partment of Labor and Industry, this type has the most varied and numerous different schemes involved in it. Creative billing and “upcoding.” Each deal with billing the Workers’ Compensation Industry. The former is mainly defined as billing for services that aren’t performed, and the latter involves billing more than the scheduled amount for the services that are performed. “Unbundling” involves performing a single service but billing it as a series of separate procedures. Product replacement involves a pharmacy or dispensary billing the industry for a brand name drug when the drug dispensed was generic. These are all relatively old methods of swindling the system, but are still the most widely used because of how difficult it is for investigators to track those methods. Some newer and more sophisticated techniques have become increasingly more prevalent, partially because of the even more untraceable nature of each new method. These methods are: Under- and Over-Utilization. The term utilization refers to the level of care given to a patient for a fixed fee; under-utilization involves not providing enough care and over-utilization is providing unnecessary treatments or tests to justify higher fees. Kickbacks occur when providers are given incentives for patient referrals. Internal Fraud is when agreements are made between insurance companies and providers to defraud employers. These types of fraud are beginning to hold health care professionals and other positions thought to be held by people of solid moral fiber under close scrutiny. This does not, however, mean that the problem is any closer to being resolved.Inherent problems arise from the emphasis that is unduly placed on claimant fraud. Injured workers who have genuine claims tend to be intimidated by the threat of insulting questions under the pretense of “fraud prevention”...
