Taming the workers-comp monster in California

Crooked providers, lien setup bleed comp system

If you need more proof the workers-comp system in California is a mess, look no further than the report this week that indicted and convicted medical providers filed more than $600 million in liens against workers-comp claims.

The lien system in the state continues to be fertile ground for fraud. Designed as a safety net to ensure injured workers get treated, it’s now a slush fund for crooked medical providers and lawyers.

Fraud and abuse are rife in Southern California, where medical rings are targeting just-retired workers, says one insurance exec who wrote us this week. Runners hang out at Social Security offices and other venues frequented by retirees. They entice the retirees to file claims by offering free medical care and a windfall to supplement retirement income. The retirees are brought to lawyers’ offices, signed up and then shuttled off to medical offices for “treatment.”

The number of worker “injuries” occurring on the last day of the job is rising, this exec says.

Legislation to help weed some of these abusive providers out of the system is cruising through the California legislature. The bill would ban providers who’ve been kicked out of Medicare and Medicaid for over-billing. The bill sponsor says there’s evidence that crooked docs banned from government health plans have turned to workers comp to ply their trade.

The sponsor also says his legislation will target lawyers who sign up comp clients, but never actually interview them, then file claims for them in distant cities and ultimately settle the cases for their fees — often without the workers’ knowledge.

The legislation is a good idea, but much more needs to be done. Workers compensation in California is a huge, complex multi-faceted program. There are no easy answers on how insurers, employers, policymakers and others can hit that sweet spot of minimizing fraud while making sure injured workers get the treatment they deserve. But finding a better way than the lien system might be a good start.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Unwise Wise Guys purloin insurance money?

Mafia busts another sign that big crime rings have big ideas for fraud

Reputed mobsters from the Luchese, Bonnano and Genovese crime families were busted up and down the East Coast last week.

The epic lasso roped nearly 50 suspected hoods, including high-ranking capos who called the shots.

Extortion, gambling, loansharking, muggings and other standard Mafia schemes were alleged in the federal indictments.

Unwise wiseguys?

What stood out was health-insurance fraud. The gangsters allegedly convinced docs to write “unnecessary and excessive” prescriptions for expensive compound creams. Allied docs overbilled insurers and received kickbacks, the feds say.

Street hoods turning to respectable white-collar crime?

“Many of the Italian mafia families across the nation have sought to diversify their interests into more high-tech, white-collar crimes for a while now, dating back, really, to the 1980s,” mob expert Scott Burnstein tells Vice. “Smart mobsters in this day and age no longer just line their pockets with traditional rackets (gambling, loansharking, extortion) — and some try to stay away all together. When you compare prison sentences, it makes the most sense.”

Organized crime sinking its grubby paws into insurance fraud is a known phenomenon. The Coalition has tracked the trend for years. Complex rings, and ethnic gangs such as Russians and Armenians, have gotten rich from staged crashes, inflated health-insurance claims, medical ID theft and other insurance rackets.

The latest busts add new insights into how the Mafia itself may be larding family ledgers with insurance crime.

Drug dealers and other street types are branching into insurance crime. It’s safer, more-profitable and less likely to earn you a bullet to the head in a dark alley, they reason. Same often holds true for larger crime rings.

All this is hardly surprising. Corporations inevitably follow a good money-making idea. They add efficiencies and scale, thus magnifying profits. This is as true of insurance fraud as honest entrepreneurial ventures such as coffee, copier and hamburger franchises.

There always will be a generous niche for mom-and-pop fraudsters — average consumers who inflate claims for “lost” engagement rings or “stolen” sound systems.

It’s the corporate fraud players who may be the most dangerous. In addition to size and organization, many complex rings could have resources to bring in tech-savvy players who can hack and breach insurers.

Sensor-driven devices such as telematics also may be hackable, thus allowing hi-tech crash rings to alter data and seemingly legitimize setup car wrecks. Shifting alliances among fraud rings with differing skill sets likely will surface. Align medical providers with breach techies and the theft potential is great.

The Mafia may not be the unstoppable octopus of yore. Yet the upcoming Mafia trials still will give fraud fighters useful field intel on the threat they’re up against. They’d be smart to watch closely and mine for actionable insights. Whether the Mafia is a bit fraud player or serious actor, they’re another reminder that size does matter with insurance fraud.

About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud.

Fraud fighters must get in legislative game

Play strong role in enacting stronger state fraud laws

Two truths will govern our success in getting strong state fraud laws onto the books: We must prepare our 2017 legislative agenda now; waiting until December or January is too late. Fraud fighters also can play a pivotal role in getting fraud bills on the front burner in many states.

We’re in an election year, with less than 90 days until we vote for a new president and Congress. We’ll also vote for quite a few state legislators, and a handful of governors.

We tend to be Washington-centric, thinking that who we put into the White House and Congress will affect us the most.

Actually, most of us are directly affected more by what happens in our state capitals than in Washington. Fraud fighters thus should be alert to creating opportunities in our own backyards.

The Coalition is using the summer to plan the states where there’s the  strongest need for new fraud laws — and a solid chance we can get bills enacted into law.

The Coalition’s government affairs committee meets this week to discuss the best hotspot states. Later this month, I’ll be on a conference call with state IASIU chapters. We’ll discuss the grassroots role that fraud fighters can play in writing their legislators in key target states next year.

The best way to convince insurers to make anti-fraud bills a priority in a given state is to make a business case why statehouse efforts are in everyone’s best interests.

Let me know if you think your state is a prime candidate for strong fraud bills in 2017. Partnerships among fraud fighters and other allies give us the best chance of success.

Together, we can make a difference.

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

Limiting Medicare billing may weed out cheaters

Home-health and medical transport companies in crosshairs

What to make of the federal government extending its moratorium on allowing new medical providers to bill Medicare and Medicaid in six states?

Does CMS still need to get a handle on pre-screening providers before allowing them to bill?

Or is fraud is so rampant in those areas that CMS must weed out existing bad actors before allowing new providers to enter?

Probably both.

Shutting down enrollment is a drastic move that can hurt honest providers. It also can limit patient access to needed care. But it’s a necessary step for the federal government to  effectively manage fraud in its programs.

The areas affected by the extension include home-healthcare and medical transport — two that are rife with fraud.

Congress gave CMS the power to shut down enrollments a few years ago, but CMS hesitated at first. Nudged by Congress, CMS started restricting enrollments in limited areas where fraud was most out of control.

The enrollments seem to be a qualified success, but it will take a few years to fully know if provider fraud has started moving downward.

In the meantime, CMS is taking a smart approach to using its power to restrict enrollments. Moratoria are targeted. The latest extensions, for example, impose home-health enrollment limits in Florida on just three of the worst counties. Plus, CMS now allows exceptions to the moratoria if providers pass heightened screening.

Taking action before crooked providers can bill is the best answer to the old “pay-and-chase” model. It should also deter many would-be cheaters, especially organized fraud rings looking to soak federal programs.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Celebs draw fentanyl addict headlines

Reminds that insurance fraud helps finance opioid epidemic

Reminds that insurance fraud helps finance opioid epidemic

First came Prince, who died from an overdose of the painkiller fentanyl in his Minnesota home.

Next came singer Chaka Khan. She beat the reaper by entering into rehab this month, along with her sister.

The Grammy winner admitted fentanyl is her escape drug of choice. Chaka wisely gave up her summer concert appearances to focus on getting clean.

“The battle of addiction is a serious and long process, which is why I chose to address my use of prescription medications — which came about as a result of the knee surgery I had a few years ago,” she said.

Fentanyl is one of latest prescription painkillers to grab headlines. It’s used for severe pain, and is approved for longterm treatment. The stuff also is up to 100 times stronger than morphine, and 50 times stronger than heroin.

Fentanyl quickly shoots into the bloodstream. Dopamine then elevates, stoking the brain’s reward areas. The sweet euphoria grows into dependence, then addiction.

States like New Jersey and Mississippi are reporting spikes in fentanyl overdose deaths.

Insurance fraud is the largely untold story. It’s helping finance America’s epidemic of opioid addiction — billions of stolen insurance dollars worth.

Some fentanyl addicts reportedly are scamming health insurers to score prescriptions that feed the need. Same with other painkillers such as hydrocodone, or anti-anxiety meds and muscle relaxants.

Insurance scams may or may not have funded Prince’s or Chaka’s highs. Yet scams still are part of the bigger opioid picture, so we should be very concerned.

Insurers are stepping up investigations, plus education of doctors and patients to head off addiction. Law enforcement is going after shady pain clinics and pharmacies that dole out insurer-paid scripts.

Still, we risk getting exhausted by it all. We’re subject to steady parades of news stories about people dying from insurance-paid overdoses. Plus welcome busts of cold-blooded pain docs. They’re keeping addicts fed with pills — are we getting fed up?

Sadly, it may take a celeb’s drug death or rehab to keep headlines fresh and the public concerned. Let’s stay concerned, whether it’s a Grammy winner or small-town factory worker just trying to get clean.

About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud.

Dodging auto premiums should be crime

Lying about garaging vehicles burdens honest drivers

Summer driving season is in full swing. It’s a reminder that dishonest drivers are illicitly registering their vehicles in states where premiums are lower. The Coalition is calling for states to go after these drivers.

Using out-of-state addresses to insure a car illegally reduces the driver’s auto premiums. It also burden honest insurance consumers who insure their vehicles with their real address. They may pay higher auto premiums thanks to drivers who cheat the system.

North Carolina was the first state to tackle this issue by requiring new insureds to show proof of residence before an insurer could write a policy. Out-of-staters were registering their vehicles in North Carolina for the lower auto premiums.

North Carolina recently went a step further and put more teeth in the existing law. Trucking firms are falsely registering their fleets in the state yet have no operations there. The new law requires businesses to prove they ply the roads in the Tar Heel state.

Falsely registering vehicles in New Jersey is a specific insurance crime.

The Coalition seeks a similar law in New York. Bills have stalled, though we and our partners there are planning to reboot in 2017.

A Maryland bill would’ve let insurers rescind policies of drivers who falsely registered their vehicles in the state. The state held a public meeting. An insurer told about a claimed loss in Maryland by an insured who lived in New York — where the insurer doesn’t write coverage. The insurer paid the claim to avoid a baseless yet potentially costly bad-faith suit.

The statehouse will revisit legislation in 2017.

The Coalition strongly supports targeting auto rate evasion. Tough state laws can remove a driver’s incentive to take the risk.  Consumers who lie about where they drive to lower their auto premiums add burdens to the many thousands of honest drivers. This undermines the integrity of the auto-insurance system.

Fraud fighters have taken the forefront on this issue. Stay alert to auto-premium evasion in your state. Tell the Coalition and your state insurance department. Falsely registering a vehicle should be a ticket to jail, not an easy source of summer spending money.

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

Protecting insurer rights to EUOs vital to fraud fight

Adverse decision in Kentucky could embolden crash rings

A Kentucky lower court has thrown a wrench in the campaign to combat the growing scams involving PIP crashes in the Bluegrass State. The court agreed with two claimants in an auto crash. They’re suspected of fraud. Insurers have no right to compel them to attend an examination under oath (EUO), the lower court ruled.

The Coalition and NICB filed an amicus brief this week asking the Kentucky Supreme Court to overturn the decision and restore insurer rights to use EUOs.

EUOs are a powerful weapon to get at the truth. When summoned, many fraudsters don’t bother showing up —especially lower-level ring members. They feel the few dollars they’re making don’t offset the potential of getting caught.

EUOs are a deterrent as well. Knowing there’s a chance you might have to give details of a claim under oath helps keep people honest.

Take the EUO away, and more fraud rings likely will escape detection and feel emboldened to commit more fraud.

The Kentucky claimants contend insurers use EUOs to harass and intimidate honest claimants. We’ve found no evidence to support this contention. We determined that insurers use EUOs very infrequently, and only when necessary to discover truth about a claim.

In fact, EUOs can be an important tool to validate legitimate claims.

Sometime later this year, the Kentucky supreme court will announce its decision. Here’s hoping they support uncovering the truth about potentially fraudulent auto claims.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Zero tolerance of fraud?

Strengthening backbone rewards insurers, customers

Zero tolerance is an popular catchphrase for insurers to bandy around. It implies a blanket boycott of dubious claims, the marshaling of an insurer’s full resources at every turn.

In practice, zero tolerance is a moving target. Few insurers can assert they contest every dubious claim. Even the most principled insurers decide which claims to challenge, and which to let slide through.

Focusing limited staff resources on a complex staged-crash ring that’s stealing hundreds of thousands of dollars might make more sense, from an insurer’s standpoint, than taking on a handful of smaller homeowner claims that prosecutors likely aren’t interested in pursuing.

Perhaps paying a $5,000 nuisance claim from a clearly setup fall in a restaurant makes more sense, as an insurer sees it, than spending many times that amount in legals fees to defend against the determined crook’s civil suit. A sympathetic jury could dole out $500,000 to the swindler, who’s faking a convincing limp in court. Just pay off the guy and make his claim go away.

That said, one of best business cases for zero tolerance recently was mapped by former CNA chief claims officer George Fay. He writes movingly in the Journal of Insurance Fraud in America

Most claim denials for fraud result in a lawsuit against the company, no matter how solid your case,” George wrote soon after retiring. “A strong anti-fraud position can earn your insurer a reputation within the criminal underworld for being an undesirable target to try and bilk. This principled stance saves legal fees in the long run.”

And helps build customer loyalty: “When you make customers aware of your anti-fraud efforts, they see it for themselves and usually stay with you for life.

Zero tolerance also reflects an insurer’s character, from the leadership down through line staff. “An insurer that knowingly pays a fraudulent claim violates its values statement,” George writes. “And certainly the insurer lacks character. The same is true of insurer employees — from the SIU director to claims personnel to adjusters. Character is critical to building the foundation of successful fraud-fighting efforts.”

Zero tolerance — strengthen your backbone, stop false claims and reap rewards. George Fay writes an inspiring roadmap. Insurers should study that vision closely — your honest policyholders will be glad you did.

About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud.

New fraud laws start with open dialogue

Md. public meeting helped focus on needed reforms

Last week I took part in a public meeting the Maryland Insurance Administration held in Baltimore to review anti-frauds effort in the state. Part of the discussion surrounded anti-fraud bills that stalled this year when the 2016 session closed in mid-April.

The state insurance commissioner Al Redmer Jr. chaired the meeting. He stayed the entire time. He went beyond simply giving an opening statement, then handing the meeting to the fraud unit’s chief. Redmer’s lengthy presence showed a strong interest in strengthening state’s anti-fraud efforts.

I called for the state to redouble its efforts to target drivers who lie where they garage their cars to illicitly lower their auto premiums.

Maryland drivers should register and insure their vehicles in the state. Similarly, out-of-state drivers should pay a steep penalty for lying that they drive and garage their vehicles in Maryland to lower their auto premiums.

Maryland should be applauded for last week’s effort. The session started dialogue for targeting auto-premium evasion and other insurance crimes. This could spark renewed pushes for anti-fraud legislation next year. The 2017 legislative session opens in January.

Other states can learn from sessions like this one. A state’s anti-fraud effort is organic. Fraud fighters and the insurance department must continually review its direction and impact. No state should rest on its laurels, thinking it’s doing a great job. Nor should a state grow reluctant to act, believing the anti-fraud environment can’t be changed so why talk about it.

Maybe such a meeting in New York could help break up the logjam in Albany that has stalled so many worthwhile anti-fraud measures in recent years. Or, a state like Oregon which has no insurance fraud law or anti-fraud infrastructure. Imagine what the insurance departments and governors would learn if they held such meetings. Same with Michigan, which needs a fraud bureau.

More often than not, legislatures act in a vacuum when they look at anti-fraud laws. Too often they’re pulled in several directions, making it hard to focus on enacting anti-fraud laws.

Fraud fighters should assume leadership and start action-driven dialogue. Reach out to the state insurance department, insurance commissioner and state attorney general. Co-sponsor open meetings to review their state’s fraud trends, and where new fraud laws are needed.

These joint efforts can go a long way toward enacting needed laws and regulations that make a state’s anti-fraud efforts stronger than ever.

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

Slip and falls: The big waste

Scams suddenly real when guy fakes tumble during bus ride

Imagine coming home from a long day at work. You climb on a full bus. Soon the vehicle suddenly screeches to a halt. An elderly man outside falls onto the pavement. The bus hit him at a stop light, he screams in seeming pain. The passengers have to clear out, and you’re still a mile from home.

You hear ambulance sirens rushing to the scene. Yet nobody’s fooled. Children and adult passengers are calling out this fraudster. They’re yelling things like, “He just wants to get money!”

You remember sitting in the front of the bus, and it never touched the man … at all. No bump, no thump.

If you’re wondering if that insurance grab happened … it did … to me.

I’m an insurance-fraud researcher with the Coalition Against Insurance Fraud. I read about and see videos of fraudsters faking slip and falls all the time. They seemed like a fantasy until I saw this guy’s scam first-hand.

Slip-and-fall cons may steal billions of dollars a year. Honest businesses are sued. They pay in higher premiums. We pay in higher prices at the cash register.

Some fraudsters place liquid detergent or other slippery stuff on supermarket floors. They sit down on the floor and scream they slipped on the mess. They’re blithely unaware that security cams record every false move.

Selena Edwards of California claimed a scalding cup of hot coffee with a loose lid slipped off and burned her hand at a McDonald’s drive-thru. But she’d used a photo of someone else’s burned hand. And her medical records also were forged. Edwards was convicted.

Some consumers even joke about it on social media.

Slip-and-falls are a quick way to make big bucks, people often yack. Search the hash tag #BoutToSlip on Twitter. You’ll see youngsters joking about slipping and falling to claim insurance money. This kind of peer-to-peer chatter can egg others to fake a money-grabbing slips.

Or check out the #insurancefraud hash tags on Vine and Instagram. Plenty of quick videos of young people joking how to pay college tuition by scamming insurers with bogus tumbles.

My experience on the bus plus my research with the Coalition made one thing clear: Slip-and-falls are a big waste for everyone. This is especially true of scammers who end up with permanent criminal records after their cons slipped, fell and broke.

About the author: Elijah Mercer is research associate of the Coalition Against Insurance Fraud.