The fight against workers comp fraud


The fight against workers comp fraud

“We do not have the attitude that all workers comp claimants are frauds. We know the majority are legitimate, and that they want to get back to work full time,” said Eileen Cook, supervisor of the Texas Mutual Insurance claimant fraud unit and an experienced investigator. “We find that folks don’t really like light duty. They want to get back to a full paycheck.”

Formed by the State of Texas in 1991 to get the workers comp system and premiums under control, Texas Mutual is mandated to investigate and prosecute fraud, including criminal activity through ineligible claims. The company now provides workers comp for 30 to 35 percent of Texas businesses.

Fraud investigator Eileen Cook

Cook said there is a small percentage of employees who are determined to get something for nothing from the workmen’s comp system. They continue to claim a disability after they have recovered from an injury, which means the employer is still paying medical costs and wages.

Cook encourages policyholders to call her office when they have a gut feeling something is not right. “You are our eyes and ears,” she told TMI members attending a workshop on fraud prevention. “However you come by the information or suspicions, let us look at them. You are not required to determine if a fraud is occurring. Your responsibility is giving us the information and the opportunity to look at what is going on. We build a case, make it strong and turn it over to the prosecutor’s office.”

Workshop participants represented Valley retail stores and medical offices, welding and machine shops, staffing and insurance agencies, non-profits and home health businesses.

Fraud arises when a person receives benefits they are not entitled to, acts deceptively to retain those benefits and is aware their actions are wrong. Feigning injury after healing is fraudulent. Each claimant is informed about fraud initially and with each weekly check.

Being noncompliant (not going to the doctor) is not fraud, Cook said. “But to us, that’s like a little red flag as is activity inconsistent with the injury. Let us see if there’s something we should investigate and make a determination about it.”

In 2011, Texas Mutual’s claimant fraud office got 1,600 referrals, which were divided between seven investigators.

For more of this story by Eileen Mattei, pick up a copy of the May edition of Valley Business Report, on news stands now, or visit the “Current & Past Issues” tab on this Web site.

Freelance writer Eileen Mattei was the editor of Valley Business Report for over 6 years. Her articles have appeared in Texas Highways, Texas Wildlife Association, Texas Parks & Wildlife and Texas Coop Power magazines as well as On Point: The Journal of Army History. The Harlingen resident is the author of five books: Valley Places, Valley Faces; At the Crossroads: Harlingen’s First 100 Years; and Leading the Way: McAllen’s First 100 Years, For the Good of My Patients: The History of Medicine in the Rio Grande Valley, and Quinta Mazatlán: A Visual Journey.