Breaking it all down - Investigating & Prosecuting Fraud Syndicates in CA Workers Comp

Investigating & Prosecuting Fraud Syndicates, Fraud Rings in CA Workers' Comp is ridiculously challenging so the trick is to listen to those with battle scars. Step 1, breaking everything down to its simplest form. Materiality. Suspect's representation of facts. Statutory Definitions. Theories of Liability. Effective translation of case facts. Recently retired Kern County Prosecutor Kate Zimmermann walks us through what it takes to take on these cases and present them to juries for successful prosecution. She's a regular contributor to Fraudcraft, the podcast where subject matter experts take you on a ride inside the fraud world of commercial insurance & CA Workers Comp so that we decrease the victim count in this space and help fraud fighters learn from the best. Come join our community. Subscribe to the podcast (it's free), watch the videos all the way through, like the videos and add your comments so we can engage with each other.
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Transcript

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SPEAKER_00 0:00

Right. I call it the materiality black hole. Anybody who's done investigations has probably taken a case in and somebody says, Well, how is this material? Well, it matters because the statutes tell you it matters. If the system says you have to meet certain criteria to collect out of the system, anything you say in an attempt to demonstrate that you've met those definitions is the representation. As soon as you come up with that you knew that wasn't the truth, congratulations, winner, winner, chicken dinner. Like I said, it's I'm a slow learner. It took a while to get to that point. But once you look at it from that perspective and you say, I have to do the heavy lifting to some degree, I have to understand what are my authorizing statutes, and then start playing with what are the definitions, it's very quick to see where your fraud syndicates have said, this is the word I'm going to exploit, whether it be I don't actually have an employee, whether it's it's not medical care, reasonably calculated to cure or relieve the effect of the industrial injury. And then from there, you you just distill it down, distill it down. And yes, you're charging something out of the labor code or the penal code, but you can't do it in a vacuum. You have to understand the system that you're attempting to regulate to then point to the dysfunction to say, here's that material misrepresentation that applies to the penal code.

SPEAKER_01 1:21

Right.

SPEAKER_00 1:22

I know I just threw a whole bunch at you right there, didn't I?

SPEAKER_01 1:25

I love that you did that because we're talking to the Kate today about the Kate several years ago when Kate would have never known that several years, you know, when I started, there was no way I knew that.

SPEAKER_00 1:36

It was more, oh my God, look at all these things they're doing. Oh my God, they're committing fraud. Okay, but how are they committing the fraud? And if you say that everything that they're doing is set up simply to make it look like the representations are truthful to meet those statutory definitions, it suddenly becomes very, very, I won't say easy, but easier to pick out what are going to be your quality theories of liability, what are going to be the things that you're able to prove beyond a reasonable doubt. Because at the end of the day, if you think about prosecutors, we really are translators. I know you've been talking a lot about interpreters lately, but to some degree, that's what a prosecutor is is you're you're taking people who speak one language and you're breaking it down into a language that your jury can understand what's being said. And your job is to put on the evidence in a way that makes sure that the people in the jury box are hearing what the people who have the knowledge know. And if you can't do that, you're gonna have a really hard time. So, you know, one of the questions I used to get was, well, you know, do juries get it? Not only do they get it, they lap it up like candy. I mean, they're they're they're shocked and horrified to truly realize how much fraud is in the system. They're shocked, they're they're they're horrified to see what this does to the people that get caught in the system.