California's Workers' Compensation Insurance Rating Bureau (WCIRB) is deeply concerned about potential fraud…but apparently, only fraud committed by providers and injured workers.

The insurer-funded WCIRB's website includes a direct "hotline" on its "Research and Education" page for reporting suspected fraud to the state. Clearly, the WCIRB wants to do its part to rally the public against the scourge of patients and providers bilking insurers.

Yet, nowhere on the WCIRB's website is there a hotline for providers or injured workers to report fraud, potentially illegal behavior, or other abuse by insurers.

Since 2022, daisyBill has submitted formal Audit Complaints to the California Division of Workers' Compensation (CA DWC), reporting 547,476 documented violations of state laws and regulations by insurers and their Third-Party Administrators (TPAs).

In response, the CA DWC has never imposed a single monetary consequence or taken any effective deterrent action that we know of or have seen reported.

There are no hotlines for medical practices; instead, there's a bureaucratic process by which the state can receive reams of evidence of serious wrongdoing, impacting providers and injured workers statewide, and take no substantive action of which we’re aware.

Meanwhile, insurers and their vendors continue to delay and deny medically appropriate care, improperly refuse correct reimbursement to providers, disregard state law and regulations, and (through the WCIRB) convince the state to hike employers' premium rates based on data that don't pass the sniff test.

We have a question on behalf of employers, providers, and injured workers statewide: when faced with insurers' abuse, where's our hotline?

One-Way Fraud Enforcement

The WCIRB's fraud hotline directs reports to the California Department of Insurance (CDI), which Ricardo Lara leads as Insurance Commissioner.

In a twist of irony that would be funny if it weren't so infuriating, Lara himself is currently under investigation by California's Fair Political Practices Commission for potentially using taxpayer funds on luxury travel, including safaris, five-star hotels, and VIP rooftop parties with little discernible connection to his official duties.

Lara's Department of Insurance profile page champions his pledge to "crack down on fraud, which continues to cost consumers and businesses millions of dollars." Let that sink in.

The WCIRB's fraud page outlines "red flags" for potential fraud involving employees, employers, medical providers, and attorneys. Conspicuously absent from this list: insurers and TPAs.

What the WCIRB Won't Mention

One of Merriam-Webster’s definitions of “fraud” is “an act, expression, omission, or concealment calculated to induce another to part with something of value or to surrender a legal right.”

Using this definition, we pose the question: can one reasonably describe any of the following as "fraud"?

• Refusing to reimburse providers for medical services that insurers themselves authorized, and producing inapplicable or demonstrably false justifications for non-payment.
• Systematically violating state laws and regulations with zero penalties, and zero accountability from the regulators tasked with protecting the system.
• Obstructing medically necessary care with pages of irrelevant boilerplate. Insurers bury doctors' treatment requests under dense Utilization Review decisions. These documents, filled with inapplicable guidelines and generic medical jargon, deny injured workers the care their physicians say they need.
• Forcing California employers to pay inflated workers' comp premiums based on data so unreliable that the WCIRB itself disclaims.

If “fraud” fairly describes any of the above, then providers, injured workers, and employers throughout California are victims of fraud by insurers and their vendors daily.

Who's Really Driving Up Costs?

While workers' comp premiums are declining nationwide, California employers face premium increases. The WCIRB would have you believe this is due to the costs of medical care and managing claims, including fighting provider and injured worker fraud.

In reality, California employers are paying more in part because insurers and TPAs systematically violate regulations without penalty, submit data that the WCIRB itself can’t verify, obstruct legitimate care (driving up costs through complications and appeals), and refuse proper reimbursement (forcing providers to waste resources fighting for payment that should never have been withheld).

California employers are less often the victims of scheming workers and doctors, and more often the victims of insurers and industry vendors that operate with impunity while pointing fingers everywhere else.

Meanwhile, the CA DWC is happy to accept mountains of documented evidence of wrongdoing (547,476 violations and counting) before, at least in our experience, filing it under "who cares?"

Providers, injured workers, and employers don't have a hotline or a powerful insurer-funded entity in their corner. We have only a regulatory body that has done virtually nothing about the abuses we've documented.

So we ask again: where's our hotline?

daisyBill shows you when payers improperly deny or reduce reimbursement. Click below to see how.

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