Are Your Wages Killing You? Study Opens The Door For Workers Comp Fraud


Personally, I love studies.  They help put things into context, and when done well, provide an independent and hopefully unbiased view of the forces that shape our lives.  They are also a great way to see government funds used in strange ways.  For example, the new NIOSH (National Institute for Occupational Safety and Health) study linking hypertension (aka high blood pressure) and wage rates.  The study, published in the European Journal of Medicine, covered 5,651 employed persons in the U.S. between 1999 and 2005.   Based on the results, it estimates that just a five percent increase in inflation-adjusted wages for 110 million employed workers between 25 and 65 would result in 66,000 fewer cases of hypertension a year.  Doubling wages brings a 25-35 percent drop in hypertension in younger workers, and for women, a 25-30 percent decrease.

The upshot of all of this?  If you are diagnosed with hypertension, which can lead to more serious heart disease and death in some cases, there is now a perfect link to file a workers' compensation claim, blaming it all on your job.  As a job-related condition, you are eligible for medical coverage, time loss, and potentially a pension.  Separating the work impacts from diet, other stress in life, smoking and weight is possible, but difficult, and the laws of states vary on how much the work contribution needs to be.  What an amazing open door for fraud!  All you need to do is drink a bunch of coffee before heading into the doctor, show that high number on the blood pressure, and ta dah, there's your claim!  For some people, just going to the doctor spikes their blood pressure, which the medical industry calls "white coat hypertension".  Even easier to fake.

As more and more conditions that are really just side-effects of life become diagnosed as diseases, and better yet, have links to employment, the door for fraud for private health insurerers, Medicaid and Medicare, and workers' comp insurers and providers is flung wide open. They are exposed to skyroketing costs and higher thresholds to provide fraud, waste or abuse.  The best defense is to put strong systems in place like the SAS Fraud Framework that take a comprehensive view of individuals from many perspectives, including anomalies about their behavior and condition, predictive models based on past cases, and connections through social link analysis to others.  That will help identify connections to past fraud or abuse they have committed, connections to other bad claims and claimants, as well as suspect medical providers.  Knowing the risks doesn't solve everything, but it helps target investigative and audit resources, and gives ammunition to convince would-be fraudsters to shut down claims early.

Come to think of it, I've been diagnosed with hypertension for years now.  Maybe it was 21 years of low government wages.  Time to file a workers' comp claim?  No, maybe I'll just ask my boss for a raise.


About Author

Carl Hammersburg

Manager, Government and Healthcare Risk and Fraud

Carl Hammersburg manages the SAS Government and Healthcare Risk and Fraud team, and has been with SAS since 2012. Prior to that, he spent 20 years in anti-fraud activities for Washington State’s exclusive workers’ comp insurer, the Department of Labor and Industries. In 2004, Carl formed that agency’s comprehensive fraud program, covering tax and premium audit, claim investigation, provider fraud and collections. Data sharing and investigative partnerships with other State and Federal agencies, as well as driving public availability of information and awareness served as cornerstones to the anti-fraud activities of the program. During his stewardship, audit and investigative activities doubled and outcomes tripled, based on a focus on data mining and predictive analytics that improved efficiency and case selection. Program success under Carl’s leadership resulted in awards from two successive Governors of Washington State.

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