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ARGUS WEST SIU - CRIMINAL FILING
Farm Laborer Felony Charges Filed
Tulare County, Calif., February 13, 2018 --- This claim involves a 53-year-old male Farm Laborer who was first hired by the insured on April 14, 2014. In the late morning of May 13, 2016, the Farm Laborer sustained significant injuries to his face, including contusions, lacerations and a nasal fracture. He was transported by ambulance to the hospital where he was admitted and remained for six days before his release.
Argus West, Inc. was called to investigate the case and found there were some variations and inconsistencies in the exact description that the Farm Laborer told the insured and all initial medical providers. He said that his injuries were sustained as a result of tripping and falling while walking in the orchard at work. In direct contrast, interviews with other workers and witnesses revealed that the Farm Laborer had been drinking the morning of the injury incident and was antagonizing another worker, which resulted in a physical altercation with the other worker.
The claim was denied on June 9, 2016. To date, the Farm Laborer has not litigated or contested the denial. Although no benefits were provided, the treating hospital filed a lien against the carrier for approximately $45K and, additionally, there are investigation costs and legal costs as a direct result of the misrepresentations made by the Farm Laborer.
Argus West SIU prepared and submitted a full Documented Referral Package to Tulare County District Attorney’s Office on November 21, 2016. Criminal charges were filed on February 13, 2018 and an arrest warrant is pending. The final restitution figure is pending conviction and is estimated to be approximately $4700. More significantly, the charges will provide a valid defense to contest paying the $45K hospital lien.
CA DIR Medical Fraud Prevention Heats Up
The top lien filers are responsible for roughly 75% of all lien claims filed. Many of these individuals filing liens are either being prosecuted for or had already plead guilty to fraud.
The state enacted two new laws addressing this lien problem. On January 1, 2017, SB 1160 and AB1244 became law. SB 1160 requires the CA DIR to automatically stay all liens owned by providers indicted or charged with a crime. Also, AB 1244 requires the AD to suspend any provider from participating in workers' compensation once they have been convicted of fraud.
The current list of providers whose liens are automatically stayed at the current time can be found at:
Our Provider Fraud Task Force Team is currently working on many of these high profile cases.
California bucks trend as workers comp claims increase
Employment Practices Workers Comp Coverage Claims Management Workers Comp Pricing California workers compensation claim frequency increased 3% from 2010 to 2014 despite an 11% fall in claim frequency in most other states during that time, according to the California Workers' Compensation Insurance Rating Bureau.
In a report released Thursday, Oakland, California-based WCIRB compared its comp claim frequency data with claim frequency in 35 states and the District of Columbia, where the National Council on Compensation Insurance Inc. acts as the workers comp ratemaker.
WCIRB said in the report that California workers have shifted toward more hazardous industries, such as construction and manufacturing, as those sectors have increased hiring in recent years.
California Has Highest Claim Frequency in Nation
Sacramento, CA (WorkersCompensation.com) - In the latest update to the Analysis of Changes in Indemnity Claim Frequency report, WCIRB researchers find that indemnity claim frequency increased in California by 3% from 2010 to 2014 while frequency for National Council on Compensation Insurance (NCCI) states declined by 11% over the same period. The WCIRB report reflects insurer unit statistical and aggregate financial call data submitted to the WCIRB through the third quarter of 2015, as well as other external data, in order to identify the key factors driving these recent frequency increases.
Workers' compensation executive pleads guilty in federal court
A former El Dorado Hills man has pleaded guilty in federal court to using business funds for personal expenses. Gregory J. Chmielewski, 46, of West Bend, Wisc., operated a business in Roseville and later Sacramento called Management Resources Group California LLC, which also went by the name Independent Management Resources. The company was supposed to sell and manage workers' compensation insurance for companies, eventually paying money for valid claims. But Chmielewski spent funds that were supposed to be reserved for claims, and the company couldn’t cover claims. On Friday he pleaded guilty in Sacramento to two counts of mail fraud for transferring business funds to his own personal use. According to the plea agreement, California workers' compensation insurance rates rose quickly in early 2003. Some entrepreneurs negotiated agreements with California Indian tribes to collaborate on business ventures to sell alternative insurance plans not subject to the state's insurance regulations because the ventures operated under the sovereign domestic nation status of the tribe. That’s what Chmielewski did.
Southern California Family Arrested in $24M Fraudulent Workers’ Comp Billing Scheme
California Department of Insurance detectives arrested nine individuals involved in a complex scheme allegedly targeting more than 230 workers’ compensation insurers and self-insured employers. Siblings Francisco Javier Gomez, Jr. and Angela Rehmann, owners of G&G Interpreting Services, allegedly fraudulently billed more than $24.6 million for interpreting services for injured workers with Latino surnames.
California Construction Company Owner Nabbed for Workers’ Comp Fraud
The owner of a Northern California construction firm was arrested Thursday on nine felony counts of workers’ compensation insurance fraud and tax evasion totaling $187,707 in losses. William Huffman, 47, of Sacramento, owner of Capitol City Contractors, allegedly underreported $755,899 in payroll to avoid paying workers’ comp premiums for dozens of employees.