Indicators of Workers’ Compensation Fraud
Most claims are legitimate, but many are inflated or fraudulent. These indicators, or fraud possibility factors, should keep isolate those claims meriting closer scrutiny. No one indicator by itself is necessarily suspicious. Even the presence of several indicators, while suggestive of possible fraud, does not mean that a fraud has definitely been committed. Indicators are “red flags” only, not actual evidence.
The Claimant, Prior Claim History and Current Work Status
· Employee is disgruntled, soon to retire, or facing imminent firing or layoff.
· Employee is involved in seasonal work that is about to end.
· Employee took unexplained or excessive time off prior to claim injury.
· Employee takes more times off than the claimed injury seems to warrant.
· Employee is nomadic and has a history of short term employment.
· Employee is new on the job.
· Employee is experiencing financial difficulties and/or domestic problems prior to the submission of the claim.
· Employee recently purchased private disabilities policies.
· Employee changes physician when a release for work has been issued.
· Employee has a history of reporting subjective injuries.
· Review of the rehab report describes the employee as big muscular, well tanned, with callused hands and grease under the fingernails.
· First notification of injury or claim made after employee is terminated or laid off.
· Disputes the average weekly wage due to additional income (i.e. cash, per diem and/or 1099 income)
· Has several other family members also receiving workers’ compensation benefits or other “social insurance” benefits, i.e. unemployment.
· Demands quick settlement decisions or commitments.
· Demands quick payments for medical providers, etc.
· Is unusually familiar with workers’ compensation claim handling procedures and laws.
· Is consistently uncooperative.
· Surveillance or “tip indicates that the totally disabled worker is currently employed elsewhere.
· Employee has submitted material misrepresentation on the employment application.
· Employee comes to office for delivery of benefit checks, avoids use of U.S. mail.
· Employee refuses to allow visits or rehabilitation at home or specifies plenty of warning time prior to a visit.
· Employee participates in contact sports or physically demanding hobbies.
· After injury, employee is never home or spouse/relative answering phone states the employee “just stepped out,” or may have to contact him/her by pager.
· Return calls to residence have strange or unexpected background noises which indicates it may not be a residence.
· Employee protests about returning to work and never seems to improve.
· Employee cancels or fails to keep appointment, or refuses a diagnostic procedure to confirm an injury.
· Employee complains to carrier’s CEO or executive management at home office to press for payment.
· Social Security number provided does not belong to employee.
Medical Treatment
· Diagnosis is inconsistent with treatment.
· Physician is known for handling suspect claims.
· Treatment for extensive injuries is protracted though the accident was minor.
· “Boilerplate” medical reports are incidental to other reports from the same doctor, do not identify by gender or get gender wrong.
· Workers’ compensation insurer and health carrier are billed simultaneously; payment is accepted from both.
· Summary medical bills submitted without dates or descriptions of office visits.
· Medical bills are submitted as photocopies of originals.
· Extensive or unnecessary treatment for minor, subjective injuries.
· Treatment directed to a separate facility in which the referring physician has a financial interest (especially if this is not disclosed in advance).
· Referral for treatment/testing to facility close to referring facility.
· Injuries are all subjective, i.e. pain, headaches, nausea, inability to sleep.
· Treatment dates appear on holidays or other days that facilities would ordinarily not be open.
· Employee is immediately referred for a variety of psychiatric tests, when the original claim involved trauma only. These claims usually present with vague complaints of “stress”.
· Inappropriate expensive medical equipment prescribed for minor injury.
· Alleged injury relates to a pre-existing injury or health problem.
The Claims Pages. (2004-05). Indicators of Workers’ Compensation Fraud. pp. 73-74.
2004 Nationwide Publishing Company, Incorporated
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