Thursday, July 2, 2009


An analytic study by OCI found that over 4% of all workers' comp claims have a duplicate bill sent to a group health plan.

OCI conducted the analyses on a large employer from their proprietary Reference Database on duplicate workers' compensation and healthcare payments. The purpose of the study was to determine how frequently and how much greater costs occur if and when providers are billing both workers' comp and healthcare for the same services, patient or claimant.

The results of the study were presented at a recent meeting of the Fraud Assessment Commission, under the California Department of Insurance Fraud Program. The study found the following:

  • 4.2% of ALL workers' comp claims have a duplicate healthcare claim
  • Over half of the duplicate claims filed received payment
  • The employer paid over $1.2 million dollars in duplicate payments
  • One-third of the duplicate claims filed were paid more than what was billed
  • The employer paid over $100,000 in overpayments on duplicate claims

"There is an occurrence of duplicate billing on the exact same workers' comp claim, same date of service, same ICD-9, same billing codes, same provider also billing to group health," says Archie Anderson, president of OCI. "This was an aged claim analysis, meaning all the payments have been made. This particular employer was not even aware."

The cause of duplication cannot be determined from the data, however the claim set is easily identified for follow up.

According to OCI, to prevent duplicate claims, an employer or organization must commit to integrating its workers' comp and healthcare billing and claims data to identify where the duplicate billing and payments occur.

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