March 28, 2022
Fraud-fighting team identifies $9.9 million in fraud and abuse in 2021
At Texas Mutual, our dedicated team of fraud specialists work to protect our policyholders from those who take advantage of the system. In 2021, we received 1,923 referrals and identified $9.9 million in fraud and abuse. We estimate our work helped prevent over $3.8 million in fraud and abuse. While not all investigation results rise to the level of fraud, our team actively reports and acts on abuse as well. Read about our zero tolerance for fraud and abuse below.
Claimant fraud
Claimant fraud is when an employee fails to report when he or she has returned to work, falsifies an incident, or falsifies the severity of his or her injuries. We reviewed 1,686 referrals for claimant fraud and identified overpayments due to fraud on 158 cases. We identified $721,846 in claimant fraud and abuse in 2021 and estimate our work prevented $3.7 million in payments to dishonest claimants. In the past three years, the courts convicted eight Texas Mutual claimants.
|
CLAIMANT FRAUD |
|||
|
|
2019 |
2020 |
2021 |
|
Fraud & abuse identified |
$891,323 |
$818,893 |
$721,846 |
|
Restitution & recoveries |
$363,501 |
$345,800 |
$288,342 |
|
Future savings |
$5,527,733 |
$3,293,188 |
$3,696,344 |
|
Indictments |
0 |
2 |
1 |
|
Convictions |
7 |
1 |
0 |
Health care fraud
Health care fraud is when medical providers overbill Texas Mutual for services or provide excessive treatment. Our health care fraud and abuse unit also handles investigations involving attorneys that overbill. In 2021, our work resulted in indictments against three attorneys and two law firms. We saved $1.8 million through specialized audits on medical bills from providers under investigation.
|
HEALTH CARE FRAUD |
|||
|
|
2019 |
2020 |
2021 |
|
Fraud & abuse identified |
$4,142,683 |
$3,123,115 |
$2,463,493 |
|
Restitution & recoveries |
$1,034,045 |
$243,879 |
$67,780 |
|
Future savings |
$2,370,846 |
$274,857 |
$111,675 |
|
Fraud & abuse prevented |
$1,611,219 |
$2,013,011 |
$1,872,350 |
|
Indictments |
0 |
0 |
5 |
|
Convictions |
1 |
0 |
0 |
Premium fraud
Premium fraud is when an employer misrepresents his or her business operations and payroll to the workers' compensation company in order to pay a lower premium. Using this workers' compensation fraud scheme could give an employer an unfair advantage over competitors and negatively affect all involved in the workers' compensation system. We identified $6.8 million in premium fraud and abuse in 2021 and three cases resulted in convictions.
|
PREMIUM FRAUD |
|||
|
|
2019 |
2020 |
2021 |
|
Fraud & abuse identified |
$6,262,990 |
$6,026,083 |
$6,814,180 |
|
Restitution & recoveries |
$2,043,135 |
$2,007,787 |
$1,293,643 |
|
Indictments |
5 |
2 |
0 |
|
Convictions |
1 |
2 |
3 |
We take fraud seriously and when you choose Texas Mutual, you can count on our team to protect your premium dollars. Learn more about how to prevent fraud and what to do if you suspect fraud.