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Over the years, investigators and auditors for workers’ compensation programs in various states have discovered that some medical providers employ methods through which they defraud the system.
Medical provider fraud, which occurs when a doctor, hospital, or other caregiver attempts to profit off the workers’ compensation system, can include schemes and scenarios like:
So-called managed care systems integrate the financing of health care with their delivery to covered individuals, generally through preselected health care providers. Usually these programs offer a package of benefits and have detailed and explicit standards for health care provider choice. Managed care typically involves a prepaid payment method, meaning a certain dollar amount is set to cover the cost of the health care provided to an individual. This amount is paid in installments, often on a monthly basis, to the health care provider. The provider is then responsible for providing to those individual members of the plan all health care services agreed to under the plan.
Unfortunately, managed care systems can provide dishonest providers with specialized means of defrauding the workers’ compensation system. The following is a brief list of such means:
In the field of workers’ compensation, schemes developed, usually between attorneys and health care providers, to defraud insurance companies and employers are often called mills. Mills are generally organized around a ring of professionals who recruit workers to file false workplace injury claims. The recruited workers are sent to complicit medical clinics for provision of health services and are provided an attorney who pursues the workers’ compensation claim for this allegedly injured worker.
Claims’ auditors have detected mill fraud in the following ways:
In workers’ compensation, legal and medical professionals have sometimes conspired to defraud the system, often enlisting workers themselves to participate in the schemes. In some cases, workers’ compensation mills have cheated the system of millions of dollars in unearned fees – money meant to alleviate the financial burden of legitimately injured workers.
Do you have questions about provider fraud under New Jersey workers’ compensation? Contact the experienced New Jersey workers’ compensation attorneys at The Epstein Law Firm, P.A. today at 201-231-7847 for a free consultation about your case.
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