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Advanced Analytics Is a Promising Means to Fight Workers' Compensation Fraud

• Advanced analytics techniques that social welfare programs use for detecting fraud have had generally favorable results.
• These techniques offer California workers' compensation similar promise.
• Shortcomings in how data are currently collected and accessed should not prevent the Department of Industrial Relations from utilizing these tools.

Postemployment Claims Generating Questionable Medical Liens Lack Cost Controls

• Employers must furnish up to $10,000 in medical treatment after a claim is filed and can limit the employee's discretion as to the provider; if the employer rejects the claim, the employee can then receive treatment on a lien basis.
• Postemployment claims have a strong likelihood of denial, and liens that follow are concentrated in certain locations and providers, routinely settling for a fraction of claimed value, which suggests that they remain a significant source of profit.
• Lien volume and claimed value in denied postemployment claims would be reduced if medical care were subjected to the cost controls available in nondenied cases.

A Medicaid Policy Could Be Used to Prevent Payments to Suspected Fraudsters

• Many liens are filed by providers who are under indictment or have been convicted.
• Existing law offers means to stay liens or suspend providers but either require a formal prosecution or affect only a narrow set of liens.
• A Medicaid policy that suspends payments when there is an investigation of a credible fraud allegation would apply to providers who are only under suspicion and would cover all of their liens.