California Workers’ Comp report examines medical provider fraud

The Workers’ Compensation Insurance Rating Bureau of California, in a follow-up analysis of its 2018 study that assessed the potential impact of law enforcement on healthcare provider fraud, shows that indicted providers treated many more injured workers and rendered more services per injured worker.

WCIRB’s report, Treatment Patterns of Medical Providers Indicted for Fraud in California Workers’ Compensation, reflects changes to Senate Bill 863 and subsequent legislation that led to reduced medical costs, measures anti-fraud by various stakeholders also contributed.

The WCIRB findings include:

  • The average total medical bills paid per charged provider was 10 times higher than that of other providers between 2013 and 2018, in large part because indicted providers treated significantly more injured workers and rendered more services per injured worker.
  • The shares of medical payments for medico-legal and medical privileges of indicted providers were two to three times that of other providers. Charged providers also received a significantly higher share for complex office visits and ML assessments.
  • Charged providers in the Los Angeles Basin made up about half of the charged providers linked to WCIRB data, but they received more than 90% of the medical payments made to these indicted providers. The share of claims involving CT in the LA basin was consistently higher for indicted providers between 2013 and 2015, but the trend did not continue in 2016.

WCIRB’s new research brief compares treatment patterns and types of services rendered by charged / suspended providers to non-charged / suspended providers as well as regional variations and differences in treatment levels on cumulative trauma claims .


California Workers’ Compensation Fraud Medical Professional Liability

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