitted an altered medical invoice to show that she had been admitted to the hospital.
The investigation concluded that Kagler intentionally attempted to defraud Teachers by submitting the fraudulent medical invoices.
In late June, troopers arrested Kagler at her Franklinton residence and booked her into the Washington Parish Jail without incident.(WCxKit)
Editor’s Note: All individuals are innocent until proven guilty in a court of law.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See for more information. Contact:

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

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