Workers' Compensation Provider Fraud
As a reporting party, you have a legal obligation to refer insurance claims or transactions where you have reasonable belief that insurance fraud may have or might be occurring. Reasonable belief is defined as "a level of belief that an act of insurance fraud may have or might be occurring for which there is an objective justification based on articulable fact(s) and rational inferences therefrom."
After your claim/transaction has been referred to the California Department of Insurance (CDI), it will be reviewed by a supervisor to determine whether the claim/transaction should be:
- Assigned for investigation
- Referred to another agency
- Closed due to a lack of resources
- Closed due to a lack of evidence
When determining if a claim is viable to be assigned for investigation, the CDI supervisor will be evaluating the information provided from your referral. If there are questions, the CDI supervisor may contact you to ask additional questions. Your responses to the following questions are helpful when determining if a case rises to the level of an investigation:
- What facts caused the reporting party to believe insurance fraud occurred or may have occurred?
Facts to consider include:- Whether this claim is part of a pattern
- Whether medical bills (Pharmacy/Pharmacist, interpreter, and Physical Therapist, etc.) for treatment were up coded or were for treatment not rendered
- What are the suspected misrepresentations and who it was that allegedly made them?
- How is the alleged misrepresentation(s) material, how do they affect the claim or transaction?
Summarize the financial impact of the misrepresentation here and how it changed your decision on the claim or transaction. - Who are the pertinent witnesses to the alleged misrepresentation and what documentation exists?
Describe whether the reporting party conducted suspect and/or witness interviews/depositions and whether the interviews/depositions confirmed that fraud occurred or may have occurred. Additionally, identify all records obtained to confirm the allegations of Provider/Billing fraud. - Include a statement as to whether or not the investigation is complete.