Arrests of fraudulent claimants, medical providers and other service providers are on the rise. BHHC Special Investigations Unit (SIU) is contributing to this positive trend. Our SIU’s sole purpose is to fight fraud and minimize our exposure to suspect claims.
Our SIU integrates claims handling and special investigations by partering with Claims Professionals who review each new claim file for “red flags”. We assign investigators and litigation specialists as needed to pursue potential instances of fraud and coordinate with claims examiners to track the claim and make sound referrals to appropriate law enforcement agencies.
BHHC believes proactive vigilance and early detection helps minimize exposure. Timely reporting of suspicious behavior improves our ability to contain costs and fight fraud. We focus on training for all employees to ensure that smart, effective, and timely referrals are made to the SIU.
It is important to remember that aggressive pursuit and investigation of fraud lessens the financial impact of claims on the premiums paid by our clients.
We encourage clients to promptly report suspicious behavior. With your help, we can put criminals behind bars.
Or make an anonymous, toll-free call to (800) 300-JAIL
Fighting Fraud Success Stories:
A 53-year-old vineyard laborer sustained an accepted injury to his back and right shoulder when he tripped at work. Surveillance of the claimant was obtained which showed the claimant exceeding his work restrictions while lifting, carrying and selling crates of produce from a roadside intersection. The surveillance was forwarded to the primary treating physician for review. After reviewing the surveillance, the primary treating physician found that the claimant had fully recovered from his injury with no permanent disability and no need for future medical care. The local District Attorney’s office charged the claimant with workers compensation fraud. The claimant pled no contest to one count of fraud and was ordered jail time, 3 years formal probation, and had to pay over $11,000 in restitution.
False Medical History
A 33-year-old sanitation prep worker claimed an injury to his back while lifting. The claim was accepted and benefits were provided. The claimant denied any prior injuries to his back to the primary treating physician, the Agreed Medical Evaluator, and under oath at his deposition. BHHC uncovered that the claimant had utilized several social security numbers in the past. Accordingly, BHHC was able to track down medical records showing that the claimant had filed three prior back claims utilizing different social security numbers. This information was forwarded to the primary treating physician and the Agreed Medical Evaluator. After reviewing these records, both the primary treating physician and Agreed Medical Evaluator found that the claimant had not sustained an injury as alleged. The Workers’ Compensation Appeals Board dismissed the case. The claimant was charged, found guilty of workers’ compensation fraud and ordered to pay restitution in excess of $66,800.