Workers Comp Zone


In any large industry, there are temptations to cut corners.

Workers’ comp is no exception. Among those who may be tempted are some medical providers.

Today a 181 page indictment was announced in Orange County. Prosecutors have charged Newport Beach radiologist Dr. Sim Carlisle Hoffman with alleged $17 million in workers’ comp fraud.

Other alleged co-conspirators charged were a neurologist, Dr. Thomas Michael Heric, of Malibu, and clinic administrative employees Louis Umberto Santillan of Chino Hills and Beverly Jane Mitchell, of Westlake Village. Facilities alleged to be part of the scheme were in Buena Park: Advanced Professional Imaging, Advanced Management Services and Better Sleeping Medical Center.

Among other things, they are charged with billing for tests which were never performed.

According to research by Britney Barnes of the L.A. Times, ” In 2001, the state’s Medical Board disciplined Hoffman for excessive billing and putting a patient through unnecessary radiology treatments.
Heric was previously convicted of felony federal fraud in 2008 and had his medical license suspended for 60 days.”

Concern over provider fraud has led some to suggest that sending injured workers an explanation of benefits paid might deter provider fraud. The concept is that workers might look at the form and spot billings for services that were not provided.

Those explanation of benefits forms have been used in Medicare and in some private health policies.

I’m starting to see such forms sent to my clients by Travelers Insurance.
What isn’t clear is whether clients really look at these forms or simply throw them out.

Typically the forms explain what has been bill and what bills have been paid to providers for the worker’s treatment.

Several years ago there were efforts by Disney and some other stakeholders, including the Employers Fraud Task Force, to design an explanation of benefits form that would be mandated by law. A bill proposed at the time to require such a form, SB 156, failed to advance.

Whether the explanation of benefits letters will generate some tips to catch provider fraud, or whether they simply generate more expense, isn’t clear at this point.

Proponents have also argued that they give the employee some sense of what treatment is costing, injecting a dose of reality into a system where the relationship between costs and benefits often aren’t even considered by the worker.

Stay tuned.

Julius Young

Category: Medical treatment under WC