FISCAL AFFAIRS SUBCOMMITTEE

BUDGET & FISCAL AFFAIRS

COMMITTEE

WORKERS' COMPENSATION

PROGRAM COMPLIANCE REQUIREMENTS

DIRECTOR, OMAR C. REID April 30, 2013

Workers' Compensation Fraud Overview

Our Philosophy Common Types of Fraud

Employee Fraud Indicators Worker's Compensation Medical Providers Fraud

Indicators

How Does the City Combat Fraud? How Does Third Party Administrator (Sedgwick

Claims Management Services) Combat Fraud? Statistics

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Our Philosophy

We value our employees and expect them to go home in the same condition they came to work. We strive to return our injured employees back to Transitional Duty, as soon as they are medically able to safely perform a productive work assignment.

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Our Team

Working together to help our employees to return to work

HR Risk Management Department Supervisor Designated Department Representative Sedgwick Claims Management Services (Third Party

Administrator) Injury Management Organization (Utilization Review Agent)

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Workers' Compensation Program Regulations

Executive Order 1-33, Workability Guidelines***

Workers' Compensation Rules **

Labor Code

City of Houston State

** The State utilizes the Medical Disability Advisor (MDA) to provide expected length of disability duration.

** The State utilizes the Official Disability Guidelines (ODG) to indicate the appropriate medical treatment.

*** The City utilizes Executive Order 1-33, Workability Guidelines to manage return-to-work process, in conjunction with the MDA.

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Common Types of Fraud

An employee is drawing benefits because he/she is supposed to be unable to work and is working full time at an unreported job

An employee fakes an injury in order to collect benefits

A medical provider assists the employee in a fraudulent scheme

A medical provider bills for services not provided

- Texas Department of Insurance

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Workers' Compensation Employee Fraud Indicators

Injury that has no witness other than the employee Injury occurs late Friday or early Monday Injury not reported until a week or more after it

supposedly occurred Injury occurs before a strike, holiday or in anticipation

of termination Injury occurs in a location where the employee would

not normally work, or is inconsistent with normal job duties

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Workers' Compensation Employee Fraud Indicators cont.

Employee has prior workers' compensation claims Conflicting diagnoses from subsequent treating

medical providers Employee observed in post-accident activities

inconsistent with the reported injury Evidence of employee working elsewhere while

drawing benefits

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