Top Signs that Help Employers Detect Workers’ Compensation Fraud

by | Published on Jun 26, 2019 | Medical Record Review

Workers’ compensation provides wage reimbursement to employees who have suffered a work-related injury or illness. These benefits are usually paid in the form of lost wages, compensation for economic loss, reimbursement of medical expenses as well as benefits paid to dependents of workers killed on the job. Lawyers evaluate workers’ compensation cases with medical record analysis and reviews to determine whether the claim has legal validity.

This insurance coverage is for employees who are unable to work due to an injury/illness that occurred at the workplace. But a major concern the employer may have is whether the worker’s injury is real or fake? Though most employees are honest, a small percentage may commit fraud and contribute to increased workers’ compensation costs. The National Insurance Crime Bureau (NICB) has reported that workers’ compensation fraud costs American employers, workers, consumers and shareholders around $7.2 billion each year.

Employers should be aware of the ways to spot the key signs to successfully fight Workers’ Compensation fraud.

Certain types of fraud workers indulge in include the following:

  • reporting an injury that never happened
  • exaggerating injuries that happened
  • filing claims for injuries even when off the job or non-occupational injuries
  • collecting benefits for a job-related injury, while working in another office

Such frauds happen when the worker is supported by dishonest physicians and lawyers. Healthcare providers in such cases may submit a claim for treatment the worker never received. They may also blow up the cost of the treatment and provide unnecessary treatment to the worker. Such practitioners may also join forces with fraudulent attorneys to win these fraud cases and get millions of dollars.

All such fraud claims may lead to higher insurance premiums for employers, and hurt business operations. It also affects those who are legitimately injured on the job. Employers may have to pay other workers to get the job done and all these extra costs could affect the productivity of the organization.

Detect fraud with these signs

Workers’ compensation fraud can often be difficult to identify due to its nature of covering injury and illness. Make sure to launch an investigation, if you observe these suspicious signs in your employee’s workers’ compensation claim –

  • There are no witnesses to the incident.
  • The injury occurred during a weekend or on a Monday.
  • There was delay in reporting the injury – such as it took months.
  • The employee’s own description does not reasonably support the cause of the injury.
  • The description does not match the medical history or injury report.
  • The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.
  • The claimant has a history of filing such fraud claims.
  • The claim arises at the same time when the employee changes positions or is terminated.
  • The worker’s medical providers or legal consultants have a history of handling suspicious claims for many claimants.
  • There is an unusual coincidence between the claimant’s alleged date of injury and his/her need for personal time off.

To prevent workers compensation fraud

If you suspect worker’s compensation fraud, make sure you gather all the current and prior medical records of the claimant and compare them against the accident report and continue to monitor them throughout the treatment.  The claim adjuster should be notified and ensure that your carrier does not pay any of the costs. Here are some tips to prevent such false claims.

  • Screen all new job applicants – perform workers’ compensation background checks and criminal record checks before hiring
  • Sponsor safety programs -this makes workers aware of how to remain safe at work and how to report any workplace injuries in the right way
  • Educate to prevent fraud – teach the employees about workers’ compensation and explain the consequences of fraudulent claims, which can assist in reducing fraud claims
  • Train supervisors – A manager or immediate supervisor should be trained well on the ways to handle injuries
  • Detect fraud – plan innovative ways to detect fraud such as monitoring claimants’ activities, watching CCTV footages for any evidence of injury and so on
  • Listen to employees – if they are concerned about any working conditions, act to correct the situation
  • Contact injured employees – frequently communicate with injured employees because this makes them feel valued, which encourages them to return to work early
  • Document all injuries – also interview injured employees and witnesses for more details of the accident and get written statements

Employers can also consider establishing a fraud-reporting process, which makes it easier for employees and their supervisors to report any suspected fraud. Many businesses also pursue criminal cases against fraudsters. Experienced and reliable attorneys consider medical chart review and other formalities to ensure that the compensation is distributed only to deserving applicants.

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