Monday, June 13, 2016

This Could Be Huge

My blog post on fraud and audits on June 7 attracted the attention of Christine Baker, Director of the Department of Industrial Relations, State of California.

She took issue with my statement that the Brown Administration was actively inhibiting audits of anti-fraud activity.

Baker explained that while an audit is a great process for keeping government in check, she has been through this process numerous times in the past and the issue is that the auditors don't understand work comp, don't understand the nature of work comp fraud, they come in and ask a bunch of questions then make budget recommendations and suggest which agencies could or should coordinate more...

In the meantime the auditors do not get to the root cause of the issue and create a huge distraction away from actually combatting the crime.

I get it. Any of us who have been in positions of accounting for where the money goes have been through audits, and for the most part, unless one is truly trying to hide something, audits are a huge expenditure and a significant distraction that take up a lot of resources for little return other than to assuage the bill payer...

In my blog I had suggested that keeping the consumer/injured worker informed via some explanation of benefits or other reporting mechanism would go a long way, not only in deterring fraud, but also towards increasing consumer engagement in their own treatment and case activity.

Baker isn't interested in another form, and another piece of paper to accompany the 30 million medical bills that get through the system every year. She is interested in a more robust solution.

What hasn't been clear to the workers' compensation public is that the administration has been using EAMS data (more specifically lien filings) and marrying it up with Independent Medical Review to see which providers are operating in the shade.

Some of those providers have already been indicted, and surprisingly continue to pursue lien collections (perhaps to fund their legal defenses?); others are in the indictment cross hairs as the administration works with the FBI and other law enforcement to build cases.

This activity is the start of something bigger, more comprehensive, and hopefully will result in not just capturing criminals but getting consumers more engaged in their own claims.

The future will bring us, Baker promises, a portal for anyone on any given case to log in and see everything that is going on, and in particular medical billing. This is the administration's answer to giving consumers/injured workers an EoB for every medical bill - instead of individual pieces of paper, the administration proposes that folks will have essentially real time access to the complete status of their cases (and I'm assuming even those that are not litigated) for more engagement, greater understanding, increased transparency.

This is a huge task.

Making all of this disparate information and complex workers' compensation metrics accessible without violating privacy, and also making it understandable to the consumer is going to be very, very difficult.

I hope that those who are planning this project engage some of the best user interface designers they can hire because while information is great, if it can not be understood by the consumer of that information then it is of no utility.

If the administration can pull this off, however, it will be a model that all other jurisdictions can, and should, adopt.


  1. It may interest CA law makers and Mrs. Baker that here in WA State the injured workers can all ready see via the computer all charges by medical professional in our claim, even the IME's, and how much they charge. We have a system all ready in place where I was able to see my claim all through out the process, and yes I was very involved, and even caught one error in my claim, that was quickly corrected by my claims manger at the time.

    If WA can do it, I would think CA certainly could as well. IF we have been doing it close to 5 years now, why is it so hard for CA to do it? Just asking.

    None the less, Im glad your being heard. That's better than being ignored by those in charge. Do take note though, that it was not until you offended the State and it's leaders, that they actual acknowledge your complaints. Funny how that works these days.

    First they ignore you, then they laugh at you, then they fight you, then you win. Mahatma Gandhi

    1. A HUGE difference Darren is that WA is a monopolistic state - which means all the data goes directly to the state without any intermediaries (i.e. insurance companies). And CA work comp is ten times the size of WA, so the volume is much greater. Still, WA does provide a model!

    2. I think it's also important to note, that first off Im sayings something "positive" about my States workers comp system for a change. Yeah! A good thing. And secondly, that while I was able to see things clearly in my claim being an injured state employee, in my father in laws claim, who was through a self insured employer, the information about cost and charges was not available to us. So while were doing good on one hand, the self insured side still needs more transparency. Peace and thanks for explaining things. And your correct, the model for how to to things better, is out there, and could easily be implemented on a larger scale, should the States leaders choose to do so. Peace and thanks, as always.

  2. I'll have to refer back to the previous article, but I'll bet that it doesn't touch on fraud that is facilitated by the workers compensation insurer, defense firm, employer and network medical providers > against the injured worker. Maybe you can touch on that sometime. What are injured workers to do when the aforementioned entities, colluding with the WCAB and DIR employees, are committing crimes against injured workers? For example;
    1. Judges who delete copies of documents that are submitted by the injured worker for trial.
    2. Judges who do not allow the injured worker to speak during the trial unless they are spoken to and who will not allow the injured worker to present their side of the claim / case no matter how many pages were submitted for trial. This is when the injured worker is in proper.
    3. Medical and surgery reports are falsified!
    4. Documents are changed over and above the injured workers signature.
    5. A multiple page document is presented for signature, however the top page is completed differently than the pages underneath. Of course, the IW does not know that they should be turning pages to make sure that they are not marked differently.
    6. Intrusions into the IW private residence wherein WC related documents and their medical history is stolen while at the same time their food is tainted with chemicals that harm their nervous system, heart or soft tissue.
    7. Most depraved of all - the injured worker is intentionally maimed during medical treatment / procedures!
    8. Malicious prosecution!
    Although I could continue with more examples of the fraud, trickery and crimes that befall injured workers in today’s corrupt corporate and government world, I think that they will suffice for now.

  3. How is it legal for Department of Industrial Relations to use the number of lien filings and Independent Medical Review data "to see which providers are operating in the shade?" Does this mean all large clinics are now targets of criminal investigations based on the number of patients they see, the volume of reimbursement denials and treatment denials leading to IMR disputes ? Department of Justice needs to take a long hard look at the insurance money - fueled corruption that criminalizes medical care of injured workers