Fighting Workers Compensation Fraud
The detection and prevention of workers compensation fraud is a major priority for every insurance company. And because the price of insurance coverage takes into account all claims, it should also be a primary concern for business owners.
Most workers compensation claims are legitimate. Unfortunately, there are some that are inflated or fraudulent. The following are Red Flags that may be evidence of a false claim. One indicator alone may not make the claim fraudulent, however, if multiple indicators are present, the chance of a claim being fraudulent increases.
If you suspect that fraudulent activities are occurring, call our Fraud Hotline at 1-800-932-3969.
Red Flags
Here are some key points to look for when attempting to identify symptoms of fraud:
Timing
- The alleged injury reportedly occurs either late Friday or early Monday morning
Current Employment Status
The alleged incident occurs just prior to:
- a strike, job termination, or layoff
- completion of a project
- a disciplinary action or suspension
- a plant shutdown
- the end of seasonal work
- retirement
Incident Description
- Incident is not promptly reported to supervisor
- Employers first report and medical history present conflicting descriptions of:
- the incident
- its location
- the actual occurrence - There are no witnesses to the incident
- Incident is not consistent with the type expected for their normal job (i.e., office worker injuries back loading boxes on dock)
Work History
- New to the job
- A transient with history of short-term employment, or self-employment with "odd jobs," perhaps only for cash
- Misrepresents employment history and status
- Excessive tardiness and/or absenteeism
- History of reporting subjective injuries or malingering
- Experiencing financial difficulties; limited availability/poor attitude
- Disabled, but never home when called. Claimant said to be "on the phone" or "sleeping" and cannot be disturbed
- Repeatedly disagrees with physician's diagnosis
- Changes physicians for no apparent reason
- Uses physicians known to be involved with suspect claims
- Defensive, argumentative, angry
- Receives mail at post office box and won't return requests for information
- Makes calls from a pay phone; no known residence phone number
- Moves residence out of state or country
- Excessive demand for compensation
- fRecently purchased private disability policies
- Refuses to work, but "surveillance" or "tip" indicates they are working elsewhere or participating in recreational activities inconsistent with injury or limitations
Medical
- Repeatedly avoids availability for transitional duty assignments
- Diagnosis is inconsistent with treatment
- Workers Compensation insurance company and health carrier billed simultaneously
- Submitted bills are photocopies of summaries with no dates or descriptions
- Employee cancels or fails to keep appointments
- Extensive treatment for minor, subjective complaints
- No present physical basis for disability. All indications are that claimant has made a full recovery
- Appears to be taking more time away from work and treatable plan prescribes
It is important to remember that these indicators are not proof of fraud. They are Red Flags that may signal a need for further investigation. Our team of claims specialists will work with you by thoroughly investigating potential fraudulent activities.
If you have suspicions, call our insurance services office nearest you or our Fraud Hotline at 1-800-932-3969.
