Northwest Labor Press - June 9, 1998

Employers and insurers both can be investigated for workers' comp fraud

Help is available if trouble starts after you file a workers' compensation claim

SALEM ---- Who can you call when you witness fraud or abuse in the Workers' compensation system? The Investigation Unit.

Over the years the State of Oregon has developed a substantial workers' compensation system. Despite laws and rules established to assure a fair system, fraud and abuse still occur.

The Investigation Unit of the Workers' Compensation Division was established eight years ago. The unit is an investigative entity, tracking fraud and abuse complaints received from throughout the industry.

Investigations are conducted on possible rule and statute violations by health care providers and facilities, employers, insurers, vocational providers, managed care organizations, attorneys and, in certain circumstances, injured workers.

Examples of investigations conducted include: Employers directing injured workers to a specific medical provider; non-reporting of claims by employers to their insurer; abuse of the state programs for hiring injured workers, and with use of the associated funds; improper claims handling; employers not providing a Form 801 to the injured worker (the form used to file a workers' compensation claim); and direct payment to medical providers by employers without reporting the injury to the insurer. The unit also investigates problems found throughout the industry such as the potential hazards of integrating safety bonuses into production bonuses. Instances where an injured worker is observed performing potentially injurious acts are referred to the insurer.

These types of rule violations are found throughout the state, regardless of the type of industry. To handle these issues, the unit currently has five field investigators, one intake specialist, one office specialist and a unit manager. The investigators respond to complaints received. Complaints come by phone, letter, or in person. Some requests are received from other units within the Workers' Compensation Division. Occasionally complaints come through the governor's or a legislator's office. Areas of the complaint that are not under the jurisdiction of the Workers' Compensation Division are referred to the appropriate agency, as well as advising the complainant to contact that particular agency. Most all fraudulent claim filings are investigated by the insurance company involved. Also, the unit does not investigate requests to determine the compensability of a claim.

If a violation of law is found as a result of an investigation a variety of options are available. If the violation is found to be due to a lack of knowledge or a problem that is easily fixed, then a warning letter is issued. If violations are egregious enough, sanctions are applied. All parties to, and the facts of the investigation are considered when determining the outcome of the investigation. If the complaint is determined unfounded, then the affected parties are notified.

The Investigation Unit was set up to investigate potential fraud and abuse of the workers' compensation system. If you have filed a claim and there appears to be abuse of the system, or you witness fraud within the workers' compensation system, give the Investigation Unit a call at 1-800-422-8778. It is available to help.