If you’ve ever filed for workers’ compensation (or any other kind of insurance), you might have felt as though you were in the “hot seat,” being interrogated about the validity of your claim. Claims adjusters are trained to try to spot fraud, and there are claimants who try to get more from the system than what they’re entitled to receive.
Unfortunately, fraud can be committed by anyone in the process — the claimant, the employer, or even the health care provider.
These are some of the ways various people commit workers’ compensation fraud:
| Claimants | Employers | Health care providers |
|---|---|---|
| Exaggerating symptoms | Under-reporting payroll | Unnecessary treatment or testing |
| Failing to report income while on disability | Incorrectly classifying employees in order to pay lower insurance premiums | Billing for treatment or services that were not performed |
| Incorrect mileage reports | Failing to have correct workers’ compensation coverage | Double-billing (i.e. billing the worker’s health insurance and workers’ compensation insurance for the same expense) |
| Claiming to have been injured at work when the injury happened outside of work | Deducting costs for premiums from a worker’s wages | Charging higher amounts for services covered under workers’ compensation |
Fraud costs everyone money, though it might be indirect.
For instance, if the company that your employer uses for workers’ compensation insurance is a victim of fraud by other companies, it could raise your employer’s premiums. While increased premium payments don’t come directly out of your paycheck, the more your employer pays for overhead costs like insurance, the less it can afford to pay employees in wages or salary.
In other words:
There’s a cycle... and fraud isn’t a victimless crime.
Doctor pleads guilty to workers’ compensation fraud
Dr. Robert Dale Bernauer Sr., a Louisiana physician, was in the news recently after pleading guilty to workers’ compensation fraud. The orthopedic surgeon made more than $1 million between 2011 and 2017 by taking “kickbacks,” which are illegal financial incentives made to compensate healthcare providers for recommending certain treatments, prescriptions or services.
Dr. Bernauer was “recruited” by a company to dispense pain creams and patches to workers’ compensation patients. In return, he was offered a 50% split of the profit from the billing insurers. The company would bill insurers at a markup of 15 to 20 times the cost of the medications.
While Dr. Bernauer wasn’t the only physician involved in the scheme, he was charged and pleaded guilty to conspiracy to commit mail fraud, wire fraud, health care fraud, fraud to obtain federal employees’ compensation and illegal remunerations and taking kickbacks.
The workers’ compensation insurers lost about $2 million from the scheme.
How workers’ compensation fraud impacts the injured worker
Would the type of scheme committed by Dr. Bernauer hit you right in the pocketbook?
No.
But it affects you in other ways.
Every doctor has certain preferences for treatments they use and drugs they recommend. But when a doctor is receiving kickbacks, as Dr. Bernauer was, they are more likely to steer a patient toward a treatment that will earn them money... rather than what’s best for the patient’s care.
Fraud also puts more strain on the system. The more fraud becomes rampant, the more effort has to go into verifying claims — and it may take longer for you to receive your benefits.
Penalties for Georgia workers’ compensation fraud
The State Board of Workers’ Compensation sets forth a set of penalties for anyone (employee, employer, or health care provider) who commits fraud.
| Offense: | Penalty: |
|---|---|
| Fails to file any required form or report, follow any order, or violate a rule or regulation of the Board | Fine of $100 to $1,000 per violation |
| Knowingly and intentionally makes a false or misleading statement to obtain or deny benefits or payment | Fine of $1,000 to $10,000 per violation |
| Employer did not provide adequate coverage under Georgia workers’ compensation laws | Fine of $500 to $5,000 |
| Employer refuses or neglects to secure insurance coverage | Misdemeanor and fine of $1,000 to $10,000; imprisonment up to 12 months |
Workers’ compensation-approved physicians
Georgia workers’ compensation law provides that there are specific physicians included on an approved “panel,” and an injured employee who submits a claim must choose a physician from the panel. This authorized treating physician can refer to specialists if necessary, but will generally oversee the treatment.
A referral physician may not make a referral to another physician. However, if the patient is dissatisfied with their treatment, they may see a different panel physician. If the employer does not allow the employee to choose a different doctor according to the law, the employee could be granted the opportunity to select the physician of their choice and there could be penalties against the employer.
How do physicians commit workers’ compensation fraud?
The vast majority of physicians and other medical professionals are always doing the best they can to treat patients to the best of their abilities, and to achieve the best possible outcome for the patient.
But, as in any profession, there might occasionally be a few bad apples in the basket.
Here’s how medical provider fraud could happen:
- A physician provides unnecessary medical treatment. This could happen because the more treatment is provided, the more money the physician earns. A doctor might continue treatment longer than necessary or recommend procedures that are not warranted for the patient’s specific injury.
- A lawyer and physician will conspire to commit fraud. For instance, the injured person’s lawyer and the doctor have a “quid pro quo” arrangement where the lawyer sends their claimants to the doctor, the doctor writes the claimants highly favorable disability ratings, and the biased medical reports earn them more clients from the lawyer.
If a medical provider knowingly provides false or fraudulent medical reports or billing, or if they provide services beyond what is medically justifiable, it’s fraud.
Why a physician’s workers’ compensation fraud is a problem for YOU
No employee plans to get injured. And most people will always do the right thing and make honest, justifiable claims.
But what if you get caught in the crossfire with an unethical doctor?
It can be a problem.
First, you don’t want treatment you don’t need. It can delay your return to work. While it might be relaxing to be able to stay home and receive benefits, that’s not a permanent solution. Your workers’ compensation benefits are only a percentage of your salary, so if you’re able to return to work and don’t, it actually costs you money.
Second, the more treatment the doctor says you need, the more carefully the workers’ compensation adjuster is going to review your file. If you have previous workers’ compensation claims, or if it seems that the doctor is recommending more than the amount of treatment expected for the type of injury, it’s possible that the workers’ compensation claim reviewer could suspect that you are the one committing fraud.
The workers’ compensation system is complicated. It isn’t perfect, but it is a time-tested method for receiving benefits to cover your medical costs and a portion of your wages while you recover from a work-related injury.
But there’s a lot to navigate to ensure that you receive the correct benefits to cover your injury. If your injury was minor, required only minor treatment, and was quickly and easily approved for workers’ compensation benefits, then you’re probably fine to be on your way to recovery on your own.
If your injury or illness will require long-term or ongoing care, or if there are any questions about its legitimacy or whether you will receive benefits, then it’s time to consult with a workers’ compensation attorney near you.
About Tom Holder
Tom Holder is an award-winning workers’ compensation attorney. After graduating from Emory University School of Law, Tom worked as an attorney at 2 highly respected law firms. In 1986, he founded his own law firm in Atlanta where he represented injured workers for 32 years. In 2010, Tom joined forces with Atlanta workers’ compensation attorney Ben Gerber to form the law firm of Gerber & Holder. Today, Tom’s practice is exclusively devoted to representing injured workers in Georgia. He is a nationally known and award-winning attorney in the area of workers’ compensation law. View his Enjuris profile today.
