Impaired Thinking

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There are lots of things that can cause impaired thinking – sleep deprivation, alcohol and drug use, certain medications or diseases, and then there’s just plain stupidity. Two Texans, who worked for a company that determined workers’ compensation benefit eligibility, weren’t thinking logically when they participated in an organized criminal scheme to commit workers’ compensation fraud. (They erroneously thought they could get away with stealing thousands of dollars that didn’t belong to them.)

One of the men, who was from Harlingen, Texas, was responsible for performing functional capacity evaluations to determine if injured employees were eligible for workers’ compensation benefits. (He essentially conducted medical exams to see if an injured employee could physically perform their duties after being hurt while on-the-job.)

The man from Harlingen falsified workers’ compensation claims, certifying that it took more time to perform the evaluations than it actually did. He then submitted the bogus claims for payment.

A co-worker, who was from Deer Park, Texas, also performed functional capacity evaluations and claimed the medical exams took longer than expected. (These two obviously thought they had a great scheme going by billing for a little more than they should have. A little bit here and a little bit there eventually adds up to a lot.) The insurance company that was evaluating the bogus claims submitted by the two evaluators alleged that their employer was also using unlicensed providers to perform the medical exams.

The man from Harlingen pleaded no contest to workers’ compensation fraud. He received a sentence of three years’ deferred adjudication, must complete 120 hours of community service and is obligated to pay $10,000 in restitution to the insurance company he defrauded. (Deferred adjudication is essentially probation. In this case, if the probationary period of three years is successfully complete, the case will be dismissed.)

The healthcare worker from Deer Park was sentenced to three years’ deferred adjudication and ordered to pay $10,000 in restitution for his part in the workers’ compensation fraud scheme. He must also participate in any court-ordered treatment or counseling.

It’s safe to say that most fraudsters suffer from impaired thinking. For some reason, the two men in today’s fraud case thought they were entitled to steal money from companies who pay insurance premiums to protect their employees and from the insurance companies who make sure their medical needs are met. In the end, it’s the business owners who have to pay higher premiums, then have to jack up prices to cover the cost. And, let’s not forget the most vulnerable – the injured worker, who has to earn a living while trying to recover from an injury. (Let’s hope that the perpetrators in today’s case appreciate the light sentence and will think twice before committing any more fraudulent crimes in the future.)

Today’s “Fraud of the Day” is based on an article entitled, Texas Mutual Announces 2 Workers’ Comp Fraud Convictions,” posted on Insurance Journal on May 22, 2018.

Texas Mutual Insurance Co. recently announced that Marcos Ricoy of Harlingen, Texas and Enrique Colon of Deer Park, Texas, pleaded no contest to a felony charge of engaging in organized criminal activity involving workers’ compensation healthcare fraud.

The convictions are in connection to alleged fraud committed by Expert Medical Evaluators International Inc.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.