Workers’ Compensation Takes an Aggressive Lead against Fraud

About the Program

Category: Risk and Emergency Management (Best in Category)

Year: 2013

ALERT [Abuse and Lien Effective Resistance Taskforce] was implemented three years ago at the County of Riverside to combine our Special Investigation Unit and our Lien Specialist program to address the fraud and abuse which is rampant in the California Workers’ Compensation lien system. This blending of two specialists and resources creates a more effective way of dealing with an ever-growing problem. ALERT evaluates the validity of liens and uses both litigation and prosecution to defend the County of Riverside against abusive billing or fraudulent practices by vendors in the workers’ compensation system. Abuse is addressed through litigation. Unprofessional conduct is filed against licensing boards. Fraud is reported to the Department of Insurance and criminally prosecuted. This program is unique from other Counties and claims operations. Throughout California, claims operations normally depend on defense attorneys to represent them and negotiate liens for a lesser value. The fraud involved in the liens is never addressed, identified, or reported. Paying fraudulent bills and liens has been accepted as a cost of doing business in California. The County has a Lien Specialist who oversees the lien resolution stage of claims, and once all legitimate liens have been resolved, the questionable liens are referred to the Lien Specialist. Few claims operations even have an in house Lien Specialist, but rely upon defense attorneys. The ALERT Program is unique because it empowers the Lien Specialist by combining the position with the Special Investigation Unit trained to know how to identify fraud, how to document the fraud, how to report the fraud and how to aid in the prosecution of the fraud uncovered by the Lien Specialist. No other claims operation has this kind of structure, organization, or position.