February 8, 2023

Fraud-fighting team identifies $13.7 million in fraud and abuse

At Texas Mutual, we have a dedicated team of fraud specialists who work to protect our policyholders from those who take advantage of the system. In 2022, we received 1,636 referrals and identified $13.7 million in fraud and abuse. We estimate our work helped prevent over $4.3 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 1,403 referrals for claimant fraud and identified overpayments due to fraud on 144 cases. We identified $685,928 in claimant fraud and abuse in 2022 and estimate our work prevented $3.2 million in payments to dishonest claimants.

Health care fraud

Health care fraud is when medical providers overbill Texas Mutual for services or provide excessive treatment. We saved almost $2.6 million through specialized audits on medical bills from providers under investigation.

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 $11.7 million in premium fraud and abuse in 2022 and cases referred for criminal prosecution in previous years resulted in four indictments and four convictions.

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.