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Study recommends weapons for California provider fraud battle

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Workers compensation provider fraud is an ongoing issue in California, and solutions must focus on prevention, detection, remediation, restitution, retribution, or deterrence, according to a report issued Tuesday by Santa Monica, California-based research organization RAND Corp.

The report looks into remedies for workers comp fraud in California. The authors reviewed academic journal articles on methods used to detect and prevent fraud, policy literature on the characteristics and sources of workers comp fraud, media articles on the use of fraud-detection technologies, and legal treatises, RAND said in the report.

One way of combating provider fraud outlined in the report is using advanced analytics, a “field of information science that involves intensive examination of large volumes of data in order to discover relationships across records,” to detect fraud. Advanced analytics, including predictive modeling, descriptive analytics, or social network analysis methods can look across data that organizations collect for business purposes and detect unexpected patterns that suggest suspicious behavior, according to the report. 

Bringing post-employment claims back into the system is another method to prevent provider fraud. The generation of large numbers of liens of substantial size could be reduced if medical treatment for conditions discovered postemployment were handled like workers comp claims made during employment, the report said.

“Medical care providers subject to utilization review would be unlikely to order numerous separate procedures and prescriptions with claimed values in the tens of thousands of dollars, seemingly with the expectation that a profitable compromise could still be reached even if the ultimate reimbursement is a fraction of the original asking price,” RAND said in the report. 

Another possible method is suspending lien claims while providers are suspected of fraud. An estimated 17% of all liens in the system were filed by parties who are either under indictment or had been convicted, according to the report.