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Identifying
Workers’ Compensation Fraud
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Fraudulent
worker’s compensation insurance claims cost businesses in lost time and
increased insurance premiums. Insurance companies pay millions of dollars
each year to healthy workers and their unethical lawyers and medical
providers. These workers, lawyers and medical care providers are all breaking the law,
yet are seldom found out and prosecuted.
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Workers
may attribute a non-work related injury to their job because they have no
health insurance. Workers commonly exaggerate legitimate injuries to
collect disability benefits instead of working. There are some who
malinger refusing to follow recommend treatment and delaying recovery.
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Some
workers with no injuries file claims with the assistance of corrupt
attorneys and physicians who treat them. Regardless of the reasons,
motivations or levels of willful participations all are perpetrating workers’ compensation insurance fraud.
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Injuries
at the workplace generally occur  in the presence of other
workers. Some
injured workers will report an "incident" when it happens and others
will attempt to "tough it out" and notice may be withheld for a
few days. The legitimately injured worker’s account of the injury will
be fairly consistent with witnesses and not tend to change over time.
Additional injuries may become apparent as time progresses and this is not
unusual.
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Any
one fact in any category can be an indicator of fraud, yet proves nothing
unless combined with other factors. Two or three "hits" in the list below in different
categories are pointing toward fraud, yet can legitimately be justified in
many instances. If you have a predominance of "hits" your job is
to investigate and learn the truth.
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"Hit
List" of Fraud Indicators
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Accounts
of injury accident are inconsistent
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worker’s
account of incident changes as it is retold |
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worker
may claim to have initially "forgotten" to report an
important mechanism of injury |
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worker’s
initial account differs from physician’s First Report of Injury |
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Un-witnessed
injuries
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lack
of physical evidence to support claims |
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alleged
injuries appear to be physically impossible |
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mechanism
of injury is inconsistent with alleged injuries |
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more
suspect
if incident reported after days off |
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Injuries
or pain is inconsistent with account and/or physician evaluation
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| worker dramatizes physical condition |
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constantly
draws attention to collars, braces or other supportive devices |
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worker
is seen away from work without appliances |
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worker
"forgets" injury and moves normally at times |
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worker
does not "appear" to be injured |
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Reticence
to accept treatment
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worker
complains of pain and/or disability yet doesn’t follow treatment
plan |
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misses
regular doctor appointments |
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fails
to make or keep appointments for diagnostic or expert examinations |
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Indiscretions
around diagnostic tests
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workers
repeated failure to make or keep appointments |
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consistent
failure to submit to tests may indicate a feigned or exaggerated
injury |
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numerous
diagnostic tests or those inconsistent with the alleged injury may
indicate an unethical physician attempting to inflate the billing |
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Timeliness
of incident and report of injury
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Monday
morning or Friday evening claims are common with fraudulent injuries
as weekend or off job injuries can be attributed to the workplace |
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claims
filed more than a few days after the alleged injury |
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claim
occurs in conjunction with layoffs or announcements of changes |
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claims
occurring after termination |
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History
of
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multiple
prior claims |
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many
job changes |
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numerous
changes of physician and/or attorney |
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frequent
address or phone changes |
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inability
to contact claimant at home although disabled |
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several
workers with same attorney or doctor |
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As
your investigation progresses you will want to determine the degree of
legitimate injury for which the employer or insurance company will be liable. As a
final step you may want to determine whether the claimant is acting alone
or in a conspiracy with others. Those are other articles for other days.
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Here’s
hoping this one gives you an understanding, at least, of workers’ comp fraud and
gets you off to a good start. |
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Diane
Evans, CPI
Academy
Investigations
PI
#13850
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| ©
2001 ISS Network |
California PI Connection
