According to a report from the Insurance Journal, California regulators are stepping up the fight against insurance fraud—especially workers’ compensation fraud committed by medical providers. California Insurance Commissioner, Ricardo Lara, has announced more than $50 million in insurance fraud prevention grants to 34 District Attorneys’ (DA) offices across the state.

Notably, a significant portion of the grants are specifically earmarked to target “the investigation and prosecution of medical provider fraud in the workers’ compensation system.” Here, our Sacramento workers’ compensation defense law firm explains the key things to know about our state’s latest push to crack down on insurance fraud. 

What is Medical Provider Workers’ Compensation Fraud?

Unfortunately, workers’ compensation fraud is a serious problem in California. It has been described as a billion-dollar issue—and medical provider fraud is one of the most prevalent areas of workers’ compensation fraud. Broadly defined, medical provider workers’ compensation fraud refers to deceptive practices by healthcare providers to unjustly profit from the workers’ compensation system.

Examples of Medical Provider Workers’ Compensation Fraud

As part of its crackdown on medical provider workers’ compensation fraud, California regulators emphasize that this type of fraud can take a wide range of different forms. The new grants are designed to give local District Attorneys’ (DA) offices the tools and resources that they need to investigate and prosecute violations. Some of the most notable examples of healthcare provider workers’ compensation fraud in California include:

  • Upcoding Services: Upcoding is essentially billing for more expensive procedures than what was actually performed. For instance, a simple wound dressing might be billed as a complex surgical procedure.
  • Unbundling of Services: Some procedures encompass various services. However, a provider may list these services separately in the billing, making it appear as though multiple procedures were performed, and thus fraudulently inflate the bill.
  • Billing for Phantom Services: This is when a provider bills for services that were never rendered. For example, a provider may bill for a series of physical therapy sessions that the patient never attended.
  • Unlawful Kickbacks and Patient Referrals: A healthcare provider might receive kickbacks for referring patients to specific facilities or for prescribing certain medications, even if not medically necessary.
  • Dispensing Unnecessary Services or Products: A medical provider might prescribe unnecessary treatments, procedures, or durable medical equipment (such as braces or wheelchairs) that are not medically necessary simply to increase billing.
  • Falsifying Patient’s Condition or Diagnosis: The provider may manipulate or exaggerate a patient’s diagnosis or the severity of their condition to justify more treatments, higher levels of care, or longer duration of services than necessary.

Contact Our California Workers’ Compensation Defense Advocates for a Fully Private Consultation

At Yrulegui & Roberts, our California workers’ compensation defense lawyers are tenacious, effective advocates for our clients. If you have any questions about a California workers’ compensation case involving allegations of medical provider fraud, we are here as your legal resource. Give us a phone call now or contact us online to set up your confidential consultation. We serve WCAB locations throughout Central California, including Fresno, Bakersfield, Sacramento, Stockton, and beyond.