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| | York's Success in Fighting Workers' Compensation Fraud Recovers More than $1.5M for Clients
By Lonce LaMon and York RSG Press Release - April 3, 2015
York Risk Services Group (York), a third-party-administrator of workers’ compensation claims, states its efforts to combat workers' compensation fraud has enabled them to return to their public entity clients in California more than $1.5M in workers’ comp restitution.
Of that amount, more than $1M was returned to clients in Southern California. These recoveries are associated with 91 successful prosecutions and convictions.
“This is an important milestone in our ongoing efforts to combat fraudulent workers’ compensation claims in the state of California,” said Jody Gray, President of York Public Entity, a division dedicated to providing claims and risk management services exclusively to public entities.
Each year, $10 billion in workers’ comp claims are filed in California, and the California Department of Insurance estimates that one out of every four is fraudulent. Compared to a nationwide average that runs well under 10%, the state continues to face a very real crisis with this costly crime.
York reached this milestone by utilizing its internal team of expert in-house AOE/COE investigators, York Investigations, and two SIU partners, RJN Investigations and Probe Information Services. Both RJN and Probe are certified leaders in the field of special investigative services (fraud investigations) for carriers, third-party administrators and self-insured entities.
The partnership with RJN and Probe starts with training. The companies work with York to educate adjusters and examiners on how to identify warning signs of fraud. When an examiner spots signs of fraud, they refer the claim to York Investigations, which functions as York's front line in the battle against workers’ compensation fraud.
York Investigations will conduct a preliminary investigation -- obtaining detailed statements from the injured worker, employer and witnesses to preserve the facts before memories fade and evidence disappears. The York Investigations team will also run background checks and review social media posts, court records, DMV records and other sources looking for signs of possible fraud or abuse. If the warning signs of fraud are detected during this initial investigation, the claim is reviewed with a York claims professional. If they determine that facts warrant it, the case is then sent over to RJN and Probe.
RJN and Probe complete the investigation into the suspected fraud using best practices like surveillance and activity checks, conducting background checks using the Internet and social networking, and all facets of field and return to work investigations. The final phase of the process is thorough documentation of the findings and careful preparation of files to bring to the appropriate district attorney for prosecution.
“We have found that District Attorneys and the Department of Insurance need a complete case file and evidence beyond a reasonable doubt in order to move a case to prosecution. Our strong partnership with York enables us to provide solid documentation for every stage of claim investigation,” notes Robert Nagle, President of RJN Investigations.
Dalene Bartholomew, CFE, CIFI, of Probe adds “Workers’ compensation fraud cases are complicated, which is why busy DA offices accept only 10% of referred cases. We are proud of both the acceptance and successful prosecution rates for our files and cases.”
“The partnership with RJN and Probe has helped York secure one of -- if not the -- highest prosecution and restitution rates for our clients and do our part to combat workers’ compensation fraud. We are very proud of our accomplishment,” said Gray. “Workers’ compensation fraud robs each and every one of us through higher overall premiums, wasted tax dollars and increased costs of goods and services. York’s diligence as a good steward of resources, both for our clients and for taxpayers in California and nationwide, remains steady and strong."
by Lonce LaMon, journalist, lonce@adjustercom.com and from the Press Release of York RSG dated April 2, 2015
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