Contents
Protecting Premiums: Fraud-fighting team identifies $9.9 million in fraud and abuse in 2020
Infectious diseases standard for health care industry a priority, OSHA tells court
Patient Safety and Workers Safety Go Hand and Hand
Protecting Premiums: Fraud-fighting team identifies $9.9 million in fraud and abuse in 2020
Texas Mutual has a dedicated team of fraud specialists who work to protect their policyholders from those who take advantage of the system. In 2020, Texas Mutual received 2,146 referrals and identified $9.9 million in fraud and abuse. They estimate their work helped prevent over $3.5 million in fraud and abuse. While not all investigation results rise to the level of fraud, their team actively reports and acts on abuse as well. Read about Texas Mutuals’ zero tolerance for fraud and abuse below.
Claimant fraud
Claimant fraud is when an employee fails to report when he or she has returned to work, falsifies an incident, or falsifies the severity of his or her injuries. Texas Mutual reviewed 1,887 referrals for claimant fraud and identified overpayments due to fraud on 174 cases. They identified $818,893 in claimant fraud and abuse in 2020 and estimate their work prevented over $3.2 million in payments to dishonest claimants. In the past three years, the courts convicted 19 Texas Mutual claimants.
CLAIMANT FRAUD
| 2018 | 2019 | 2020 | |
|---|---|---|---|
| Fraud & abuse identified | $836,179 | $891,323 | $818,893 |
| Restitution & recoveries | $290,077 | $363,501 | $345,800 |
| Future savings | $4,148,005 | $5,527,733 | $3,293,188 |
| Indictments | 1 | 0 | 2 |
| Convictions | 11 | 7 | 1 |
Health care fraud
Health care fraud is when medical providers overbill Texas Mutual for services or provide excessive treatment. In 2020, They saved $2 million through specialized audits on medical bills from providers under investigation.
HEALTH CARE FRAUD
| 2018 | 2019 | 2020 | |
|---|---|---|---|
| Fraud & abuse identified | $7,553,413 | $4,142,683 | $3,123,115 |
| Restitution & recoveries | $453,124 | $1,034,045 | $243,879 |
| Future savings | $2,406,511 | $2,370,846 | $274,857 |
| Fraud & abuse prevented | $1,099,953 | $1,611,219 | $2,013,011 |
| Indictments | 1 | 0 | 0 |
| Convictions | 2 | 1 | 0 |
Premium fraud
Premium fraud is when an employer misrepresents his or her business operations and payroll to the workers’ compensation company in order to pay a lower premium. Using this workers’ compensation fraud scheme could give an employer an unfair advantage over competitors and negatively affect all involved in the workers’ compensation system. They identified $6 million in premium fraud and abuse in 2020 and saw two indictments.
PREMIUM FRAUD
| 2018 | 2019 | 2020 | |
|---|---|---|---|
| Fraud & abuse identified | $10,389,956 | $6,262,990 | $6,026,083 |
| Restitution & recoveries | $1,235,254 | $2,043,135 | $2,007,787 |
| Indictments | 7 | 5 | 2 |
| Convictions | 1 | 1 | 2 |
They take fraud seriously and when you choose Texas Mutual, you can count on their team to protect your premium dollars. Learn more about how to prevent fraud, what to do if you suspect fraud or join one of the free virtual seminars.
To help you prevent and spot workers’ compensation fraud in your workplace, Texas Mutual’s fraud team is hosting two free virtual seminars for policyholders on March 24, 2021 and April 21, 2021. Register today to reserve your spot.
Infectious diseases standard for health care industry a priority, OSHA tells court
Safety+Health
San Francisco — OSHA is prioritizing an infectious diseases standard for the health care industry, according to a motion filed Feb. 16 in the 9th U.S. Circuit Court of Appeals.
The joint motion, signed by Department of Labor counsel Joseph G. Gilliland and Democracy Forward Foundation counsel Michael C. Martinez, requested a suspension of a lawsuit brought against the Trump administration’s DOL, former Labor Secretary Eugene Scalia and OSHA. The court granted the motion Feb. 19.
Democracy Forward filed the suit Oct. 29 on behalf of the American Federation of State, County and Municipal Employees; the American Federation of Teachers; the Washington State Nurses Association; and the United Nurses Association of California/Union of Health Care Professionals. The four labor unions were attempting to get the court to compel OSHA to move forward on the standard, which was stalled since 2017.
Oral arguments in the case were set to begin March 3, but the motion states: “Since January 20, 2021, new leadership at OSHA have begun reassessing the agency’s priorities in light of the goals of the new administration. In particular, the agency intends to prioritize the development of an infectious diseases standard for the health care sector.”
The motion cites an Executive Order signed by President Joe Biden on Jan. 21 directing OSHA to consider an emergency temporary standard for COVID-19 that would cover all workers, including those in health care. If an ETS is considered necessary, the agency is instructed to issue one by March 15.
“We are encouraged by the Biden administration’s representations about prioritizing rulemaking on a permanent infectious diseases standard,” the unions state in a Feb. 22 press release from Democracy Forward. “Health care professionals across the nation are working tirelessly in the fight against COVID-19. They should be able to rest assured that their employers are required to take steps to protect them from exposure to infectious diseases like COVID-19, the flu, Ebola and more.”
The release contends that, before the COVID-19 pandemic, worker infections in the health care industry totaled 1.7 million a year. During the pandemic, more than 408,000 workers in the industry have become infected with COVID-19 and more than 1,400 have died.
The two parties intend to file a status report in April, in which OSHA “will update the court on the agency’s prioritization of the infectious diseases standard.”
Patient Safety and Workers Safety Go Hand and Hand
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