September 15, 2020

Fraud-fighting team identifies $11.3 million in fraud and abuse in 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 2019, we received 2,925 referrals and identified $11.3 million in fraud and abuse. We estimate our work helped prevent over $7.8 million in fraud and abuse. While not all investigation results rise to the level of fraud, our team actively reports and takes action on abuse as well. Read about our zero tolerance for fraud and abuse below.

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. We reviewed 2,607 referrals for claimant fraud and identified overpayments due to fraud on 188 cases. We identified $891,323 in claimant fraud in 2019 and estimate our work prevented over $5.5 million in payments to dishonest claimants. In the past three years, the courts convicted 22 Texas Mutual claimants. 

CLAIMANT FRAUD

 

2017

2018

 2019

 Fraud & abuse identified

$857,684

$836,179

$891,323

 Restitution & recoveries

$24,064*

$290,077

$363,501

 Future savings

$5,408,473

$4,148,005

$5,527,733

 Indictments

6

1

0

 Convictions

4

11

7

*recoveries not tracked


Health care fraud is when medical providers overbill Texas Mutual for services or provide excessive treatment. In 2019, our work led to one health care fraud conviction. We saved $1.6 million through specialized audits on medical bills from providers under investigation.

HEALTH CARE FRAUD

 

2017

2018

2019

 Fraud & abuse identified

$230,254

$7,553,413

$4,142,683

 Restitution & recoveries

$184,116

$453,124

$1,034,045

 Future savings

$3,840,968

$2,406,511

$2,370,846

 Fraud & abuse prevented

$1,045,609

$1,099,953

$1,611,219

 Indictments

4

1

0

 Convictions

0

2

1

 
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. We identified nearly $6.3 million in premium fraud and abuse in 2019 and saw five indictments.

PREMIUM FRAUD

 

2017

2018

2019

 Fraud & abuse identified

$5,364,414

$10,389,956

$6,262,990

 Restitution & recoveries

$626,563

$1,235,254

$2,043,135

 Indictments

1

7

5

 Convictions

1

1

1


We take fraud seriously and when you choose Texas Mutual, you can count on our team to protect your premium dollars. Learn more about how to prevent fraud and what to do if you suspect fraud.