Workers’ compensation is a no-fault insurance system designed to provide benefits to employees who are injured or become ill due to their job duties. Under this system, employers or their insurance carriers are responsible for medical care and wage replacement—regardless of who was at fault.
Unfortunately, this system can be exploited. One persistent concern is medical provider fraud, which increases claim costs, delays recovery, and puts financial pressure on employers through higher premiums.
The Role of ICW Group
ICW Group’s Special Investigations Unit (SIU) steps in when fraud is suspected. If an investigation supports the belief that fraud has occurred, the SIU refers the case to regulatory agencies and/or law enforcement for potential prosecution.
Medical fraud can take many forms:
- Billing for services not rendered
- Recommending unnecessary treatment
- Double-billing or inflating charges
- Issuing biased reports in exchange for attorney referrals
This kind of fraud compromises care for injured workers, can delay return to work, and significantly increases claim costs.
National Spotlight on Medical Fraud
The scale of this issue was highlighted during the recent 2025 National Health Care Fraud Takedown. This was the largest in U.S. history, with 324 individuals charged and over $14.6 billion in fraudulent activity uncovered. The crackdown reflects the broad collaboration—from insurance carriers and SIUs to federal agencies—aimed at stopping this type of abuse.
How Employers Can Help Prevent Fraud
Employers play a crucial role in stopping medical fraud before it starts. Here’s how:
- Establish Strong Reporting Procedures
- Require prompt injury reporting, seek statements from all with knowledge of the event, and timely medical evaluations. A structured process deters fraud and protects against inflated or false claims.
- Hire Thoughtfully
- A thorough hiring process helps create a culture of accountability and reduces risk from the start.
- Leverage Data and Investigations
- ICW Group’s investigative team monitors provider credentials, licensure, and treatment patterns using advanced analytics and industry-wide databases.
- Use the Medical Provider Network (MPN)
- Referring Injured Workers to trusted providers within the MPN helps ensure high-quality, evidence-based care—and avoids over-treatment or inflated billing.
- Educate Supervisors
- Ensure your frontline managers understand how to document injuries properly and recognize red flags.
A Shared Responsibility
Medical provider fraud remains a persistent impediment to an optimal workers’ compensation system. Recent federal actions show that consequences for fraud are severe—and that a collaborative effort between employers, insurers, and government is key to making progress.
At ICW Group, all claims are reviewed within 24 hours of claim creation. All questionable claims are investigated and assign twice the number of claims for investigative support versus the industry average. Our in-house SIU team is dedicated to fraud prevention, and we continue to partner with our customers to detect, deter, and defeat workers’ compensation insurance fraud.
Current ICW Group policyholders are encouraged to visit the Policyholder-Perks section of our website for additional resources to help protect your business.
