Workers' Compensation Fraud Section

Benefit Fraud

An employee who is drawing benefits because he/she is supposed to be unable to work and is working full time at an unreported job
An employee fakes an injury in order to collect benefits
A health care provider assists the employee in a fraudulent scheme
A health care provider bills for services not provided

Premium Fraud

An employer misrepresents the amount of payroll or classification of employees in order to obtain a lower premium
An employer avoids a higher insurance risk modifier by transferring employees to a new business entity rated as a lower risk category

Fraud by Employees

Fraud by Employers

Classification codes inconsistent with duties normally associated with the employer's type of business (e.g. a construction company reporting mainly clerical classifications)
Payroll information on the insurance application inconsistent with payroll reported to the Texas Workforce Commission
Much larger premium paid for the previous year's policy
Unusually small payroll reported by a large employer or employee leasing company
Frequent additions and cancellations of coverage, especially if several business entities appear to be owned or controlled by the same person or group

Fraud by Health Care Providers

Bills or explanation of benefits for services from health care providers, insurers or attorneys that seem unnecessary or fictitious
"Boilerplate" medical reports, or reports that are merely copies of previously submitted reports
Treatment dates on holidays for non-emergency situations
Bills from a healthcare provider or attorney that represent an unreasonable amount of billable hours per day
Complaints from the employee that the attorney is rarely available although the attorney files fee affidavits for services
Attorney relationship with a health care provider that appears to be a partnership in handling workers' compensation claims