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.”
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!
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