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In Pennsylvania, almost every employer is required to carry Workers' Compensation (WC) Insurance for their employers. WC is a type of small business insurance that covers employees for work-related injuries. A typical Workers Comp policy pays lost wages and medical expenses incurred due to a work-related accident while also protecting the employer against accident-related lawsuits. According to Forbes, the average cost per $100 in payroll in 2020 was $1.19.

Most businesses need this crucial insurance to obey the law and to help protect their business and employees. While most employees are honest and most Workers' Comp claims are legitimate, Workers' Compensation insurance fraud does occur, increasing the cost of WC premiums.

What is Workers' Comp Fraud?

Experts estimate that WC insurance fraud costs companies $5 to $7 billion annually, representing 1-2% of all WC benefits paid. Fraud can be perpetrated by the employer, the insurance company, or the employee, and it can be claim or premium-related. According to a 2024 Marketdata report, claim-related fraud accounts for about 80% of the cases, and about 82% of claim and premium-related fraud is perpetrated by employees.

Employee claim-related fraud occurs when an employee provides false information on a claim, such as filing a claim for an injury that didn't happen, filing a claim for an injury or illness that is not work-related, exaggerating the severity of the injury, misrepresenting their ability to work, or filing a claim for an old injury that didn't heal.

One way to minimize the risk of Workers' Compensation fraud and lower Workers' Compensation costs is to investigate every workplace accident.

What is an Accident Investigation?

When a workplace accident occurs, it's in the employer's best interest to investigate the accident. Investigations provide many benefits, including identifying hazards and shortcomings in a business's safety and health programs, uncovering fraudulent claims, and lowering Workers' Compensation Insurance costs.

The PA DLI defines an accident (incident) Investigation as "An organized process using written procedures that are applied every time an accident occurs regardless of its severity."

 

Surveillance may be a part of any WC claim investigation, but it can be expensive and time-consuming. Social media is a cost-effective surveillance tool that investigators can use to help verify the legitimacy of a claim.

How Can Social Media Assist in Workers' Comp Claim Investigations?

"Social media is a part of everyday life for most internet users in the United States and is frequently used for socializing, business, and dating," Statista reports. "As of 2022, the United States had the third-largest social media audience worldwide, after China and India. The United States is home to over 302 million social media users at a social networking penetration rate of over 91 percent."

Facebook is the most popular social media platform, followed by YouTube, Instagram, and TikTok. People of all generations frequently share information, photos, videos, and more on social media platforms.

Many people falsely believe that their social media accounts are private and that no one can see them. However, Aura reports, "In some cases, posts you share privately with friends or in private groups can be shared publicly without your permission. And if your friends don't follow the same stringent social media privacy settings that you do, this information could be accessed by anyone—even scammers and employers." Furthermore, everything posted on social media leaves a "paper trail." Social media is considered a public record in every state.

This makes social media a helpful tool when investigating WC claims. Investigators can gather information for free while in the comfort of their office. By searching the claimant's social media, investigators may find background information, monitor post-injury activities, discover information confirming or contradicting statements in the WC claim, and find evidence that the worker is lying about a disability or physical limitation.

While social media is a great tool, investigators should ensure they are using the tool ethically and that the information they are gathering is admissible.

Lower Your Workers' Compensation Insurance Costs

At American Insuring Group, Ltd., we offer cost-effective Workers' Compensation Insurance from multiple competing insurance companies. It's our mission to get you the best price on quality insurance to protect your employees and your business!

Call us today at (800) 947-1270 or (610) 775-3848, or connect with us online.

When a workplace accident occurs, it’s in the employer's best interest to investigate the accident. Investigations provide many benefits, including lower Workers’ Compensation Insurance costs.

What is Pennsylvania Workers’ Compensation Insurance?

“Workers’ Compensation (WC) is mandatory, employer-financed, no-fault insurance which ensures that employees disabled due to a work-related injury or disease will be compensated for lost wages and provides necessary medical treatment to return them to the workforce,” the PA Department of Labor & Industry (DLI) explains.

If an employer does not have WC Insurance and an employee files a WC claim, the employer will be required to reimburse the Uninsured Employers Guaranty Fund in relation to the claim, including costs, interests, penalties, attorney fees, and fees under section 440 of the Worker’s Compensation Act. Failure to carry WC coverage can also result in “grave civil and criminal risks.”

What is an Accident Investigation?”

The PA DLI defines an accident (incident) Investigation as “An organized process using written procedures that are applied every time an accident occurs regardless of its severity.” According to the PA DLI, “The purpose of the accident investigation is to determine the direct cause of the incident and to prevent similar occurrences by documenting facts, providing cost data, and reinforcing the joint labor-management commitment to safety in the workplace. Identifying the causal or contributing factors in a workplace accident provides the opportunity for these facts to be evaluated in order that corrective actions may be taken.”

Benefits of an Accident Investigation

Yes, an accident investigation will take time and resources, but the benefits it provides far outweigh the costs. And remember, the sole purpose of the investigation is not to lay blame but to determine the root cause of the accident.

Here are some benefits of an accident investigation:

• Detects and prevents any violations or misconduct, including WC fraud
• Ensures compliance with applicable laws and regulations
• Helps identify hazards and shortcomings in a business’s safety and health programs and allows for corrective measures to avoid future accidents.
• If an insurance company questions a Workers’ Compensation Insurance claim, they will launch an investigation. A thorough accident investigation performed immediately following the accident can help expedite the insurance company’s investigation and get the claim closed more quickly, which is in everyone’s best interest.

Accident Investigation Procedures

“The amount of action will depend on the severity of the accident. Follow established company procedure. Begin your investigation as soon as possible,” according to the PA DLI.

Experts recommend the following steps immediately after a workplace accident:

1. Provide Medical Care – Address minor injuries with a first aid kit. For more serious accidents, call 911 immediately.
   
   
2. Secure the Scene – Keep the scene as intact as possible to ensure an accurate investigation.
   
   
3. Collect Evidence – Collect physical evidence, record or photograph the scene, study conditions and environment, and take notes.
   
   
4. Interview Involved Parties – Interview the injured employee and any witnesses. Ask questions such as, what did you witness? Do you know the cause of the accident? Who else witnessed the accident? Is any PPE required for this task, and was the employee wearing it?”
   
   
5. Identify the Root Cause – Remember that an accident may have multiple causes.
   
   
6. Prepare an Investigation Report to communicate the findings to management.
   
   
7. Implement a Corrective and Preventive Action (CAPA) Plan to prevent future accidents. The plan should include corrective and preventative actions
   
   
8. Follow Up to ensure the CAPA Plan is being implemented.

Lower Your Workers’ Compensation Insurance Costs

At American Insuring Group, Ltd., we offer cost-effective Workers’ Compensation Insurance from multiple competing insurance companies. It's our mission to get you the best price on quality insurance to protect your employees and your business!

Call us today at (800) 947-1270 or (610) 775-3848, or connect with us online.

One way to lower Workers’ Compensation (WC) Insurance is to close claims quickly. Unfortunately, some claims seem to take on a life of their own, and what starts out as a small medical claim morphs into a lost time claim. Proactively and carefully managing WC claims is key to minimizing the risk of that happening and affecting your bottom line (higher WC costs, lower productivity, unnecessary use of resources, lower employee morale, and lost time). The first step is to recognize what causes small claims to morph into big ones.

6 Things that Cause Small Workers Comp Claims To Morph Into Big Workers Comp Claims

1. Lack of Communication With Injured Employees

As with any relationship, communication is vital. Unfortunately, many business owners are under the false impression that communicating with injured employees can cause WC claims and increase the cost of those claims. Nothing could be further from the truth. 

An injury can be frightening for an employee. They may worry about their injury, recovery, or how they’ll continue to support their family. They may be in pain or facing unfamiliar medical treatments. Furthermore, WC claims can be complicated. Regular communication helps employees understand your policies related to injuries and return-to-work programs, helps ease their minds, and creates a more collaborative relationship to bring claims to a close quickly.

Furthermore, one study found that “46% [of injured employees] said they hired attorneys because they felt the claim had been denied when, in fact, it had not yet been accepted into the process.” And the truth is that WC cases that involve attorneys often cost more. 

2. Lack of Medical Care

Continuing to work with the injury may cause a minor injury to turn into a more severe injury. But sometimes injured employees are not aware that their medical expenses will be paid in full by WC if the injury occurs in the workplace, or they may be concerned about losing time from work, so they don’t go to a physician.

Furthermore, it may seem easier for the supervisor/manager to make an incident-only record instead of a WC claim when the injury occurs. That can lead to many headaches and cost more down the road, so injured employees must be encouraged to seek medical attention if injured on the job immediately.

3. Lack of Proper Medical Triage

Some bigger businesses and insurers have triage nurses who can evaluate an injured employee and recommend appropriate medical treatment. Many small to medium-sized businesses do not have this luxury and rely on a physician in an emergency room or urgent care.

As an employer, you need to ensure that employees understand your Return-to-Work program and encourage them to describe their regular work duties to the physician who treats them, so the physician can make an informed decision about whether an injured employee can go back to their regular work duties or perhaps lighter duties.

4. Improper Medical Care

Primary care physicians are great at handling routine sickness but may not be the best choice for workplace injuries. However, there are medical care providers who specialize in work-related injuries and realize that many employers offer RTW programs and the benefits of these programs to both employer and employee.

The PA Workers’ Compensation Act allows employers to establish a list of designated healthcare providers and states that injured employees “must seek treatment for the work injury or illness with one of the designated providers for 90 days from the date of the first visit.” Without this list, injured employees can seek medical treatment from any provider. Creating a list of good healthcare providers for your injured employees not only helps you manage healthcare costs and lower WC insurance; it also helps ensure that your injured employees receive the best care possible. 

5. Fraud

Fortunately, most employees are honest and hardworking; however, a few will try to take advantage of the system by committing WC Fraud. Examples of fraud include faking an injury, inflating an injury, and reporting an injury that happened off the job. Employers and medical providers can also engage in fraudulent WC activities. There are steps you can take to recognize and prevent WC fraud.

6. Not Having a Return-to-Work (RTW) Program

We’ve mentioned RTWs several times, so it may be obvious how crucial they are to prevent small claims from morphing into big claims and, of course, lowering WC costs. An RTW program is designed to get injured employees back to work as soon as possible (based on their doctor’s recommendation). That could mean the injured employee returns to modified duties or a temporary position to accommodate any limitations caused by the injury.

Lower Your Workers’ Compensation Costs

Doing what you can to ensure that small WC claims don’t morph into big WC claims is one way to lower your Workers’ Comp costs. Buying the right WC Insurance is another. Our experienced independent agents at American Insuring Group can help you save on the insurance that's right for you.

Call us today at (800) 947-1270 or (610) 775-3848, or connect with us online!

In most states, including Pennsylvania, almost all employers are required to carry Workers’ Compensation (WC) Insurance. WC helps cover lost wages, health care expenses, disability payments, death benefits, and permanent injury payments (such as the loss of a body part) when an employee suffers a work-related injury or disease. It also helps protect your business against lawsuits related to the injury. 

How is Your WC Premium Calculated?

Your Workers’ Compensation premium is based on the following calculation:

          WC Premium = Classification Code Rate X Experience Modifier X payroll/$100.

Your experience modifier compares the history of your losses to what is typically expected in a class similar to your company. It is based on the following:

• Number of Claims
• Cost of Claims
• Frequency of Claims
• Severity of Claims
• Closed vs. Open Claims
• Claims History of other businesses in your industry
• Years in business
• Number of employees
• State minimums

 The lower your experience modifier, the lower your premiums. Unfortunately, WC fraud, waste, and abuse can raise your experience modifier and increase your WC premiums. In fact, the Insurance Information Institute reports, “workers’ compensation insurance fraud alone costs insurers and employers $30 billion a year.”

 What is WC Fraud, Waste, and Abuse?

The first step to minimizing WC fraud, waste, and abuse is the ability to recognize each.

• Fraud – According to the PA Department of Labor & Industry, “An employee commits fraud by knowingly and intentionally receiving wages while collecting total disability benefits or receiving partial disability benefits in excess of the amount permitted while receiving wages.” Examples include faking an injury, inflating an injury, and reporting an injury that happened off the job. Employers and medical providers can also engage in fraudulent WC activities.
• Waste – WC waste occurs when an injured employee overutilizes WC benefits. An example of WC waste is an employee who injures their back on the job and continues to see a chiropractor after full recovery.
• Abuse – WC abuse occurs when an employee who is injured on the job expands their symptoms to receive additional benefits. For example, an injured employee may falsely report symptoms to prevent them from participating in a return-to-work program.

 Signs of Possible WC Fraud, Waste, and Abuse

There are a few common signs of WC fraud, waste, and abuse that you can watch out for:

• No witnesses to an incident
• Conflicting diagnoses
• Refusing treatment
• Not reporting injury immediately
• Inconsistent or suspicious recount of the injury
• A history of WC claims
• A history of frequently changing physicians, jobs, and addresses
• An injury that occurs right after a weekend, strike, or holiday
• The inability to reach an injured employee
• A post-termination claim
• Pre-existing medical conditions
• Financial problems
• An unwillingness to cooperate in the injury investigation

 11 Tips to Prevent WC Fraud, Waste, and Abuse

Industrial Safety & Hygiene News offers the following tips to “keep claims above board”:

1. Create a fraud-free work environment by having a strong policy against fraud.
2. Establish a culture of safety.
3. Hold regular safety meetings.
4. Institute sound hiring procedures by screening potential employees.
5. Communicate regularly with injured employees.
6. Follow proper WC reporting and investigating procedures.
7. Educate employees on WC fraud, waste, and abuse and their consequences.
8. Make it easy to report injuries
9. Use surveillance equipment
10. Implement a drug testing policy
11. Choose credible medical providers that have WC experience.

 Lower Your Workers Compensation Insurance Premiums:

In addition to preventing WC fraud, waste, and abuse, another way to lower Workers’ Compensation Premiums is to work with one of the experienced independent agents at American Insuring Group. Our independence gives us the freedom to shop the market to find the right insurance to meet your specific needs at the best price.

Call American Insuring Group today at (800) 947-1270 or (610) 775-3848, or connect with us online.

Workers' Compensation (WC) Insurance is mandated by Pennsylvania (and most other states) for all employees. WC was designed to protect employees injured on the job by providing lost wages, medical expenses, disability expenses, and funeral costs. As a no-fault benefit, WC also helps protect your business from direct lawsuits by employees injured on the job. Failure to comply can lead to misdemeanor or felony charges and fines.

However, just because it is mandatory doesn't mean that there aren't steps you can take to lower your WC costs.

10 Tips to Save on Workers' Compensation Insurance Costs

1. Vet Employees – Employees can be your greatest asset or your biggest liability. Every employer hopes they hire an honest worker, but did you know that 95% of businesses encounter problems with employee theft. When hiring a new employee, conduct background investigations and reference checks. Also, if you're hiring a driver, check their driving record. You may also want to include a pre-employment drug testing policy.
   
   
2. Develop a Safety Program - Providing a safe and healthy workplace benefits employers with lower Workers' Compensation Insurance costs, reduced absenteeism, increased productivity, and better employee morale. A workplace safety program can lower expenses, reduce paid time off and litigation, provide higher employee satisfaction and a positive public image, and much more. According to OSHA, a study of small businesses found a statistical correlation between workplace safety and the health and survival of a small business. The study found that companies that failed within one to two years of start-up had an average injury rate of 9.71, while businesses that survived more than five years had an average injury rate of 3.89 in their first year of business.
   
   
3. Provide Appropriate Training - OSHA states, "Training in the safe way for workers to do their jobs well is an investment that will pay back over and over again in fewer injuries and illnesses, better morale, lower insurance premiums and more."
   
   
4. Use the Right Job Classification Code – Every employee in Pennsylvania is assigned a PCRB classification code to help determine WC rates. These codes are based on the level of risk each employee faces. For example, if an office worker is assigned the code for a construction worker, they will be considered more of a risk, and you will pay higher WC premiums for that employee. Ensuring all of your employees are correctly classified can help save you on WC costs.
   
   
5. Work With Your Medical Team – PA Workers' Comp laws allow employers to create a list of designated health care providers. When the list is properly posted, injured workers must seek treatment for the work injury or illness with one of the designated providers for 90 days from the date of the first visit. By carefully researching the physicians you include on that list, you can help ensure your employees get the best treatment and that you don't pay more than you have to for WC premiums. In addition, building a relationship with those physicians can further expedite WC claims.
   
   
6. Develop a Return-to-Work Program - The longer an injured employee is out of work, the less likely they'll return to work and the more it costs the employer. Return-to-work programs reduce the length of claims and help injured employees recover more quickly. Return-to-work programs save employers' medical costs, lost time days, and workers' compensation insurance costs.
   
   
7. Design an Injury Response Protocol – If an employee is injured, the quicker they get treatment, the better chance they have of making a speedy recovery. Therefore, you should have an injury response protocol in place that employees understand.
   
   
8. Manage Claims – Properly managing WC claims helps you avoid liability and fraudulent claims, resolve claims more quickly, and lower WC costs. WC claim management includes an injury reporting process, investigations, ongoing communication, etc.
   
   
9. Investigate Injuries - Every workers' compensation insurance claim should be investigated because it's imperative to make accurate and legal assessments related to primary liability.
   
   
10. Review Your Loss Run Report – A Loss Run Report lists the date of all of your business's losses and claims, a brief description of each claim, the amount paid to the insured, and whether or not the claim is closed. You can think of it as a credit report or report card for insurance companies. They use the information in the report to determine how risky a business is to insure, which can affect the premium you pay for insurance or even if an insurance company will issue a policy or renew a policy for your business. Conversely, you can use the information to lower your insurance costs and improve other business areas.

BONUS Workers' Comp Savings Tip

Work With a Trusted Independent Insurance Agent – The independent agents at American Insuring Group specialize in Workers' Compensation Insurance. We can answer all of your WC questions, help you control loss, and lower your premiums!

Give us a call at (800) 947-1270 or (610) 775-3848, or connect with us online.

You’ve purchased the appropriate Workers’ Compensation (WC) Insurance, as required by Pennsylvania law. That’s a significant first step to protecting your employees and your business, but there’s more to a healthy WC program, including the prompt reporting of injuries and claims.

We understand that you have a lot on your plate and may wear many hats, but not reporting a claim promptly can have a negative impact on your WC program, your business, your injured employee, and your worker's comp insurance costs.

5 Reasons Prompt Reporting of Workplace Injuries and WC Claims is Crucial to Your Business

Preserve Evidence

When an injury occurs, it’s essential that the injury is investigated as quickly as possible, or you could risk losing crucial evidence. Therefore, as soon as an injury occurs, someone should document details of the injury, investigate to try to determine how the injury occurred, interview the employee and any witnesses, and of course, ensure that the injured employee receives appropriate medical attention.

Lower Cost of Claims

The National Council on Compensation Insurance (NCCI) found that the median cost of WC insurance claims that were reported between one day and two weeks were “significantly lower,” and the cost rose as the time it took to report a claim rose. The bottom line is that delayed reporting can increase WC claim costs up to 51%.

Better Medical treatment

When an injured employee receives prompt medical treatment from competent, in-network healthcare providers, they are more likely to receive a proper diagnosis and effective treatment to heal faster.

Plus, even seemingly minor injuries can escalate into more significant issues if they are not immediately looked at by a medical professional.

Quicker Return to Work

The sooner you can get an injured employee back to work safely, the better it is for everyone – the injured employee, co-workers, and your business. Having a return to work program can shorten the length of time an injured worker is out of work by an average of 3.6 weeks, according to the RAND Institute for Civil Justice.

Health providers who are familiar with treating workers’ compensation injuries will focus on facilitating an early return to work for the injured employee. The sooner the injury is reported, the sooner that process can begin.

Decrease in Litigation

Promptly reporting an injury and keeping in touch with the injured employee throughout the claim process helps reduce employee’s fears and makes them feel as if their employer cares about them and is treating them fairly. According to NCCI research, this all translates to a lower chance of litigation.

Fraud Prevention

According to the National Insurance Crime Bureau (NICB), “Workers’ compensation claimant fraud and medical fraud are significant contributors to our nation’s annual $30 billion insurance fraud problem.”

Prompt reporting of an injury helps ensure 1) the injured worker receives proper medical treatment, 2) the injured worker feels they’ve been treated fairly, and 3) allows a better investigation of the incident. All this helps minimize fraud.

Quicker Closure

The longer a claim remains open, the more resources you have to use. Promptly reporting an employee injury can get an employee back to work and the claim closed more quickly.

Safer Workplace

When an injury is reported and investigated quickly, you are more likely to recognize safety issues, correct them, and ensure the safety of your employees.

One More Step: Lower Workers Compensation Insurance Costs

If you want to learn more about how to get the lowest cost on WC Insurance and other commercial insurance, give the independent agents at American Insuring Group a call at (800) 947-1270 or (610) 775-3848 or connect with us online. We shop and compare competing insurance carriers to get you the best rates on quality insurance protection. Call today.

Most employers in Pennsylvania are required to carry Workers' Compensation (WC) Insurance to pay medical expenses and lost wages if an employee is injured or develops an illness on the job.

The majority of WC claims are legitimate; however, Workers' Comp fraud is costing businesses billions of dollars every year. WC fraud occurs when employees fake an injury, exaggerate an injury, claim an injury occurred at work when it did not, etc.

If an employer doesn't want to pay more than they have to for WC Insurance, they need to be on the lookout for questionable claims. Here are 4 valuable tips:

Report All Injury Claims

Even if you suspect a claim is not legit, you must report all injury claims to your Workers' Compensation Insurance carrier. Failing to do so could result in hefty penalties.

To do this, complete an injury/illness report. Some employers have their own reporting forms, and others use forms from their WC carrier or state WC agency. You should have every type of workplace accident report form available to avoid legal issues. Fill out the form with the injured employee if possible or deliver the form to the doctor who attended the employee first.

Typical information requested on these forms include (but is not limited to) the following:

• Date of injury
• Where the injury occurred
• A description of the injury or illness
• When the employee became aware of the injury or illness
• The date the injured employee received AND returned the form

Inspect and Document

You can help any WC investigation by gathering information as soon as an injury occurs while the information is fresh in everyone's minds.  That includes surveying the scene of the accident, collecting information (such as talking to witnesses and writing down the details of the accident), and completing an incident report.

Try to determine the leading cause or causes of the accident and answer (in writing) the following questions:

• Were company rules and regulations followed?
• Were there any witnesses?
• Did something unique happen that caused the accident?
• Could the accident have been prevented?
• If it could have been prevented, why wasn't it?
• Is the risk still there?

As soon as possible, take photographs where the accident happened and any potential causes of the accident. Ask the doctor to document the state of the employee's injuries.

If there are witnesses, get the following information from them:

• Their name
• Their address
• Contact information
• A summary of what they saw

Let Your Claim Handler Know if You Believe a Claim is Questionable

The claim handler has experience and training in investigating WC claims – both legitimate and false claims, and they have the authority to deny a claim. However, you know more about your employees, your work environment, and the circumstances of an employee's claim than the claim handler.

If you feel a claim is questionable, you must let your claim handler know so that they can conduct a proper investigation.

Continue Communication

Once a claim is filed, the employer must continue to communicate with the carrier. Immediately forward any relevant information, such as medical documentation. Your claim handler may ask for additional information, such as the number of lost workdays, the RTW status, etc. If you want the claim resolved quickly, respond to claim handlers promptly.

 

How to Immediately Lower Workers' Compensation Insurance Costs:

If you want to lower your WC costs, work with an independent insurance agent like the pros at American Insuring Group. We can offer you lots of choices in WC insurance carriers. We'll make sure you get the right coverage at the right price. Give us a call today at (800) 947-1270 or (610) 775-3848 or connect with us online.

You often hear horror stories about fraudulent workers compensation insurance claims, but fortunately, most employees that make WC claims are honest, hard-working individuals.

Occasionally, you’ll run across an employee who seems to be a repeat WC claim offender. Some are legitimate claims, and some are not, but repeated WC claims can be annoying, time-consuming, and costly.

Here are steps you can take to determine if workers are trying to take advantage of the system, and ways to stop them from making repeated false claims or from incurring repeated injuries:

 

1 - Don’t Antagonize - Give Injured Employees the Benefit of the Doubt

Your first step is to remember that both you and the injured employee are human, and as humans, we all have emotions and make errors. Injured employees need to be treated with respect, or you may inadvertently antagonize the employee and make matters worse, or you may be dealing with a worker with a legitimate claim.

For example, an employee who is willing to do whatever it takes to get a job done may do things that increase their risk of injury. An employee may be naturally clumsy, or they may not be aware of the right way to get a job done safely.

If you encounter an employee who has multiple WC claims, you need to investigate it, so you know what steps to take to reduce the number of claims. It’s vital that you go into the investigation with an open mind. Start the investigation by giving the injured employee the benefit of the doubt until or unless you find a reason not to.

2 - Investigate the Injury

Investigations are essential with any WC claim but especially with an employee with repeated claims. Gather statements from the employee, supervisor, any witnesses, and the treating physician, so you can understand the extent of the injury and how the injury occurred. If you don’t think the treating physician is being honest or is not providing the best information or treatment, it’s okay to get a second opinion.

You also need to figure out the actual cause of the accident. A cause may seem obvious but upon a more in-depth inspection may prove to be a secondary cause – or not the cause at all. Review studies conducted on similar injuries; look at all potential factors; consider other factors such as previous injuries and comorbid conditions such as obesity, mental health issues, substance abuse, etc.; consider the validity of testimonies; and with all that information, make a conclusion.

3 - Talk to the Injured Worker

As mentioned earlier, injured workers are human and have emotions. Like everyone, some of those emotions are logical, and some are not. Having an open, non-confrontational conversation with the injured employee can reveal things such as personal challenges at home, psychosocial issues, or problems with a supervisor or with your company.

4 - Take Steps to Avoid Future Claims

Once you understand the reasons for the repeated WC claims – whether they’re legitimate or not – you can take steps to avoid future claims. If it turns out they don’t know how to perform their job safely, provide additional training and education. If you determine that they are physically unable to do their job effectively, consider transferring them to another job that they can perform safely.

However, if they’re trying to take advantage of the system, be respectful, but let them know that you will be watching them and will take appropriate action if abuse of the system is found, up to and including termination.

Protecting Your Bottom Line

Repeated workers’ compensation claims affect your bottom line while potentially harming productivity and employee morale.

You know what else affects your bottom line? Paying more than you need to for workers comp insurance!

To get a GREAT deal on your WC insurance, give the independent agents at American Insuring Group a call at (800) 947-1270 or (610) 775-3848 or find us online. As independent agents, we’re free to shop and compare rates among competing insurance carriers to make sure that you are getting the best WC insurance at the best possible price!

Call or click today to get started.

The majority of employees are honest, and the majority of workers compensation insurance claims are legitimate.

Unfortunately, there is a small group of people who commit workers compensation fraud, and they cost companies billions of dollars every year in rising insurance premiums, production delays, and training costs. 

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What is EMPLOYEE Workers Comp Insurance Fraud?

Workers Compensation fraud occurs when a WC claim is filed that is not entirely truthful to get money or extended time off. Fraudulent claims include faking or exaggerating an injury, claiming an injury that occurred off the job, or claiming an old injury that didn’t heal.

Workers comp fraud is a serious crime, and one of the fastest growing types of insurance fraud in the U.S. Estimates place the cost of WC fraud to companies at $6 to $7 billion every year.

The good news is that there are steps you can take to minimize WC fraud by both employees and providers.

One of the first steps is to recognize common warning signs.

 

13 Warning Signs of EMPLOYEE Workers Comp Fraud

Protect your business from WC insurance fraud by recognizing the warning signs of fraudulent claims:

1. No witnesses
2. An injured employee refusing treatment
3. Delayed reporting of injury
4. Conflicting or inconsistent report of the incident
5. An employee with a history of making WC claims
6. An employee with a history of frequently changing addresses, jobs, or physicians
7. Suspicious medical providers or legal consultants
8. An injury that occurs just before or after a weekend or holiday
9. An injury that occurs right before or after job termination, layoff, end of seasonal work, a strike, or the end of a project
10. An injured employee working a side job
11. An injured employee doing activities that would not be possible with the claimed injury
12. An injured employee who is difficult to get in touch with
13. An injured employee who hires an attorney and tries to get a quick settlement

Never accuse an employee of fraud. If you see two or more of these warning signs, notify your insurance company immediately, but remember these are just potential signs that there could be an issue. It doesn’t mean that every workplace injury that occurs with no witnesses is fraudulent or that every injured employee who is hard to get in touch with is lying. They are just indicators that there may be a problem. 

How to Minimize Employee WC Fraud

• Follow a screening process for all new employees by conducting thorough background checks of all applicants, contacting references, and watching for red flags such as a spotty work record or a criminal record
• Create clear WC policies and establish a zero-tolerance policy on WC fraud
• Clearly communicate these policies with new hires and provide WC fraud training
• Create a culture of safety to reduce opportunities for fraudulent claims
• Install video surveillance
• Consider establishing ways that employees can report suspicious or fraudulent claims anonymously
• If you suspect fraud, notify your insurance carrier immediately and provide supporting documentation.

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What is PROVIDER Workers Comp Insurance Fraud?

Unfortunately, it isn’t just employees who commit WC fraud; providers of WC benefits such as medical and legal professionals sometimes take advantage of WC programs with unnecessary billing, fake clinics, kickback schemes, and inflated worker injuries or service costs

8 Warning Signs of Provider WC Fraud

1. Billing for services never received
2. Billing for equipment never used
3. Billing for treatment that was never performed
4. Duplicate billing
5. Higher than usual bills for services performed
6. Billing for procedures that don’t make sense for the reported injury
7. Increasing visits
8. Ongoing medical services that don’t improve injury

WC fraud can cause a ripple effect that touches everyone. Fraudulent claims create additional costs for insurance companies, which can turn into higher insurance premiums for employers. Increasing business costs can cause an increase in prices customers pay, a decrease in employee benefits, or even job cuts.

 

How to Get a Great Deal on Workers Comp Insurance

To learn more about preventing and recognizing WC Fraud and ways to save on Workers’ Compensation Insurance, contact the WC specialists at American Insuring Group at (800) 947-1270 or (610) 775-3848 or find us online.

Our Trusted Choice independent agents will work hard to analyze and compare plans from competing WC insurance carriers, so you’ll get the best price on quality protection.

Call or click today to get started!

It’s your responsibility as an employer, to pay close attention to your workers compensation insurance claims. The majority will be legitimate claims that your employees are entitled to. But even one fraudulent claim can adversely impact your bottom line.

There are important red flags you can watch for to identify possible workers compensation fraud. Here are ten red flags. Seeing just one red flag probably isn’t cause for alarm, but if you see multiple red flags on one workers’ compensation claim, it’s a good idea to bring it to your adjuster’s attention.

Ten Workers Compensation Fraud Red Flags

#1. Questionable Incident Description

An injured employee should be able to describe the incident – what happened, how, and when - with a fair amount of detail and clarity. The details should be consistent and not change as you ask questions or when the employee describes the incident to someone else (doctor, adjuster, employer). If there’s more than one medical report, the details of the event should be the same, and the nature of the injury should be consistent with the type of work the employee performs.

#2. Lack of Witness Corroboration

If the employee usually works around others, there should be a witness, and the witness account of the accident should match the employee’s description of the accident. If the witnesses are all close friends of the employee making a claim or if the employee’s co-workers express uncertainty that the accident occurred, it may be a red flag.

#3. Delayed Reporting

Injured employees usually report their injury immediately – not days or even weeks later.

#4. Disgruntled Employee

Is the employee unhappy with his job or employer? When a workers’ compensation insurance claim is made, check if the employee was recently demoted or passed over for a promotion, if his evaluations are less than stellar and he’s in danger of termination, or if he is scheduled to be laid off. An incident immediately before a strike, plant closing, or end of seasonal employment may be a red flag.

#5. Early Morning Claims

If the employee reports an incident that occurred over the weekend or very early in the morning before the supervisor and other employees have arrived, it could be a red flag.

#6. Inability to reach the injured employee

The employee should provide his address – not a PO Box and not a friend’s address – and you should be able to contact the injured employee. If you find they aren’t home during regular working hours or if you’re always told he’s sleeping or can’t be disturbed, it could be a red flag.

#7. Shaky Finances

If an employee is having financial issues, he may see a workers’ compensation claim as a way out. Find out if the employee has financial problems, is nearing retirement, is in the middle of a divorce, or if they took a lot of time off just before the injury. Check if the spouse is working or receiving any of these payments: workers’ comp benefits, disability, welfare, or unemployment. If the employee asks about a settlement early into the process or applies for social security benefits before the incident occurred, that could be a red flag.

#8. Medical Care

Watch out for subjective injuries - such as soft-tissue and emotional - or injuries that seem to move from one body part to another; frequent changes in physicians or inconsistencies between employee and physicians’ reports; or missed doctors’ appointments or refusal of diagnostic testing. Carefully examine the medical reports to make sure there aren’t any whiteouts, and it doesn’t look like it’s been photocopied multiple times. Most employees don’t have extensive knowledge of the medical or insurance field. If he does, it may be a red flag.

#9. Inconsistent Physically Ability

An injured employee who is out of work on workers’ compensation should not be able to do similar activities to what he was doing at work. So look for evidence that he is performing those activities outside of work such as callused or grimy hands, medical reports that use adjectives like “muscular” or “tanned.”

#10. Over-eager

If the employee is pushy to settle the claim or has an attorney letter of representation dated the day of (or even before) the injury, it could be a red flag.

Final Advice: Don't Assume Insurance Fraud, But ... 

Don’t go into every workers compensation claim assuming there’s fraud. The majority of claims are legitimate. But at the same time, don’t be blind to the red flags that may indicate fraud. If you see multiple red flags, let your adjuster know. It may just help you save on your workers’ compensation costs.

 

Remember the Easy Way to Save on Workers Comp Insurance!

To learn more about workers compensation insurance, call the American Insuring at (800) 947-1270 or (610) 775-3848, or contact us online.

And remember, the easiest way to save on workers comp insurance is to buy it from an independent agent like those at American Insuring Group! We shop competing insurance providers, matching their policies to your needs, and identifying the best value for your particular situation. Get the right coverage at a great price. Call or click today to get started!