Fraud happens when someone lies to obtain some benefit they are not entitled to, or knowingly denies an employee a benefit which they are entitled to receive. 

How Does This Affect Me?
Workers’ Compensation Insurance Fraud occurs every single day, costing billions of dollars each year. These losses not only affect insurance companies but everyone – employers, workers, consumers and shareholders.

How so?

Fraud losses increase insurers' costs and make it harder for them to cover policies. These expenses then must be passed down to employers whose premiums go up. This may then cause the employees’ pay/benefits to decline and the consumer prices to rise. 

Types of Workers’ Compensation Fraud

Claimant Fraud
Employees who make false statements or material misrepresentations about their injury claim. 
• Reporting a false injury
• Stating an injury occurred at work when it did not
• Overstating the extent of injuries
• Unauthorized employment while collecting benefits

Premium Fraud
Employers who misrepresent facts to obtain workers’ compensation insurance coverage at a lower premium.
• Paying workers in cash and falsely reporting the company’s payroll
• Not reporting injuries to workers’ compensation carriers
• Misstating the employees job description
• Company claims all employees are independent contractors when they are not 

Provider Fraud
False billing committed by healthcare providers, such as doctors, hospitals, clinics, pharmacies, or other healthcare professionals or organizations. 
• Billing for services or treatments not provided 
• Paying kickbacks for recruiting/referring patients to doctors

Uninsured Employers
Employers who do not provide workers’ compensation insurance to employees.
• Businesses with one or more employees that do not obtain workers’ compensation insurance

When workers commit fraud
• Are there witnesses to the accident?
• Are there conflicting descriptions of injuries/accidents?
• Was the claim reported late for no valid reason?
• Is the employee observed doing things they said they could not?

When employers commit fraud
• Does the employer have workers’ compensation insurance?
• Are employees discouraged from making injury reports or told to use their own health insurance plan?
• Is the employer paying workers' with cash?
• Are workers’ titles consistent with their duties and what is being reported to the insurance carrier?

When providers commit fraud
• Have “creative” billing practices ever been used?
• Are proper billing codes being utilized?
• Are claims being billed at proper rates?
• Are phantom office visits/patients being billed?

File A Workers’ Compensation Fraud Complaint
Call or email us to file your complaint. You do not have to give your name.
Phone: 559-852-2392
Email: KCDAInsuranceFraud@co.kings.ca.us

Request A Presentation or Information
Email: KCDAInsuranceFraud@co.kings.ca.us