http://www.cbs.state.or.us/external/imd/rasums/2471/8_2741.html
Research & Analysis Section
Department of Consumer and Business Services
August 1999
The Workers’ Compensation Division of the Department of
Consumer & Business Services (DCBS) investigates allegations
of statute or administrative rule violations in an effort to
minimize abuse of the workers’ compensation system. The
division investigates complaints involving abuse or fraud by
medical providers, insurers, employers, and claimants. This report
summarizes the division’s complaint investigation activity
from July 1, 1997 through June 30, 1998 (FY98).
Investigations
initiated
In FY98, 244 investigations into complaints of abuse or fraud
were initiated averaging 20 per month. This is a 15.6 percent
increase from the 211 investigations initiated in FY97. Until
FY98 the number of investigations opened had been decreasing
every year since FY93, when a high of 342 investigations were
initiated.
The most frequent complaints received were improper processing
by the insurer or medical provider (32 percent; an increase of
18 percentage points since FY97), worker collecting workers’
compensation benefits when working or able to work (28 percent;
an increase of 5 percentage points since FY97), and employer
pressure not to file a claim (17 percent; an increase of 8 percentage
points since FY97). Other complaints included: failure to or
improper reporting of claims-related documents by either the
employer, insurer, or medical provider (7 percent; a decrease
of 23 percentage points since FY97), harassment (5 percent; a
decrease of 1 percentage point since FY97), and improper billing
(3 percent; unchanged since FY97). All other complaints accounted
for 9 percent of the total
investigations initiated.
Subject of investigations
initiated
Thirty-one percent (75) of the 244 complaints initiated in FY98
were against workers. This represents an increase of 2 percentage
points from FY97. Most of the complaints against workers, 92
percent, were for collecting workers' compensation when able
to work. Twenty-nine percent (70) of the FY98 investigations
were employer related; 53 percent of these complaints were investigations
into allegations of employers pressuring employees not to file
claims. Twenty percent (49) of the total FY98 complaints were
against insurers; 67 percent of those complaints were for improper
claims processing. All medical providers accounted for 9 percent
(23) of the initiated investigations; 76 percent of these involved
complaints of improper claims processing. Self insured employers
were the subject of 7 percent (18) of the 244 complaints; 61
percent of those complaints also involved improper processing.
Investigations
closed
In FY98, 287 investigations of abuse or fraud complaints were
closed compared to 194 closures in FY97. An average of 24 complaint
investigations were closed each month in FY98. Compared to FY97
average closed investigations increased by 8 per month. These
complaints were closed either by disposition (60 percent) or
referral (40 percent). Of the 173 disposed complaints, 32 percent
were retained for future reference and pattern development, 31
percent were unfounded, 20 percent were given a letter of reprimand
or warning, 11 percent were issued a notification letter, and
five percent were issued a penalty.
Forty percent (114) of the investigations were closed by referral. Sixty-one percent (70) of these referrals were made to the insurer (or self-insurer). Complaints referred to the insurer most often consisted of claimant fraud such as collecting workers’ compensation benefits when able to work (94 percent). Nine percent of the referrals were made to MCOs, 10 percent were made to another division within the Department of Consumer & Business Services, 10 percent were made to other sections within the Workers’ Compensation Division (WCD), and 6 percent were made to other state agencies.
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If you have questions about the information contained in this document please contact by e-mail or phone: Kathy Thomas, Assistant Manager, Research & Analysis Section, Information Management Division (503) 947-7308.
This document was originally published in August 1999.
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