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Crackdown on workers' comp billing fraud is dealt a setback

Insurers, complaining of the paperwork, squelch a provision in a state Senate bill that would require them to send notices to injured workers to verify that services billed were actually performed.

August 19, 2009|Marc Lifsher

SACRAMENTO — California's powerful insurance lobby has quietly scuttled an effort to combat fraudulent medical billing that drains hundreds of millions of dollars from the state's workers' compensation insurance system.

At issue was a proposal aimed at preventing billing scams backed by a task force of public and private employers, including Los Angeles County and Walt Disney Co. It would have required insurers to send notices to injured workers to check whether they actually received all medical services billed.

But insurers balked, complaining about the high cost of increased paperwork. They persuaded state Sen. Roderick Wright (D-Inglewood) to strip the plan from a bill he introduced in February, Wright's office confirmed.

The proposal's setback frustrated employers seeking new tools to battle illegal traffic in medical records.

"It's a massive problem. Hundreds of millions of dollars go down the tube," said David O'Brien, a workers' compensation attorney active in the employers' task force. "It's mind-boggling that the insurance industry says this is just another unnecessary form."

But insurers said they saw no reason to change current practices.

Sending out notices is "prohibitively expensive" and would confuse injured workers, said Steven Suchil, an attorney with the American Insurance Assn. The association said it did not have a detailed analysis of how much the mailings might cost.

There are better and more effective ways to fight fraud, such as providing extra money for law enforcement investigators, said Nicole Mahrt, an association spokeswoman. Companies don't need a government mandate to send notices if that's what they want to do, she said.

In the meantime, Disney said it was not waiting for action from the Legislature. The Disneyland Resort unit plans to start mailing notices early next year to 20,000 employees when workers' compensation bills are paid.

"Once the provider realizes that someone else is looking at what's being billed, there's a built-in incentive for them to go somewhere else" to commit fraud, said John Riggs, the workers' compensation manager for the resort unit.

In many workers' compensation fraud cases, experts say, criminals typically obtain names and data about injured workers and then set up "phantom" medical laboratories. The labs then bill insurers for services that did not occur.

"You feel violated," said John O'Brien, a retired captain in the Los Angeles County Sheriff's Department who is not related to David O'Brien. The retired officer's medical records were stolen and used to bill the county for phony medical tests.

"I was never aware of this, and that's why the crooks were so successful," he said.

In February, task force members concluded that much of the fraud could be eliminated with a simple fix: sending out notices. Injured workers could then blow the whistle if they spotted any bogus billings. Such notices, though standard practice in health insurance, aren't used in workers' compensation insurance.

Faced with opposition from the insurance industry, Wright removed the notice requirement from the bill in April before the measure had its first committee hearing, said the senator's legislative director, Stan DiOrio. The bill, SB156, was left as a noncontroversial effort to encourage insurers to meet with prosecutors to talk about fraud.

According to state campaign finance reports, Wright received $45,000 in campaign contributions from the insurance industry between January 2007 and June 2009. A prodigious fundraiser, Wright collected $765,000 in total contributions in that period.

"You can't run a bill on insurance fraud when some of the insurance folk say they do not think it works," DiOrio said. "That's not effective because we were faced with them opposing the bill."

DiOrio said Wright would consider introducing a new bill next year if the insurance companies and task force members could reach an agreement.

It's "an absurd situation," said Albert MacKenzie, a Los Angeles prosecutor who came out of retirement to lead a special district attorney's unit to combat fraud. "If I know you're an injured worker and you don't get a copy of the bill, then I basically have a license to steal."

Loopholes can be exploited with "a very simple scam" by a rogue hospital billing clerk or a sophisticated ring that gets hold of a computer hard drive with thousands of individuals' names and insurance identification records, MacKenzie said.

District attorneys in Southern California in recent years have successfully prosecuted some brazen medical billing fraud cases. More prosecutions are expected, targeting gangs, doctors, owners of pharmacies and medical supply companies, insurance claims adjusters and billing clerks at clinics and hospitals.

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