February 17, 2025
Fraud teams identify $8.3 million in fraud and abuse
At Texas Mutual, we’re dedicated to protecting our policyholders’ premium dollars and state’s workers’ compensation system. That’s why we have a zero-tolerance policy for fraud. Our team of dedicated investigators works hard to stop bad actors from taking advantage of the system.
In 2024, our special investigations department received 1,454 referrals and identified more than $8.3 million in fraud and abuse. We estimate our work helped prevent over $5.1 million in fraud and abuse. While not all investigation results rise to the level of fraud, our team reports and acts on abuse as well. Read more about the work of our three fraud teams below.
Claimant fraud
Claimant fraud occurs when an employee fails to report they’ve returned to work, falsifies an incident or falsifies the severity of their injuries. In 2024, we reviewed 1,189 referrals for claimant fraud.
Investigation highlights:
- Discovered overpayments due to fraud on 150 cases
- Identified $965,114 in claimant fraud and abuse
- Prevented an estimated $2.8 million in payments to dishonest claimants
Our claimant fraud team also prepared cases that led to one indictment, as well as one conviction and sentencing of a Baytown woman (PDF 137KB).
CLAIMANT FRAUD |
|||
|
|
2022 | 2023 | 2024 |
|---|---|---|---|
|
Fraud & abuse identified |
$685,928 |
$723,836 |
$965,114 |
|
Restitution & recoveries |
$411,253 |
$358,002 |
$450,016 |
|
Future savings |
$3,262,466 |
$2,533,643 |
$2,783,626 |
|
Indictments |
0 |
1 |
1 |
|
Convictions |
0 |
1 |
1 |
Health care fraud
Health care fraud can happen when medical providers bill the insurance carrier for services never provided, overbill for services or provide excessive treatment. In 2024, our health care fraud team saved almost $1.2 million through specialized audits on medical bills from providers under investigation.
HEALTH CARE FRAUD |
|||
|
|
2022 | 2023 | 2024 |
|---|---|---|---|
|
Fraud & abuse identified |
$1,328,059 |
$1,405,899 |
$1,396,018 |
|
Restitution & recoveries |
$397,919 |
$236,160 |
$108,716 |
|
Future savings |
$1,062,740 |
$8,406,017 |
$2,331,119 |
|
Fraud & abuse prevented |
$2,592,521 |
$3,090,371 |
$1,180,977 |
|
Indictments |
0 |
0 |
0 |
|
Convictions |
0 |
0 |
0 |
Premium fraud
Premium fraud is when an employer misrepresents their business operations and payroll to the insurance company to pay a lower premium. Using this fraud scheme could give an employer an unfair advantage over competitors. It could also negatively affect everyone involved in the workers' compensation system. Our premium fraud team identified almost $6 million in fraud and abuse in 2024.
PREMIUM FRAUD |
|||
|
|
2022 | 2023 | 2024 |
|---|---|---|---|
|
Fraud & abuse identified |
$11,753,665 |
$7,624,521 |
$5,956,450 |
|
Restitution & recoveries |
$2,009,515 |
$958,402 |
$4,124,502 |
|
Indictments |
4 |
0 |
3 |
|
Convictions |
4 |
0 |
1 |
We take fraud seriously and prioritize your peace of mind. When you choose Texas Mutual, we’re here to support your business and you can count on our team to investigate suspicious activity. Learn more about how to prevent fraud and help your employees recognize and report fraud with our new posters.