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April/May 1998 Vol. 11 No.2

Workers' Compensation

Newsletter

The Aetna Frau Study at the
Workplace Safety and Insurance Board:
Where is the byte?

Four years ago the accounting firm of Peat Marwick, in the first independent study of fraud occurring at the Workers Compensation Board, discovered that 36% of the randomly chosen claims they surveyed were "irregular" (unproven fraud). Peat Marwick suggested that many of the claims that were irregular were the work of "organized crime", and gave the Board a suggestion for further steps to be taken to weed out criminal activity, which were never followed up on. Last Spring, two years into Tory rule, the Board has spent another $96,000 of employers' money to perform a review of 600 claims chosen at random, in order to explain to the Board how to find irregular claims.

The 1997 Aetna Study, which the Board refused to release to the public for 6 months, is another in a series of embarrassments relating to WCB fraud research. Employers should first consider what Aetna found wrong about the Board's procedures; and second, whether what Aetna found out is still going on nearly a year later. Employers should ask whether Aetna's recommendations are of any value and in turn what proposals that Aetna hasn't recommended would combat fraud.

What Aetna Found:

1. 20% of the 600 claims Aetna studied had enough suspicious indicators to be considered irregular. (A list of indicators is included at the end of this article to help employers with disputing claims). Not one of these claims was however investigated further by Aetna in order to determine whether their suspicions were correct. What value is a theorem without a proof?

2. The Compensation Board does not obtain from its files the claimants' prior work accident history.

Adjudicators at the Board do routinely ask the computers

for prior claims, but the results are inconsistent due to old software database failures, which Aetna did not address. 16.8% of the claims Aetna surveyed had 3 or more prior claims.This is an illustration that the rehabilitation system as currently practiced is a failure: injured workers are not being reintegrated into the workforce but only sent through a revolving door of workers' compensation.

3. Poor judgement is routinely exercised by Board adjudicators. Aetna disagreed with over 50% of WCB adjudicator decisions involving the "benefit of the doubt". Unfortunately, Aetna fails to comment for the reasons of this debacle: Board management

terminated or promoted its most experienced adjudicators over the past 3 years.

4. Decisions are made on the basis of illegible medical reports.

5. Offers by employers of return to work opportunities are ignored by adjudicators.

6. There are no reviews of medical fitness while workers are engaged in vocational rehabilitation activities.

7. Workers were not sent regularly or expeditiously for independent medical reviews. If Aetna had looked a little bit more closely at the claims they would also have noticed spotty medical treatment.


Functional Abilities Evaluation:
Your Need to Know

by Tammy DeSousa and Richard Fink

As noted in the preceding article of this newsletter, "early return to work" is the primary strategy employed by the WSIB to economize on the costs of workers' compensation. The plain fact is that you can't find modified work for your employee if you don't know what's wrong with him, and what he/she can or can not do.

The new Workplace Safety and Insurance Act addresses this issue in several places. In Section 35, the Board can order the worker to attend a health exam before it's own doctors.


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