A common question I’ve been receiving lately is how to establish jurisdiction in cases of healthcare or workers’ compensation medical provider fraud, and how to determine the appropriate office for referral. This inquiry isn’t just coming from companies in California; it’s being raised by people nationwide. Here’s a straightforward explanation: to identify the proper jurisdiction for a fraud referral, you need to pinpoint where the alleged fraudulent conduct took place.
In insurance fraud cases, the core issue usually revolves around the submission of a false claim. Therefore, it’s essential to establish where the deceptive act occurred. For instance, if a fraudulent claim was submitted to your office in Orange County, you can confidently argue that jurisdiction lies with the prosecuting office there. Similarly, if a false claim was filed as a lien with the Workers’ Compensation Appeals Board in Orange County and the perpetrator attempted to collect on it, then Orange County would also hold jurisdiction for those claims.
Conversely, if you’re uncertain about the origin of a fraudulent bill due to it being submitted through an app or an electronic billing system, which makes it possible for it to have been created anywhere, the next step is to identify where the medical provider is treating the patients associated with those fraudulent charges. The mystery deepens when the individual submitting the bill is a provider of durable medical equipment or a pharmacist who simply ships their products to the patient without ever having direct interaction. This adds another layer of difficulty in pinpointing jurisdiction.
Determining jurisdiction is becoming increasingly challenging, particularly as fraudulent claims are increasingly submitted through apps. To streamline this process, I recommend that businesses and insurance carriers take a proactive approach by adding a field in the claims application program that asks for the city and state where the individual submitting the claim is located at the time of the submission. This simple addition could greatly assist in clarifying jurisdictional issues and facilitate a more efficient response to potential fraud cases.
