January 31, 2024

Fraud teams identify $9.7 million in fraud and abuse

At Texas Mutual, we’re dedicated to protecting our policyholders’ premium dollars as well as our state’s workers’ compensation system. That’s why we have a zero-tolerance policy for fraud and a team of dedicated investigators who work to stop bad actors from taking advantage of the system.

In 2023, our special investigations department received 1,397 referrals and identified more than $9.7 million in fraud and abuse. We estimate our work also helped prevent over $10.9 million in fraud and abuse. While not all investigation results rise to the level of fraud, our team actively reports and acts on abuse as well. Read more about the work of our three fraud teams below.

Claimant fraud

Claimant fraud occurs when an employee fails to report when he or she has returned to work, falsifies an incident, or falsifies the severity of their injuries. In 2023, we reviewed 1,176 referrals for claimant fraud and identified overpayments due to fraud on 147 cases. We identified $723,836 in claimant fraud and abuse and estimate our work prevented $2.5 million in payments to dishonest claimants. Additionally, the work of our claimant fraud team led to a conviction on fraud-related charges.

Health care fraud

Health care fraud can happen when medical providers bill the insurance carrier for services never provided, overbill for services or provide excessive treatment. In 2023, our health care fraud team saved over $3 million through specialized audits on medical bills from providers under investigation.

Premium fraud

Premium fraud is when an employer misrepresents their business operations and payroll to the insurance carrier to pay a lower premium. Using this fraud scheme could give an employer an unfair advantage over competitors and negatively affect all involved in the workers' compensation system. Our premium fraud team identified over $7.6 million in premium fraud and abuse in 2023.

We take fraud seriously and prioritize your peace of mind. When you choose Texas Mutual, we’re here to support your business and you can count on our team to investigate suspicious activity. Learn more about how to prevent fraud and what to do if you suspect fraud.