EOB: Useful for WC Fraud Detection?

Almost exactly one year ago an article featured in the LA times laments the death of a bill targeted to improve Workers’ Compensation insurance claim fraud detection by requiring California insurers to issue Explanation of Benefit (EOB) forms to injured workers who receive medical treatment.  The forms have long been used by health payers to inform patients of the treatment they received and what was billed to the insurer (as well as what is covered and not covered by the insurance plan).  While the EOBs seem like a good idea – consumers can spot a false medical claim submitted by a provider for a service never rendered, for example – there is little evidence to suggest that this actually occurs.  The effectiveness of the EOB as a fraud deterrent is questionable as it relies on the consumer to play an active roll in thwarting fraud – a role they may not realize is expected of them.  Of course, requiring such forms in Workers’ Compensation will introduce significant cost to insurers…a hard requirement to justify without concrete or even annecdotal evidence of effectiveness.  At the time, the Coalition Against Insurance Fraud suggested that the issue required more research.  And their statistics suggest that nearly 70% of the EOB forms used today in healthcare merely confuse patients.  But the Coalition indicates that the EOB idea may be gaining traction now, perhaps due to the renewed focus on fraud, waste and abuse in the healthcare system overall.  What are your thoughts?  Are EOB’s useful for detecting fraud?


One Response to EOB: Useful for WC Fraud Detection?

  1. Geoff Hayden says:

    James, The use of EOB’s in Worker’s Comp would be a step in the right direction. The EOB is used on other lines of business with fraud language. It would be a deterrent to a degree and it would generate calls from injured worker’s who do review the EOB if they have some knowledge of medical procedures.

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