The Investigations Unit of the Workers' Compensation Division's Compliance Section of the Department of Consumer & Business Services (DCBS) was established to investigate allegations of statute or administrative rule violations in an effort to minimize abuse of the workers' compensation system. The unit investigates complaints involving medical providers, insurers, employers, and claimant abuse/fraud. This report summarizes the unit's complaint investigation activity during fiscal year 1996 (FY96).
In FY96, 243 investigations into complaints of abuse or fraud were initiated averaging 20 per month. This is a 3 percent decrease from the 250 investigations initiated in FY95.
The most frequent complaints received were improper claims processing by the insurer or medical provider (24 percent; an increase of 10 percentage points since FY95), failure/improper reporting of claims-related documents by either the employer, insurer, or medical provider (16 percent; an increase of 3 percentage points since FY95), and worker collecting workers' compensation benefits when working or able to work (16 percent; a decrease of 9 percentage points since FY95). Other complaints included employer pressure not to file a claim (12 percent; an increase of 1 percentage point since FY95), harassment (9 percent; a decrease of 1 percentage point since FY95), and fraudulent claim (7 percent; an increase of 4 percentage points since FY95). Complaints about improper medical treatment/service decreased by 6 percentage points, from 11 percent in FY95 to 5 percent in FY96.
Subject of investigations initiated
Thirteen percent (31) of the 243 complaints initiated in FY96 were against medical providers. This represents a decrease of 2 percentage points from FY95. Fifty-two percent of the 31 complaints against medical providers involved managed care organizations. These complaints were most often for improper medical treatment or service. Employers were the subject of 39 percent (95) of the investigations, workers 24 percent (59), and insurers 19 percent (45). Employer pressure not to file a claim and improper reporting were the most common complaints against employers.
In FY96, 213 investigations of abuse or fraud complaints were closed compared to 253 closures in FY95. An average of 18 complaint investigations were closed each month in FY96. These complaints were closed either by disposition (72 percent) or referral (28 percent). Of the 153 disposed complaints, 31 percent were unfounded, 16 percent were issued a notification letter, 25 percent were retained for future reference and pattern development, and 25 percent were given a letter of reprimand or warning.
Twenty-eight percent (60) of the investigations were closed by referral. Seventy-five percent (45) of these referrals were made to the insurer (or self-insurer) and 8 percent (5) were made to another division within the Department of Consumer & Business Services (DCBS). Other state agencies, other sections within the Workers' Compensation Division (WCD), and MCOs each received 5 percent (3) of the referrals. Complaints referred to the insurer most often consisted of claimant fraud such as collecting workers' compensation benefits when able to work or filing a fraudulent claim.
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This document was originally published in May 1997.