Here at WCInsights we’re all about trying to inform employers and employees about the workers’ comp system so that everything runs as smoothly as possible, workers get healthy, and employers save money. Unfortunately there are some people who try to defraud the system and not only does it cost the system money it also makes people lose faith in a system that is set up to help them.
The state of New Jersey has indicted a doctor for supposedly submitting bills for procedures that he never actually performed. Hector Lopez, from Cream Ridge, billed different insurance carriers for “nerve conduction studies” that were never performed and likely never necessary in the first place. These tests are used to diagnose and evaluate abilities and functions of nerves.
In total he asked for $152,350 for 40 different studies, allegedly conducted on 38 different patients. He received somewhere between $53,811 and $58,117 from insurers for procedures that never occurred. He is being charged with 40 counts of second-degree health care claims fraud, one count for second-degree attempted theft by deception, one count for third-degree theft by deception and one count for fourth-degree falsifying records. His license was suspended in June of 2011 and remains suspended, likely pending the outcome of this case.
Lopez did not even perform these procedures, but there are cases of doctors who will bill for needless procedures and make extra money off procedures that had no medical reason to happen. In this case he was discovered when his former business partner turned him in, otherwise the insurers might have gone on much longer unwittingly paying these bills. The prosecution in the case noted that there have been many high-level fraud cases that were detected with anonymous tips, and not because the payers finally got wise to the scheme.
The scary thing is these kinds of fraudulent billing schemes can go on for long periods of time, and insurers are losing thousands of dollars without ever realizing it. That can trickle down to higher premiums for employers. There are systems that can try to catch these fraudulent activities but either insurers are not utilizing them to their capabilities or think that they don’t have a problem with fraudulent doctors so they do not even seek out these fraud detecting systems. There will likely always be people trying to cheat the system but it is through awareness and prevention that we can try to protect it.