March 2, 2021

Fraud-fighting team identifies $9.9 million in fraud and abuse in 2020

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 2020, we received 2,146 referrals and identified $9.9 million in fraud and abuse. We estimate our work helped prevent over $3.5 million in fraud and abuse. While not all investigation results rise to the level of fraud, our team actively reports and acts on abuse as well. Read about our 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. We reviewed 1,887 referrals for claimant fraud and identified overpayments due to fraud on 174 cases. We identified $818,893 in claimant fraud and abuse in 2020 and estimate our 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, we 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. We 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

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, what to do if you suspect fraud or join one of our free virtual seminars.

Join our virtual fraud seminar

To help you prevent and spot workers' compensation fraud in your workplace, our fraud team is hosting a free virtual seminar for our policyholders on April 21, 2021. Register today to reserve your spot. 

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