Employers, employees, insurance carriers, and Texas consumers pay the cost of fraud in lost jobs and profit, lower wages and benefits, and higher costs for services and premiums. The Texas Workers' Compensation Commission's Office of Investigations works with numerous special investigation units to deter fraud by assisting in the prosecution of those who commit fraud. These units include state and federal law enforcement, other regulatory agencies, and insurance carrier special investigation units.
Investigations often lead to prosecution and recovery of money gained through fraudulent schemes.
Fraud can be committed by employers, employees, health care providers, attorneys, insurance agents, and others. F raud occurs when a person knowingly or intentionally conceals, misrepresents, and makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit. The key to conviction is proving in court that the misrepresentation or concealment occurred knowingly or intentionally. Premium fraud and benefit fraud are the most common types of workers' compensation fraud. Premium fraud is usually committed by an employer who misrepresents the amount of payroll or classification of employees, or who attempts to avoid a higher insurance risk modifier by transferring employees to a new business entity rated as a lower risk category.