WHAT IS WORKERS' COMPENSATION FRAUD?

What is Workers' Compensation Fraud?
Examples of WC Fraud
NJ Workers' Compensation Fraud Act
Office of Insurance Fraud Prosecutor
Penalties for Committing WC Fraud
Reporting Fraud




WHAT IS WORKERS' COMPENSATION FRAUD?

Workers' Compensation Fraud occurs when someone knowingly makes a false representation of a material fact to obtain or to deny workers' compensation benefits or to avoid responsibility under the law.  Fraud also occurs when an employer misrepresents the amount of payroll or classification of its employees. Failure to maintain the required WC insurance coverage is also a crime.
All of us who live and work in New Jersey pay the price for fraud - in the loss of jobs and profit, lower wages and benefits, and higher costs for services and insurance premiums.  It affects workers and employers alike and is committed by workers and employers alike.


SOME EXAMPLES OF FRAUD

A worker commits a fraud

• by misrepresenting his / her job status while collecting temporary disability benefits
• by filing a claim for an injury that did not occur on or has no relation to the job
• by knowingly misrepresenting his / her physical condition to obtain WC benefits
• by misrepresenting previous trauma or treatment

An employer commits a fraud

• when it misrepresents the amount of payroll or the proper classification of its employees
• by failing to obtain workers' compensation insurance coverage. This is in violation of NJSA 34:15-79 and is punishable by up to 18 months in jail and a $10,000 fine, in addition to substantial civil penalties.

An attorney or health care provider commits a fraud

• when they assist an individual in fraudulent schemes, participate in double billing or intentionally billing for services not provided or are unwarranted

WC FRAUD ACT

Workers’ compensation fraud is governed by the NJ Workers' Compensation Statute, N.J.S.A. 34:15-57.4. This statute  provides that a criminal violation occurs if a misrepresentation is made for the purpose of wrongfully obtaining benefits or withholding benefits or premiums regarding workers’ compensation. If an individual wrongfully obtains benefits, a Judge of Compensation has discretion to terminate benefits and order the forfeiture of benefits that might otherwise be properly received.

 

OFFICE OF INSURANCE FRAUD PROSECUTOR

The Office of Insurance Fraud Prosecutor (OIFP), was created in 1998 with the mission to investigate allegations of Medicaid and insurance fraud and to develop case-specific facts and evidence. This allows the State of New Jersey to make a reasoned decision whether and how to proceed in cases involving insurance fraud, especially against those who submit false or inflated claims to private or government insurance providers. 

Office of Insurance Fraud Prosecutor website

PENALTIES

Workers' Compensation Employer Fraud           NJSA 34:15-57.4
An employer who makes a false or misleading statement, representation or submission, including a misclassification of employees, or engages in a deceptive leasing practice, for the purpose of evading the full payment of benefits or premiums shall be guilty of a crime of the fourth degree.

A person who evades the full payment of premiums pursuant to R.S.34:15-1 et seq. or improperly denies or delays benefits pursuant to R.S.34:15-1 et seq. is liable to pay the sum due and owing plus simple interest and shall be civilly liable to any person injured by the violation for damages and all reasonable costs and attorney fees of the injured person.

Failure to Purchase Required WC Insurance Coverage
NJSA 34:15-120.1(c)    NJSA 34:15-79

It is illegal for an employer to not purchase workers' compensation insurance.  Failure to purchase the required workers’ compensation insurance coverage is a disorderly persons offense and, if such failure shall be determined to be willful, a crime of the fourth degree.

Civil penalties for failure to provide such coverage are:

• up to $1,000 for the first twenty days
• and up to $1,000 for each ten days thereafter

If a judgment is entered by a Judge of Compensation against an uninsured employer, in addition to the judgment amount,

• an additional $1,000 penalty shall be imposed
• as well as an assessment of 15% (not to exceed $5,000) of the  judgment amount.
• Civil penalties may be imposed even if the case is not prosecuted criminally.  NJSA 34:15-120.1(c)

If successfully prosecuted as an indictable offense, the crime is punishable by up to:

• 18 months in jail
• a $10,000 fine
• in addition to civil penalties.  (NJSA 34:15-79)

Workers' Compensation Worker Fraud:        NJSA 34:15-57.4
A person who purposely or knowingly makes a false or misleading statement for the purpose of  wrongfully obtaining benefits shall be guilty of a crime of the fourth degree.

If that person has received benefits to which the person is not entitled, he is liable to repay that sum plus simple interest to the employer or the carrier or have the sum plus simple interest deducted from future benefits payable to that person, and the division shall issue an order providing for the repayment or deduction.

The Division of Workers' Compensation may also order the immediate termination or denial of benefits with respect to that claim and a forfeiture of all rights of compensation or payments sought with respect to the claim.

Health Care Claims Fraud:
It is illegal to submit a false claim form to an insurance company in order to be paid for health care services which were not received or provided.  This is a violation of the NJ Health Care Claims Fraud Act, NJSA 2C:21-4.2 and 2C:21-4.3

• Punishable by 5 to 10 years in prison if the person submitting the claim is a doctor, chiropractor, dentist, psychologist, nurse, pharmacist, physical therapist, lawyer or other licensed professional and the claim is submitted for professional services.  In addition, this person can be required to pay a fine of up to $150,000 or up to 5 times the amount of the claim.
  
• A person submitting the claim who is not a doctor, chiropractor, etc., could be sentenced 3 to 5 years in jail for just filing one false claim.
  

REPORTING FRAUD

The Division of Workers' Compensation is committed to preserving the integrity of the system.  You can also help!

If you suspect fraudulent activity by a worker, an employer, a medical provider or an attorney with respect to a pending workers' compensation case, please contact the following:

NJ Division of Workers' Compensation
Attn:  WC Fraud Coordinator
PO Box 381. Trenton, NJ 08625-0381
(609) 292-2414,   FAX (609) (609) 984-2515, 
e-mail:  oscf@dol.state.nj.us
Your referral will be kept completely confidential. 

If you are aware of an uninsured employer:

You may provide this information to the Office of Special Compensation Funds  by  e-mail ,  by completing a "Report of Non-Compliance" form. or by writing to:
Office of Special Compensation Funds (OSCF)
P.O. Box 399, Trenton, NJ 08625-0399
(609) 292-0165, FAX (609) 633-7783

You need not identify yourself but you should be prepared to provide the name and exact address of the employer and, if possible, the names of the principle operators of the business.
 

If you suspect that an employer is misrepresenting the amount of payroll or the proper classification of its employees:

Please contact:
Jim O'Hare
Compensation Rating & Inspection Bureau
60 Park Place, Newark, New Jersey 07102
(973) 622-6014 ext. 214
 

All other referrals may be directed to the Office of Insurance Fraud Prosecutor

NJ Department of Law & Public Safety
Division of Criminal Justice
Office of Insurance Fraud Prosecutor
P.O. Box 094
Trenton, NJ 08625-0094

1-877-55-FRAUD  (1-877-553-7283)