Winter 2006

Fraud-Fighting Corner
By Tim Riley
Manager of Special Investigations

Fraud costs the Texas workers’ compensation system millions of dollars every year. Those costs trickle down to everyone. Texas Mutual Insurance Company works hard to stamp out fraud, and we get results.

Health care provider fraud
SENTENCED—Alliance KMC Inc. pleaded no contest to workers’ comp fraud-related charges. The Travis County 331st District Court ordered the health care provider to pay $300,000 in restitution to Texas Mutual Insurance Company and pay a $2,500 fine.

Texas Mutual Insurance Company alleged that Alliance KMC Inc. upcoded physical therapy services. Upcoding occurs when a provider bills for a higher-level service than was actually provided.

Claimant fraud
The following cases are examples of a scam that investigators call double-dipping. Double-dipping happens when claimants collect benefits for being too injured to work when they are, in fact, gainfully employed. State law requires injured workers to contact their workers’ comp insurance company when they return to work.

SENTENCED—Arthur Menard of Spring. Menard collected $16,581 in workers’ comp income benefits he was not entitled to. A Travis County district court sentenced him to 14 months in jail.

SENTENCED—Jerry S. Amaya of Cedar Creek. A Travis County court sentenced Amaya to one year of probation and ordered him to pay $1,455 in restitution to Texas Mutual Insurance Company, plus costs.

INDICTED—Chris McCall of May. McCall allegedly collected $8,283 in workers’ comp benefits he was not entitled to.

INDICTED—Higgie Highsmith of San Antonio. Highsmith allegedly collected $7,112 in workers’ comp benefits he was not entitled to.

INDICTED—Debra Greenwell of Texarkana, Arkansas. Greenwell allegedly collected $6,253 in workers’ comp benefits she was not entitled to.

Note: A grand jury indictment is a formal accusation – not a conviction – of criminal conduct.

Zero tolerance for fraud
All of these investigations are part of the Texas Mutual^® “zero tolerance for fraud” policy. Texas Mutual Insurance Company maintains three teams of investigators permanently assigned to investigate every report of suspected fraud.

We need your help
Many of our investigations start when a policyholder reports suspicious activity by a claimant, health care provider or another policyholder. You can help us win the fight against fraud if you:

• Adopt a zero tolerance for fraud policy.
• Notify us if you suspect a claimant, health care provider or policyholder is committing fraud.
• Work with the investigator assigned to the case.
• Stay in touch with injured employees who are off work.
• Notify the investigator if the employee’s work status changes.
• Attend hearings when requested.
Allow employees to testify if requested.

Fraud-fighting resources on the Web
Employers may visit the Fighting Fraud section to read the company’s fraud-fighting success stories, download a Fraud Stoppers_SM poster in English and Spanish, and get more information about reporting possible fraud.

COMPNEWS - Winter 2006
Bird Flu: What it Means to Your Business
Personal Tips for Weathering a Flu Pandemic
New Claim Teams Help Cut Costs
Your Role in the Return-to-Work Process
President's Message: Fifteen Years of Service to Texas
Fraud-Fighting Corner
State increases fixed payroll, weekly benefit rates
Learn more about the workers’ comp system
Legislature gets set to kick off 2007 session

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Texas Mutual Insurance Company.