Cliff Bernstein Mar 1, 2018 01:24 AM
Question? Would this also apply to Utilization Review?
George Corson Mar 1, 2018 06:29 AM
When you ponder it, the Worker is often the one most able to identify fraud. They (should) know which devices, prescriptions, and treatments they actually received. The Carrier/Employer/TPA only knows what they were billed. I agree that the first EOB statement will be looked at, and the others will typically be thrown away. What is lacking for the Worker is incentive to actually care. If a worker on TTD had a financial incentive to keep the billing accurate, you could Six Sigma the crap out of this problem in about 3 years. All it would take is a statement that says â€œWorkers responsible for identifying medical treatment fraud shall be compensated up to (X%) of the over-billing upon verication.â€ Fund a Reward Account, distribute the booty to the Workers, and BOOM! Now you have 50,000 Informants, scouring each EOB for unreceived services. When 50-100 Workers make the same statement, against the same providers, the problems will QUICKLY come to light.
Micheal Wagnon Mar 1, 2018 08:30 AM
This comment has been deleted.
J anon Mar 1, 2018 10:46 AM
Get rid of the Fraud Assessment Committee....wolf guarding the henhouse.
Pete Almeida Mar 1, 2018 10:46 AM
George, you are on to something here.
Chrissie Lovold Mar 5, 2018 12:06 PM
George: I have had this conversation with multiple government and fraud "experts" for years now. The EOB incentive plan would take a big chunk of fraud out of work comp....and Medicare! Disneyland uses the EOB format, LAPD uses an EOB format - but there is no incentive in either of these programs for the claimant to pick up the phone and call if something doesn't look quite right. Some may call, but most wouldn't bother. If carriers and TPAs were to ever get on board, they need to keep in mind that not everyone knows exactly how to read an EOB....or even what an EOB represents. Clear and simple information, with a friendly 800 number to call with questions, would need to be applied.....along with wording that would incentivize the claimant to pick up that phone and call.