 | While most health care providers are honest and ethical, some are involved in billing abuse and fraud. In some cases, non-medical professionals create fraudulent medical facilities and bill for services that were never rendered. Medical fraud and abuse does not just hurt the workers' compensation system—it can hurt the injured worker, as well. Please note, a red flag does not necessarily prove fraud; even the presence of several indicators does not mean fraud has occurred. Call Zenith’s Fraud Hotline at 1-866-296-4748 if you suspect medical fraud, so that we can investigate your concerns. |
Red Flags Of Possible Healthcare Fraud
- The medical treatment is inconsistent with injuries originally alleged by injured worker.
- The medical Provider attempts to influence injured workers to seek treatment outside of Zenith’s medical provider network.
- The injured worker undergoes excessive treatment for soft tissue injuries.
- The doctor's billing records are inconsistent with the treatment, as reported by the injured worker.
- The injured worker is unable to define the medical ailments listed on the claim form.
- The injured worker can not physically describe the treating physician or building.
- The medical billing does not coincide with medical records or reports.
- The injured worker reports seeing doctor for very brief time, but billings indicate a lengthy visit.
- The injured worker’s description of the treatment indicates that non-medical personnel rendered the medical treatment.
- The injured worker lives far from medical facility, yet receives frequent treatments.
- The medical provider prescribes TENS unit or similar DME (durable medical equipment) on the first or second visit.
