Athens Administrators believes in a claims advocacy approach for our employers and their  injured workers.  This model establishes early contact and rapport with injured workers to ensure the best possible outcomes for their recovery as well as return to work.   We believe this approach ensures a positive employee experience while working to meet our employers’ financial objectives.

Even with this approach by Athens Administrators, we do sometimes discover fraud during the administration of a workers’ compensation claim. The California Department of Insurance reports that workers’ compensation fraud costs the United States about $30 billion annually, and it costs California an estimated $1 billion to $3 billion annually.

  • Athens Administrators takes a very proactive stance when it comes to potential fraud. Athens and its SIU (Special Investigative Unit) partners use a collaborative approach to stop fraud and prosecute criminal acts.  This partnership ensures that industry compliant training is available to our claims staff throughout the year, and it makes us aware of new investigative options and innovations for our client partners.  But we realize the trainings and products do not mean much without real results: In the last 5 years, Athens sent 359 SIU referrals for investigation of potential workers’ compensation fraud, which is approximately 5 referrals per month
  • During that same period, we obtained 25 criminal convictions which is approximately a 7.0% conviction rate for the SIU referrals sent
  • We have obtained $1,031,433.00 in restitution for our clients
  • Athens Administrators has 6 claims with criminal charges filed that are pending a final conviction.
  • There are currently 18 additional claim files still under review by local District Attorney or the Department of Insurance for possible criminal charges.

Athens also investigates vendor fraud with our SIU partners.  We are currently participating in vendor fraud investigations with local District Attorney offices as well as the Department of Insurance.  These types of cases span multiple counties and include millions of dollars in fraudulent charges which can result in significant restitution payments to our employer partners.

Athens and our SIU partners will continue to work diligently to ensure any fraud at any level is promptly addressed aa well as criminal charges and restitution pursued immediately.

References

“Workers’ Compensation Fraud Convictions.” CA Department of Insurance, www.insurance.ca.gov/0300-fraud/0100-fraud-division-overview/25-wc-conv/.