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How to stop fraud against the IW

I wasn't too sure what I should label this topic. I watched a podcast that discussed workers' compensation fraud which included medical provider fraud. Medical provider fraud occurs not only in the work comp system, but in private insurance and Medicare.

Not only does medical provider fraud harm the insurance carriers financially, which in turn harms all of us by having to pay higher premiums and taxes, it can also harm the patient directly with overtreatment. It can be as small as making an injured worker submit to urine testing's monthly, to exposing them to unnecessary x-rays and CT scans (which can later lead to cancer for example) to doing evasive tests such as discograms, that have shown to have limited value in determining problems but can result in blowing out a healthy disc, infection etc. Overtreatment can also be unnecessary therapies and in worse case scenarios unnecessary surgeries or overly evasive surgeries.

If a medical provider is doing things for profit and not in the best interest of their patient, the patients bodies are being used as a means to make money.

 I am going to give my own opinions of why patients can fall victim to this:

1. Primary treating physician becomes the injured workers 'advocate' especially in claims that are denied and/or the carrier is being very difficult.

2. We are all taught doctors are there to help us and most patients would not believe their doctor would not be looking out for their best interests.

3. Your attorney sent you to this doctor, so he must be good.

4.It is such a fight for some patients to get ANY treatment authorized that it feels like a 'win' to receive testing's and treatment, and why patients move forward. The more the insurance companies fight something your doctor says you need, the more some patients will want it. This is basic human nature. I find this especially true for surgery.

5. Patient is told by their doctor if you do not do this surgery things like... you will have permanent nerve damage, you will eventually be paralyzed, you wont be able to walk again, you will not be able to work again.

6. Some patients believe that surgery is the only chance to 'fix' them (after being told this by their doctor).

7. In states like California there are strict caps in conservative treatments like physical therapy and chiropractic treatments (24 for life) and patient feels like the only alternative is surgery.

8. Patients are not always provided or aware of how to obtain second and third opinions before undergoing evasive testing's or surgery.

9. Patients are unaware of what medical provider fraud is or what to look for.
10. California removed the AME/QME process where if there was a medical dispute the patient was sent to one of these doctors to make the determination. There was also a second opinion for spinal surgery process where disputed spinal surgery would be determined by a physical exam by another spinal surgeon. After 1/1/2013 this changed and now disputes go through a paper review process. Evasive testing's and surgeries are now being determined by a doctor who is reviewing patients records without any physical exam. This is a recipe for fraud on both sides of the fence. I cannot believe evasive surgeries are being determined this way.

11. As mentioned in the webcast there is no real agency actively there to look for medical provider fraud in the work comp system.

12. Physicians are taught early on in medical school not to go against another doctor. This is a real thing and I have been told this by several doctors. Doctors can be blacklisted for doing so. Ask a medical malpractice attorney how difficult it is to obtain an expert witness. There are expert witnesses out there who do it for a living but many doctors who see other physicians doing harm and/or unethical unnecessary treatments to patients do not always speak up. Bravo to the ones who do. This also hold true for when a patient is harmed by one doctor and then tries to find out what went wrong and other doctors who examine the patient after the fact remain silent.

13. POD's. These are Physician owned distributors of medical implants like hip, knee and spine. In the US 20% of orthopedic medical devices implanted into patients are being done by a surgeon who has ownership or partial ownership in the devices he is implanting into his patients. Not all surgeons who are part of a POD are doing anything wrong, however studies have shown that physicians in a POD do a lot more surgeries and more unnecessary surgeries than physicians who do not belong to a POD.

14. Physician has financial interest, or gets paid monies from a pharmaceutical or device company. This info can be found by running your doctors name through propublica dollars for docs website. Not all physicians who take monies from industry are corrupt, but some are. 85% of physicians in the US have taken something from a sales rep. There are physicians who receive tens of thousands, hundreds of thousands and even millions from the device manufacturers or pharmaceutical industry. Again, just because a physician has taken money from industry does not automatically make him dishonest. It is worth knowing about it in my opinion before hand and doing a little research before agreeing to undergo a surgery.

15. If a patient in California refuses a surgery or treatment recommended it can result in their physician stating they are permanent and stationary and their TTD payments are cut off.

16. Some applicant attorney's are not looking out for the best interests of their clients and are sending them to physicians who will claim they have multiple injuries (even when they do not), high PD ratings and then request unnecessary testing's, treatments, medications and surgeries. When these things are unnecessary, they can lead to further disability of the patient, giving a higher PD rating, this making more money for the applicant attorney. The physician obtains more monies through this and leaves the injured worker disabled for life relying on SSDI or a open WC case with future medical. This unfortunately happens in my state more than one could imagine.

17. Patients are unaware if you pick a surgeon as your primary treating doctor, or push to be evaluated by one chances are high he may recommend surgery. I am not making this up, there is statistical data that shows this. I am not saying they are doing anything dishonest, or that if they recommend a surgery it is not needed, just know that many surgeries in the US they have found are being overly done and unnecessary. Get a few opinions before having any surgery is my advice. The same goes for pain management physicians....if you pick one as your primary doctor, chances are higher you may be recommended to have a spinal cord stimulator implanted. This does not mean it is unnecessary, I just believe it is a good idea to get a second and third opinion. Spinal cord stimulators can cause a lot of damage and patients are not always being told all of the possible complications.

A question was asked in the webcast I viewed what could be done to help protect patients from becoming victims of this. My opinion:

1. Treat your injured worker fairly, and provide appropriate treatment. Once a claim becomes hostile a patient will get an attorney and the attorney and physician become the injured workers advocate.

2. Send out a list to injured workers once they submit a workers' compensation claim of common medical provider fraud scams and what to looks out for and a number to provide anonymous tips to.

3. Those medical providers who are caught committing fraud, give them appropriate sentencings. It looks like white collar crime pays from what I have seen happen to these types of criminals. Slap on the hand is not a deterrent.

4. Make a monetary fund for anyone who finds and reports fraud that results in a conviction. If the monetary number is high enough I bet WC fraud will be greatly reduced if this happens. It can have a sliding scale depended upon the type of fraud and extent. (just an idea)  

5. Get a task force to go after medical provider fraud, employer fraud and insurance carrier fraud. The DA's seem to go after injured worker fraud but these other entities are also committing fraud. Just do it.

I hope I did not offend any patients who have received appropriate testing's, treatment and surgeries. Most physicians do not commit fraud. Many testing's, treatment and surgeries are necessary. This post is about those medical provider who do commit fraud (small subset) and the patients who have fallen victim of this.

I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.

Messages In This Thread
How to stop fraud against the IW - by California_Help - 01-05-2018, 07:22 PM

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