November 19, 2019
At Texas Mutual, we have a dedicated team of fraud specialists who work to protect our policyholders from those who take advantage of the system. In 2018, we received over 2,000 referrals and estimate our work helped prevent over $13.5 million in claimant fraud, health care fraud and premium fraud. See our zero tolerance for fraud in action.
Claimant fraud is when an employee falsifies an incident or the severity of his or his injuries. We reviewed 2,137 referrals for claimant fraud and identified 165 cases. With 11 convictions, we identified $757,469 in claimant fraud in 2018. We estimate that our work helped to prevent nearly $2.5 million in future claimant fraud.
CLAIMANT FRAUD |
|||
|
2016 |
2017 |
2018 |
Claimant referrals |
1,640 |
1,698 |
2,137 |
Claimant fraud convictions |
11 |
4 |
11 |
Claimant fraud identified |
199 |
155 |
165 |
Claimant fraud amount identified |
$963,169 |
$779,824 |
$757,469 |
Estimated future savings from claimant fraud |
$4,663,622 |
$4,781,405 |
$2,457,533 |
Health care fraud is when medical providers use unlicensed providers or overbill Texas Mutual for services. In 2018, our work led to two convictions for health care fraud. We estimate we helped to prevent over $1 million of this type of fraud in 2018.
HEALTH CARE FRAUD |
|||
|
2016 |
2017 |
2018 |
Health care fraud (criminal cases) |
2 |
3 |
7 |
Indictments for health care fraud |
0 |
4 |
1 |
Convictions for health care fraud |
2 |
0 |
2 |
Health care fraud and abuse prevented |
$1,681,882 |
$1,045,609 |
$1,099,953 |
Health care fraud restitution collected (criminal) |
$58,537 |
$10,990 |
$45,153 |
PREMIUM FRAUD |
|||
|
2016 |
2017 |
2018 |
Premium fraud identified |
$2,484,261 |
$4,565,506 |
$9,989,815 |
Premium fraud indictments |
4 |
1 |
7 |
Premium fraud convictions |
1 |
1 |
1 |