Medical Provider Fraud and FECA Claims

The investigation process is slow, but that should not deter those with suspicions, evidence or inconsistencies in medical invoicing from sending the information to their investigative units.  This article illustrates the cost of just one fraudulent medical provider.



Top 5To ensure their legitimacy, claims in these categories need to be viewed along with the circumstances of the injury and the extent of the medicals versus the lost time.  If a cumulative cloud of duplicity forms then the claim warrants closer scrutiny by field investigation and surveillance.

  1. Seasonal help and temporary help –Employees can be hired as a temporary solution, but some can become a full time problem when it is decided that a workers’ comp claim is a way to extend cash flowing past the season.
  2. Staff affected by location closings or moving – This group feels abandoned and so their allegiance wanes quickly.  Where they might have quickly returned to work so as not to leave co-workers shorthanded and shouldering their load, employees of a closing or relocation lose their connection socially as well as economically.  Watch for employees that know they might lose their job to lay the ground work for a potential worker’s compensation claim for a past minor injury from which they have returned to work.
  3.  The principles of a small retailer – An owner or principle involved with day to day operations of retail seldom has a contingency plan to be out sick for a week, never to mind considering being out for an extended period with a Workers Comp injury.  A principle will usually find a way back into the store, if they don’t, that is a red flag by itself.  They might actually be back in the store, but drawing worker’s comp checks also.  This can be a side effect of financial necessity/ poor cash flow.
  4.  Employees with attendance and disciplinary issues – By definition a person in this category is not an automatic abuser of compensation benefits, but anyone disgruntled does have a higher probability of seizing upon an opportunity to stage, elaborate or misrepresent an injury for the double purposes of creating a way out from the employer with whom they have had problems, and a way to “stick it to the man”.
  5.  Comp clusters – This is a group of claims usually created by poor management that doesn’t provide for advancement, training or give encouragement or considerations for extra efforts.  This boils up into a closed loop of employees complaining to each other how badly a manager or company policy treats the peons.  So, once an employee of this network happens onto a worker’s compensation claim, it becomes viewed as an escape from the job and retribution to the lousy work environment. Friends and co-workers quickly share the antidotes of the company reaction, the process and qualifications to make it work.  The collective absolve does not see a frivolous claim as wrong as everyone is doing it, the company deserves it, and it is only do it for awhile until something else comes along.



Trends in Technology

iStock_000045362422LargeFor investigators advancements in electronics and the internet continue to move rapidly, opening new opportunities and closing others.  (i.e. a phone book is pretty useless), but some of the new abilities are gimmicks and might give a marketing edge for an investigative vendor, but don’t usually add anything substantive to the investigation process- such as streaming video from the surveillance location.  Other technology is a mine field of potential litigation, such as vehicle tracking devices, or cell phone pings.  Some of the technology crosses ethical boundaries even when it does not break laws. One area of technology that has changed the most- the video tape is no longer a supported technology. Most cameras are digital using a hard drive or flash drive.  At first there had been a stumbling block as to how to use a consumer grade camera and send the digital video over the internet while at the same time capturing the time and date.  The time and date had not been a problem with analog technology and tapes but it didn’t transfer with the picture, at first with a Firewire or USB.  The time date info was always there in the metadata with most video formats, but when uploaded we couldn’t get to it. This was not just investigators but also taped depositions and anyone that needed to record evidence and send it over the internet with the time and date.   That seems to be solved with software that now will pull the metadata off the video and burn it over the original video.  One of the advances that most investigative vendors can now do is upload video from the field to the company’s home office.  There is no original tape as we were once used to producing, but with digital, the courts seem to rule in most jurisdictions that a digital copy is the same as an original.  (Legal departments need to fully weigh in on this subject).

Trends in Accessibility

Access to open files continues with different approaches by vendors and SIU alike- some is too wide of a focus and some is too narrow. Full access to a file by the claims personnel looks at first pass to be the ultimate control mechanism, but the focus is too wide.  Until all the qualifiers are added and the information analyzed it is like the difference of watching the random video of a mall security camera, versus a documentary that has assembled and identified a cohesive narrative of information. Some SIU departments request direct access with the investigator in the field, and though this provides first hand information, it is too narrow of a focus.  It disengages the other resources of the investigative vendor.  The investigator in the field might not know all the alternatives available, as it might be in the best interest of the file to switch investigators for cost savings, logistical purposes, or variation in the investigative techniques being applied.  A conversation with the field investigator will not reveal this as easily or readily as dealing with the management.  Going through management also allows more request and instructions to be thoroughly documented.

Trends in Privacy

The ability to share confidential information securely is still a challenge to many companies. Even when there are policies and practices in place, shortcuts are sometimes taken due to the technology breakdown or time demands: emails get sent from non secure sources and encryption gets skipped.  On the vendor side of things, there is a dynamic at play where the vendor wants to comply with the encryption demands of the Client Company, but not frustrate the Client User with complicated logins and passwords.

The two answers that seem to be dominating the landscape of the industry are when a client company sets up Transfer Layer Security or TLS with vendors.  Email is then automatically secure between the two entities.

All of the larger investigative vendors and most of the intermediate size companies are using a Share Point based case management software that allows the confidential sharing of information, files and video, but does require a client to log in if wanting the information this way.  The down side of this is that with multiple vendors, there are multiple sites and variations to the logins.

Trends in Metrics

Business People In MeetingA chunk of resources for all investigative vendors is now devoted to updates and communications. Gone are the days when an assignment was picked up in a paper file and two weeks later a report submitted.

Investigations are a commodity for insurance companies and competition is being divided into those who can meet time service and communication demands and those who cannot.

There has been push-back from some of the more experienced field investigators who believe that focusing on the speed of report submissions and updates somehow diminishes the ability to conduct a thorough investigation. Their argument is that the results of an investigation can’t be rushed. An investigation takes time. An investigation is an art, with a beginning but no known end. The end occurs when it occurs, like the last brush stroke on a painting. They feel they are like an artist and need to have the control of the time table; otherwise, the investigator is just painting by the numbers. Forcing an investigator to meet exact deadlines somehow compromises their artistic integrity.

Investigative vendors are challenged with changing the mindset of the industry and are begrudgingly adopting the ability to deliver their masterpieces with the paint still wet.

The act of conducting an Insurance Investigation might be an art, but it is sold as a commodity.

The ability to keep schedules, and maintain updates, emails, and reports, is a reflection on a company’s overall handling of creative thinking, planning, organizational skills, and dedication to hard work.

Delivering the results of an investigation to clients is the business of every investigative vendor.