The software screens claims based on about 100 criteria, looking for irregularities such as delays between doctors' appointments and care that is inconsistent with the injury. Claims scoring high will be assigned to the most experienced claim managers for review. Questionable claims will be turned over to L&I fraud investigators.
"Detecting fraud early and preventing it is one of our top priorities," said L&I Director Gary Weeks. "This software gives us a cost-effective way of targeting our anti-fraud effort so that we identify and close a fraudulent claim before we've paid out thousands of dollars in benefits."
L&I has contracted with Fair Isaac Corp., which will use its software to scan every open time-loss claim twice monthly. A one-time charge of $16.26 will be billed to the claim. No matter how many times the software scans the claim, the claim only will be billed once.
L&I's Fraud Prevention and Compliance Program targets workers who file false claims and collect benefits they aren't entitled to, employers who don't pay their premiums and providers who charge for services they didn't perform. In fiscal year 2005, 19 L&I fraud investigations were turned over to county and federal prosecutors.
L&I runs the state's workers' compensation system, which provides insurance coverage to about 2.3 million workers and 161,000 employers.