Claims adjusters, data patterns unveil workers comp fraud

CHICAGO — Fraud involving medical providers and pharmacies is a fast-growing segment of insurance criminal activity that costs insurers and employers billions annually, according to claims experts who say data has been the key in discovery of such schemes.

In a packed session, panelists spoke of this growing area of fraud at the CLM & Business Insurance Workers Compensation Conference in Chicago on Wednesday, highlighting National Insurance Crime Bureau data that finds workers compensation fraud costing over $7 billion dollars annually.

The latest culprits, along with injured workers who fake injuries and boast sports activities on social media, are organized fraud rings involving multiple actors in a traditional workers comp claim.

A common scheme is a doctor who solicits an injured worker over the internet, has a Skype session with said worker, prescribes and, with the help of a pharmacist involved in the scheme, provides a compounding cream — a pain cream or scar cream — with no follow-up call but multiple refills, said Kimberly Grassel, Phoenix-based program manager at Amerisure Mutual Insurance Co.

“Telemedicine is the wave of the future, (and) with new technology comes opportunity” for fraud, said Ms. Grassel, adding that some of the creams can costs as much as $17,000 per tube with no proof of effectiveness. Providers caught in the scheme, many with licenses in multiple states, can collect upward of $100 million in fraudulent charges from insurers, she said.

Who are often the first at catching on to this wave of fraud? Claims adjusters, said Ms. Grassel.

“Some of this is brought to our attention by adjusters” who say, ‘Something doesn’t look right here,’” she said. “There are a lot of people out there perpetrating this fraud. We know the scenario, we know what to look for,” she said, adding that educating adjusters is helping to curb the activity.

Julie Fortune, a co-presenter and senior vice president and chief claims officer for Arrowpoint Capital based in Charlotte, North Carolina, said historical data has been key in uncovering fraud.

“Every claimant has a data history,” she said. “When we find a bad doctor, we look at our (claims) data to see whether we’ve had interaction with that doctor or pharmacist.”

Government agencies are also assisting with data collection and analytics, she said. The U.S. Drug Enforcement Administration over the past two months has been cracking down on providers with suspicious transactions.

“What the DEA is doing is scrutinizing and analyzing transaction reports … They have all this data … and they are looking for patterns, and when they identify patterns they then go back and target doctors and pharmacies,” Ms. Fortune said, adding that much of this information is available to insurers.

On another fraud front, scrutiny of social media and other avenues for information continues to be a trend in fraud investigations, said Steve Carman, an Indianapolis-based private investigator and workers compensation manager at trucking and logistics firm Celadon Group Inc.

Much of what can be done in terms of investigating claimant workers compensation fraud is on a computer, he said, adding that there are more than 50 social media sites worth scouring to find out what an injured worker does on his or her free time. Not only that, but looking at the social media accounts of friends and relatives is another trend that leads to convictions, he said.

But as this investigation trend continues to grow, pitfalls have emerged, according to Mr. Carmen.

A common mistake is not having the right person when coming across information on a social media site such a Facebook or Twitter, according to Mr. Carmen.

“I can’t tell you how many times I’ve heard ‘I got Joe Jones swimming on Saturday’ and it is not the right Joe Jones,” he said. “It’s a common mistake.”

Another mistake is believing what you see, he said, adding that people try to look better and more active physically on social media. “Men try to look bigger and stronger,” he said, adding that women also try to maintain a healthier appearance on social media. “What you see is not always true,” Mr. Carmen said.