Home > Fraud Awareness, SID Information > Milling about: Providers who operate injury mills

Milling about: Providers who operate injury mills

In the second article of this Provider Fraud Awareness series, we quoted Dr. Louis Lasagna as having taught medical students to meet the following standard of conduct in the modern version of the Hippocratic Oath:

“I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism” [non-treatment].”

In the last article we examined examples of overtreatment when we discussed the scourge of criminal providers who overprescribe narcotic drugs. In this article we discuss criminal providers who engage in overtreatment of their patients by overusing multiple, repetitive, often unnecessary and ineffective, medical services. For example, these criminal providers treat patients by performing many diagnostics tests with little or no advance explanation or follow-up interpretation and often for extended periods of time.

Such a practice – from which providers conspire to furnish unnecessary care in order to overbill BWC and/or other insurers – is commonly known as an “injury mill”. In an article entitled “Insurance fraud: How to spot a personal injury mill,” Stephen Barrett, MD, Charles Bender, DC and Frank P Brennan, Esq., describe injury mills as follows:

‘The key players are (a) providers who hope to profit from their expensive services; (b) attorneys who hope to profit from insurance settlements, which often are a multiple of the health-care expense; and (c) patients who may or may not have full knowledge of the conspiracy. Some mills use “runners” to recruit accident victims, but some mills even fabricate their own accidents.’

Clearly, the intent of an injury mill is not to effectively treat the patient’s unique symptoms, to provide a cure, but rather only to maximize billings per patient per visit. Consequently, these criminal providers furnish patients short, incomplete and/or infrequent medical examinations. Injury mill providers ignore the true medical care needs of our claimants.

Be on the Lookout

Red flags that may indicate a provider is operating an injury mill:

  • Provider furnishes unnecessary treatments and/or services, often for extended periods of time;
  • “One-stop shopping” — the provider practice includes multiple provider types, typically at a single location; e.g., medical doctors, chiropractors, physical therapists, and massage therapists;
  • Physical examinations of patients are infrequent, short and incomplete;
  • Provider routinely maximizes billing per patient per visit, for example by performing many diagnostics tests with little or no advance explanation and follow-up interpretation;
  • Provider has close working relationships with attorneys;
  • Provider bills increasing units of service for massage and physical therapy;
  • Provider uses the same treatment even after the patient reports physical health improvement;
  • Patients have multiple claims and frequently receive treatment from the provider; and
  • Patients file new claims shortly after settling their older claims.

Look for our next fraud provider awareness article that will discuss providers who commit fraud by unbundling and/or upcoding bills. Meanwhile, be sure to read more about provider fraud investigations in our SID FY 2011 Annual Report.

If you suspect that a subject is committing workers’ compensation fraud, let us know. You may report it online at http://bit.ly/reportfraud or you may speak with a fraud hotline agent by calling 1-800-OHIOBWC.

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  1. October 11, 2013 at 11:03 am

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