York Risk Services Group, a third party administrator, announced their return of more than $1.5M in workers’ comp restitution to public entity clients in California by fighting workers’ compensation fraud. Of that amount, more than $1M was returned to clients in Southern California. The recoveries are associated with 91 successful prosecutions and convictions.
“This is an important milestone in our ongoing efforts to combat fraudulent workers’ compensation claims in the state of California,” said Jody Gray, president of York Public Entity, a division dedicated to providing claims and risk management services exclusively to public entities.
Each year, $10 billion in workers’ comp claims are filed in California, and the California Department of Insurance estimates that one out of every four is fraudulent. Compared to a nationwide average that runs well under 10 percent, the state continues to face a very real crisis with this costly crime.
York reached this milestone, by utilizing its internal team of expert in-house AOE/COE investigators, York Investigations and two SIU partners, RJN Investigations and Probe Information Services.
The partnership with RJN and Probe starts with training. The companies work with York to educate adjusters and examiners on how to identify warning signs of fraud. When an examiner spots signs of fraud, they refer the claim to York Investigations for further investigation.
York Investigations then conducts a preliminary investigation – obtaining detailed statements from the injured worker, employer and witnesses to preserve the facts before memories fade and evidence disappears. The team will also run background checks and review social media posts, court records, DMV records and other sources looking for signs of possible fraud or abuse. If the warning signs of fraud are detected during this initial investigation, the claim is reviewed with a York claims professional. If they determine that facts warrant it, the case is then sent over to RJN and Probe.
RJN and Probe complete the investigation into the suspected fraud using best practices like surveillance and activity checks, conducting background checks using the internet and social networking, and all facets of field and return to work investigations. The final phase of the process is thorough documentation of the findings and careful preparation of files to bring to the appropriate district attorney for prosecution.
That’s where another part of the partnership comes into play. The investigation companies also provide training to examiners on how best to prepare the file that will be sent to RJN or Probe for investigation.
“We have found that District Attorneys and the Department of Insurance need a complete case file and evidence beyond a reasonable doubt in order to move a case to prosecution. Our strong partnership with York enables us to provide solid documentation for every stage of claim investigation,” notes Robert Nagle, president of RJN Investigations.
“Workers’ compensation fraud cases are complicated, which is why busy DA offices accept only 10 percent of referred cases,” said Dalene Bartholomew, CFE, CIFI, vice president of Probe. “We are proud of both the acceptance and successful prosecution rates for our files and cases.”
Source: York Risk Services Group
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