Workers Compensation Fraud

Accidents can happen in the workplace. When an employee gets a work-related injury or illness, your business could be on the line. Workers’ compensation insurance protects you by reimbursing employees when accidents take place. But, employees, employers, and even health care providers can take advantage of the system by committing workers’ compensation fraud.  Workers’ comp fraud can lead to higher insurance premiums and penalties, so it’s important to know how to protect your business and avoid costly mistakes.   

Workmans’ comp fraud can come in many different forms. Workers’ compensation fraud is any lie or misrepresentation made by an employer, employee, or provider to benefit financially.  One to two percent of all workers’ compensation payments are fraudulent.

Workers’ comp insurance fraud can be when an employee lies about their injury or illness, when an employer misclassifies employees to avoid paying for workers’ compensation insurance, or when providers exaggerate an employee’s symptoms to get more money. 

Life Insurance Fraud

 Insurance fraud occurs when an insurance company, agent, adjuster or consumer commits a deliberate deception in order to obtain an illegitimate gain. It can occur during the process of buying, using, selling or underwriting insurance. Insurance fraud may fall into different categories from individuals committing fraud against consumers to individuals committing fraud against insurance companies. Insurance fraud, estimated at over a hundred billion dollars per year, not only imposes costs on insurance companies and threatens their competitiveness and future viability, but it is also financially damaging to consumers and detrimental to the economy and society as a whole.

Health Care Insurance Fraud

Health care fraud is a crime. It's committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits payable.  The majority of health care fraud is committed by organized crime groups and a very small minority of dishonest health care providers. The most common types of health care fraud include:

• Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
• Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).
• Performing medically unnecessary services solely for the purpose of generating insurance payments.
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
• Unbundling - billing each step of a procedure as if it were a separate procedure.
• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
• Accepting kickbacks for patient referrals.
• Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship"). 

Government Procurement, False Claims Act Violations

We work with attorneys who represent individuals with evidence of fraud against federal programs and file lawsuits on the government’s behalf to recover financial damages resulting from the fraudulent acts.   In addition, we work with attorneys who are retained to defend their clients under investigation for Government Procurement Fraud matters.  There are a wide range of fraudulent actions that constitute a violation of the Federal False Claims Act. The qui tam attorneys are experienced in litigating many types of False Claims Act cases in a variety of industries, including:

• Healthcare fraud
• Financial fraud
• Government Contracts