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SELECTED INDICATORS IN WORKERS’ COMPENSATION:  A REPORT CARD FOR CALIFORNIANS

Workers’ Compensation Fraud Investigations

Types of Workers’ Compensation Fraud Investigations

The following table indicates the number and types of investigations opened and carried for fiscal years 2001-02, 2002-03, 2003-04 and 2004-05 as reported by District Attorneys.  Applicant fraud appears to be the area generating the most cases followed by premium fraud and medical-provider fraud.  

Type of Investigation

Fiscal Year

2001-02 Cases

Number / Percent

Fiscal Year

2002-03 Cases

Number / Percent

Fiscal Year

2003-04 Cases

Number / Percent

Fiscal Year

2004-05 Cases

Number / Percent

Applicant

1,29379.37%

1,26372.63%

1,17760.14%

1,47869.2%

Premium

1599.76%

20711.90%

24212.36%

1728.1%

Fraud Rings

10.06%

70.40%

391.99%

40.19%

Capping

60.37%

50.28%

50.25%

30.14%

Medical Provider

986%

975.60%

974.95%

1054.91%

Insider

80.49%

60.34%

140.71%

60.28%

Other

643.93%

935.3%

562.86%

432.01%

Uninsured

N/A

613.5%

32716.71%

32515.22%

TOTAL

1,629

1,739

1,957

2,136

Source:  California Department of Insurance, Fraud Division

Geographically, the great majority of suspected fraud cases in 2003 and 2004 came from Los Angeles County (30 percent) followed by Orange County (8 percent) and then San Diego County (8 percent).  

Trends in Workers’ Compensation Fraud Investigations

The chart below illustrates the changing focus of workers’ compensation investigations over the past three fiscal years, by showing the what types of investigations comprise what percentage of all the investigations each year.  For example, investigations of applicants were nearly 80 percent of all investigations during 2001-02; in other words, eight out of ten of all investigations were directed at applicants.  

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