Premium Fraud. Workers Compensation Fraud Prosecution Unit

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1 Premium Fraud Workers Compensation Fraud Prosecution Unit

2 Workers Compensation Insurance Every employer, that is persons or entities who have employees, shall secure the payment of compensation in one or more of the following ways... By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this state. By securing from the Director of Industrial Relations a certificate of consent to self insure. California Labor Code Section 3700.

3 Agenda Types of Workers Compensation Insurance Fraud Premium Fraud Outcomes Payroll Tax Evasion

4 Types of Workers Compensation Fraud Claimant Fraud This occurs when an employee makes a false claim of an injury; When an employee does not disclose other prior injuries to the same body part; When an employee does not divulge money being earned while receiving payments for the injury; or For any other material misstatement during the claims process.

5 Types of Workers Compensation Fraud Provider Fraud Provider Fraud is defined as fraud committed by both Medical/Chiropractic providers and legal providers. This includes over billing for services not rendered to injured employees; Billing for treating injured employees when no such medical visit ever occurred; and For billing for medical equipment provided that is improperly billed or is not necessary for the treatment of the injured employees. Capping

6 Types of Workers Compensation Fraud Denial of Benefits This occurs when a business, with workers compensation insurance willfully denies insured benefits to an injured employee; and This is often done by requiring the employee to use their health insurance to cover treatment of occupational injuries, or where the employee is told there is no coverage.

7 Types of Workers Compensation Fraud Uninsured Employer Cases Any employer that does not have workers compensation insurance coverage on his regular employees is in violation of the law. This is a violation of Labor Code Not having workers compensation insurance is a misdemeanor that carries up to one (1) year in county jail.

8 Types of Workers Compensation Fraud Premium Fraud Premium Fraud occurs when a person makes a material misrepresentation to his or her workers compensation insurance carrier for the purpose of reducing his or her premium. Provides an unfair competitive advantage.

9 Premium Fraud Relevant code sections: Insurance Code 11880(a) (applicable to cases involving State Compensation Insurance Fund); and Insurance Code 11760(a) (applicable to cases involving all other insurance companies). 9 5/13/2014

10 Premium Fraud SCIF is a quasi state agency. It operates as an insurance agency. It only handles workers comp insurance. It is the agency of last resort in other words, SCIF HAS to insure a company, absent certain mis/malfeasance. 10 5/13/2014

11 Premium Fraud How is a workers compensation insurance premium calculated? Payroll Employee classification Experience modification (ex. mod.) factor. Payroll x employee classification x ex. mod. 11 5/13/2014

12 Premium Fraud Example 1 Payroll x Employee classification x ex. mod. Payroll = $100,000 Employee classification = Roofer 50%($50 per $100) Ex. mod. = 1 Premium = $50, /13/2014

13 Premium Fraud Example 2 Payroll x Employee classification x ex. mod. Payroll = $250,000 Employee classification = Clerical 2%($2 per $100) Ex. mod. =.75 Premium = $3, /13/2014

14 Premium Fraud How does premium fraud occur? Payroll x Employee classification x ex. mod. 14 5/13/2014

15 Premium Fraud How does premium fraud occur? Payroll x Employee classification x ex. mod. Underreporting payroll Cash pay Independent contractors Labor paid in rent, vehicle or supplies 15 5/13/2014

16 Premium Fraud How does premium fraud occur? Payroll x Employee classification x ex. mod. Misclassification of employee Type of work Landscaper v. tree trimmer Janitor v. roofer Clerical v. construction 16 5/13/2014

17 Premium Fraud How does premium fraud occur? Payroll x Employee classification x ex. mod. Misclassification of employee Employee experience (dual wage classifications) Concrete over/under $24 per hour Carpentry over/under $26 per hour Roofing over/under $25 per hour 17 5/13/2014

18 Premium Fraud How does premium fraud occur? Payroll x Employee classification x ex. mod. Ex. mod. evasion Identify change Same company... different name Failing to report injuries Injured workers not provided with workers compensation benefits 18 5/13/2014

19 Premium Fraud How does premium fraud occur? Payroll x Employee classification x ex. mod. An employer can commit any combination of the three. 19 5/13/2014

20 Outcomes If the Defendant Convicted of a Felony 2, 3 or 5 years in County Prison (prison realignment) Fines Restitution If Misdemeanor Only 1 year is County Jail, along with others above

21 Payroll Tax Evasion This crime is often committed with premium fraud What is payroll tax evasion? The employer wilfully files a false tax return, or Wilfully false to pay over taxes withheld from employees

22 Payroll Tax Evasion Is payroll tax evasion a felony? Yes! (See California Unemployment Insurance Code Sections and ) These sections carry a prison term of 16 month, 2 or 3 years, or One (1) year in county jail if treated as a misdemeanor (wobbler).

23 Payroll Tax Evasion How does payroll tax evasion occur? Underreporting of employee wages Failing to report employee wages Employer withholds employee wages, but fails to submit the taxes to the State

24 Payroll Tax Evasion Consequences of payroll tax evasion Reduces operating costs Employees may have to pay taxes again Unfair competition

25 Questions?

26 How To Reach Us WorkersCompInsuranceFraudUnit.aspx

27 How To Reach Us We Tip Line (909) (909) Address

28 How To Reach Us David Simon Lead Deputy District Attorney Scott Byrd Deputy District Attorney

29 How To Reach Us Michael Chiriatti Deputy District Attorney

30 How To Reach Us Cora Brown Workers Compensation Fraud Unit Secretary (909) (909) FAX

31 Premium Fraud Workers Compensation Fraud Prosecution Unit

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