Workers’ compensation fraud occurs when someone willfully makes a false statement or conceals information in order to receive workers’ compensation benefits or prevents someone from receiving benefits to which they might be entitled.  The people who may be committing this fraud can be employers, employees, providers or anyone else involved in the system. Unfortunately, the people that commit workers’ compensation fraud are making your premiums higher, higher prices on goods and services and lost pay due to draining business profits. 

When employers commit workers’ compensation fraud, they are usually doing this to avoid paying workers’ compensation premiums.  Employers can use a variety of tricks to accomplish this goal such as using shell companies.  Shell companies are inactive companies without significant assets that can be used to disguise business ownership from law enforcement or the public. 

Here are a few examples of Workers’ Compensation Fraud

Claimant Fraud

• Malingering or exaggeration of symptoms
• Working while allegedly disabled and not reporting income
• Claiming a job-related injury that never occurred
• Claiming a non-work related injury as a work-related injury
• Falsifying mileage reports

Employer Fraud

• Underreporting payroll or misclassifying employees for lower insurance premiums
• Deducting premium dollars from employee’s wages
• Employer knowingly fails to have necessary workers’ compensation coverage

Medical or Health Care Provider Fraud

• Providing unnecessary testing or treatment of injured workers to reap financial benefit
• Billing for services or treatment never performed
• Billing the workers’ compensation insurer and the workers’ health insurer for the same services

Workers compensation is a benefit to all employees.  The Office of Workers’ Compensation is there to protect injured workers and if you need help understanding your workers’ compensation rights call the attorneys at Losi & Gangi at 716-854-1446 to help give you all of the information you may need. 

Article adapted from: https://www.thebalancesmb.com/workers-compensation-fraud-examples-4101604

Most employers offer their employees numerous benefits including health and dental insurance, 401K and more. When employees are injured at work, they usually have to go though New York State’s workers’ compensation system to get reimbursed for medical treatment and to receive other benefits.

New York State Employers must carry workers’ compensation insurance through a third party insurance carrier or through a self-insured program set up by the employer. In most cases, employers must get workers’ comp insurance when just one person is hired. Large employers may insure themselves but need to apply with the state and meet very stringent self-insurance requirements. Even if they aren’t required to buy workers’ comp insurance, many employers choose to have it for their employees.

But what happens if your employer doesn’t have workers’ comp insurance? You may sue the employer in a civil court by filing a personal injury claim. In this case you can seek the full amount of your losses without being subject to an arbitrary cap set by law. Most states only pay around two-thirds of the worker’s wage loss for temporary disability benefits only up to a certain amount for a limited period of time. You can also collect money damages for emotional distress caused by your injuries otherwise known as “pain and suffering” and may be able to collect punitive damages which are intended to punish the employer if its bad misconduct caused your injuries. Neither of these can be rewarded through workers’ comp.

If you sue in court it can be a much slower process. It can be months or even years before you see any money through a lawsuit rather than a few weeks with workers’ comp. Since workers’ comp is a no-fault system you will need to prove that your employer was at fault for the personal injury accident. Talk to a lawyer immediately so that you can start the process and make sure your suit is filed in a timely matter.

Many states have special funds reserved for people who are injured while working for an uninsured employer otherwise known as “Uninsured Employers’ Funds”. Under these funds you may be able to get your medical bills covered or receive payments for a portion of your wage loss from it. Check with New York State’s workers’ compensation office for more information on how to file a claim or call the Workers Compensation Attorneys at Losi & Gangi today at 716-854-1446 and we can get you the proper representation you will need in your case.

Workers’ compensation covers all reasonable and necessary medical treatment for an injury or illness that happens at work.  This includes doctors’ appointment, surgeries, Physical Therapy, medications and other treatments.  The doctor who treats your work injury will play a key role in your case by being the one who oversees all of your medical care and giving you opinions that will affect how much you receive in workers’ compensation benefits.  It is very important to find a treating doctor that you can trust.

In 2010, New York State promulgated medical treatment guidelines which provide detailed criteria doctors must follow in order to obtain treatment.  The attorneys and staff at Losi & Gangi are very well versed in working with your doctor to help Injured Workers obtain medical treatment in the most efficient matter.

Being able to choose a doctor usually falls under one of these categories (1) choosing a doctor from a list or medical Network provided by your employer, (2) you choose any authorized doctor or (3) your employer chooses the treating doctor for you.  Losi and Gangi can help you find a doctor who provides treatment under the New York state workers’ compensation law.

In many states, employers have the option of Contracting with a preferred-provider plan, not work, or Managed Care Organization to treat their employees work injuries.  This is a way for employers and insurance companies to reduce costs and control the medical care for workers’ compensation cases.  If your employer has a similar plan to this, you must use a treating doctor for their Network and follow their rules for getting care.  In New York State such a plan only lasts for a short period of time.

In New York you have the right to choose your own treating doctor as long as your employer doesn’t have her provider plan or Managed Care arrangement.  You will need to choose from a list of healthcare providers that the state is approved for treating workers’ comp injuries.  Your employer’s insurance company may limit your options if they have a preferred provider organization (PPO).  If this is the case, you must see a network physician for the first 30 days and may have a specific Pharmacy you have to use.  If you happen to change your treating doctor, the new doctor must be in the workers’ compensation boards list of authorized medical providers.  Your employer may transfer your medical care to a different doctor if the initial physician you choose isn’t authorized by the WCB to treat any workers comp injuries.

In other states, you first have to go to a treating doctor picked by your employer.  Some of these states only require you to see the company doctor for your initial visit or for a certain length of time.  Some workers worried that a company selected doctor may have a conflict of interest and might minimize the extent of their injuries.  If this is true, you may be able to switch doctors if you believe you aren’t getting an adequate care but must follow the rules in your state for changing workers’ compensation doctors.

Here are some tips you should consider while finding the right treating doctor:

1. Consider their experience and understanding of your medical condition
2. Willingness to accept the workers’ comp medical fee schedule
3. Have knowledge of the workers’ comp claim process
4. Willingness to support your workers’ comp claim with detailed reports and
5. Availability for medical appointments

Losi & Gangi can help you with all considerations necessary to find the right treating doctor.

Bottom line – you should choose a doctor you can trust and feel comfortable around.  If you have questions call us today at 716-854-1446 and one of your experienced workers’ comp lawyers can explain the rules in New York state covering workers’ compensation and Medical Care.

Workers’ compensation is insurance that provides cash or medical care benefits for workers who are injured or become ill as a direct result of their job. Employers must pay for this insurance, and may not require the employee to contribute to any cost necessary for  compensation. Weekly benefits such as monetary payments and medical care are given by the employer’s insurance carrier, as directed by the Workers’ Compensation Board, a state agency that processes the claims.

It is not enough to just have insurance as an employer. It is the employer’s responsibility to also provide immediate emergency medical treatment for employees who are injured on the job. They must complete a full report of the injury, with the injured worker’s review and mail it to the nearest workers’ compensation board office within a timely manner.

A claim is paid if the employer or insurance carrier agrees that the injury or illness is work-related. If the employer or insurance carrier disputes the claim, no cash benefits are paid until the workers’ compensation law judge decides who is right. If a worker is not receiving benefits because the employer or insurance carrier is arguing that the injury is not job-related, he or she may be eligible for disability benefits in the meantime. Any payments made under the Disability Program, however, will be deducted from future workers’ compensation awards.

In a workers’ compensation case, neither party is determined to be “at fault”. The amount that a worker receives is not decreased by perceived carelessness, nor increased by an employer’s fault. Although workers’ compensation laws provide treatment to injured employees, they are also meant to protect employers, as they are designed to be the only remedy that injured employees may seek from their employers. One may find that an employer frowns upon employees who file workers’ compensation benefit claims, and some blatantly discriminate against such employees.

Most states prohibit employers from punishing, discriminating against, or discharging employees who exercise their rights under workers’ compensation laws, and allow employees to bring civil actions against their employers for the tort of “retaliatory discharge.”

It is of the business owners best interest to comply with the rules and regulations set forth by the Workers’ Compensation Board. Failure to do so could easily result in further fees, punishments or even lawsuits.

If you or someone you know has been injured at work or is dealing with a workers’ compensation case, call Losi & Gangi at 716-854-1446 and speak with one of our experienced attorneys.

This article has been adapted from information gathered from other sources including http://www.wcb.ny.gov/.