Many adjusters will use surveillance on the cases to get an actual glimpse of what the claimant is up to on a day-to-day basis. Sometimes this can be helpful to the defense of the claim and other times it can yield no real pertinent results towards the actions on a case.
But you must know what to look for, and how to use these results to your advantage, to assist in the defense of a claim. [WCx]
Look for consistency
One of the biggest things an adjuster will look for is consistent objective evidence of a disability. This can be in the way a person is walking, using a cane, or other assistive device, or are actually as disabled as claimed to the treating physician. It is almost a guarantee some surveillance will be initiated if a claimant is telling the adjuster he/she is stuck on the couch unable to move due to the injury, and it is more than a few weeks post-injury.
Keys to be looking for are in the overall way a person is moving. Just having some actual surveillance footage does not mean it works to the adjuster’s advantage. In fact, it can cement the fact that the person actually is in pain and limited in the overall daily activities which is good for the adjuster to know also. But, if there are some inconsistencies, it will contribute to the overall defense of a claim.
For example, a worker has a knee injury. Surveillance shows the employee walking normally without a limp. Then at the doctor’s or IME appointment, suddenly a noticeable limp appears. When brought to the claimant’s attention the claim of “having a good day that day” is made. Therefore, it is important to have multiple days of surveillance. If it can be shown that this person does not appear disabled or hindered in any way, except for when around a medical facility, then there may be a decent defense. Consistency is key. If holes are poked in this claimant’s statements of being “constantly disabled” and show with surveillance footage this is not so and the claimant is not being 100% truthful, the defense is greatly helped.
Are canes and crutches being used? Are they being used correctly?
Sticking with the leg injury theme, if a cane or crutches are prescribed, it is always good to see if the person is actually using them, and using them correctly. There are countless cases where a cane is prescribed and, if the person is actually using it, it is used incorrectly. Sometimes the cane is carried when walking. If an attempt is made to use the cane, it is used incorrectly meaning not in a way helpful to the injury. Or even better, after leaving an IME appointment, the cane is tossed into back of the car and when surveillance people tail the worker back home, the cane is not used at any other time. Again, this is helpful to the defense.
Note: Ask the IME doctor before the appointment to examine the cane or crutches for wear and tear. If the person is indeed using it all the time, the bottoms will be worn, and the handle may have some evidence of wear. If the medical device appears new and unused, and the worker is saying it is being constantly used, then there is some good ammunition to use in the defense, or at least use this to base some additional investigation.
Is the claimant breaking the medical restrictions on a regular basis?
Another great piece of evidence is getting footage of the injured party violating prescribed medical restrictions. This can come about in a variety of ways, from lifting and carrying heavier weights than allowed, to walking and running more than recommended. There could be evidence of other prescribed behavior such as golfing or hunting. An agent once reported these scenarios:
A worker had a knee surgery, and mentioned he was an avid outdoorsman. When hunting season came around the agent sent out a surveillance team and sure enough, he was deer hunting a few weeks after his latest surgery. The treating doctor told him not to be on his feet for longer than needed, and certainly he was not to be climbing and walking over wilderness terrain.
In another case a person had a shoulder surgery and a few weeks after surgery was caught chopping wood with an axe all day! When the footage was sent to his doctor for comment, the doctor could not believe what he was seeing. Despite the fact that some people will say that these incidents are not prima facie evidence of fraud, they may be a factor in deciding whether to obtain additional video surveillance and continue the investigation – I would. Actually, I have, and was pleasantly surprised when my claimant gave me a real surprise — enough evidence to settle the claim for a fraction of the $100,000 demand, and a resignation. I might now have shown fraud because I didn't have video of the last two years showing he was not injured during that previous time, but I had enough so he did not want to pursue the claim further.
Be aware sometimes people say one thing about being disabled and being “bummed out” about not being able to return to work, when they are actually doing the opposite. When surveillance is done, real evidence is discovered of the claimant milking the claim for all it is worth.
Again try to show that these violations are happening on a regular basis, not only one time. Just because there is footage of the claimant walking to the mailbox when he reports being bedridden due to pain, does not mean there is a slam-dunk defense that warrants a denial of ongoing benefits. There is a need to establish the fact that this person is committing these violations on a regular basis, if not every day. Be a supporter of getting regular surveillance on higher exposure cases, especially those that are post-surgical. This is especially true when there are other risk drivers supporting that the person is actually benefiting by being out of work. Some examples of these risk drivers include having newborn or infant children to save on daycare costs; subjective evidence of disability without the objective medical evidence support; and also use surveillance with claimants who have a checkered past of having a lot of workers comp and auto claims, with several carriers and several employers throughout the years. [WCx]
Summary
Surveillance can be a very helpful asset to the defense of a workers compensation claim. But you have to look for key pieces of evidence and these pieces have to be shown to be occurring on a regular basis. Most Judges will say that if the claimant is proved a liar when it comes to the activity level, and you can poke holes in their claims to further disability, then there should be a favorable decision for denial or defense of a workers comp claim. This may not be the case all the time, but if some holes can be poked in the armor of the claimant, then this is closer to the right path of discovering the truth about if this person is as disabled as is claimed. As one attorney told me, "Get as many Easter Eggs in your basket as possible!"
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
A former MBTA driver (Massachusetts) is looking at a fall trial on charges that she staged an armed robbery, lied about it to police, and then claimed more than $7,000 in workers compensation funds, Suffolk County District Attorney Daniel Conley reported.
Nancy Parker, 53, of Burlington was arraigned recently in Suffolk Superior Court on charges of workers comp fraud, making a false police report, and misleading an investigator, a subsection of the state’s witness intimidation statute. (WCxKit)
Assistant District Attorney David McGowan told the court that Parker was driving an MBTA bus on Route 111 in the area of Garfield Avenue and Exeter Street in Chelsea on the afternoon of Oct. 2, 2007, when she made the initial false report.
When MBTA Transit Police along with Chelsea Police and other law enforcement officials responded to a call for shots fired, Parker allegedly told them that she was heading inbound when she stopped to pick up a passenger. The man, that Parker allegedly told Transit Police detectives about, pulled a gun, demanded her money, and shot at her. He shot her once as she sat in her seat and three more times after she tried to rush past him and he pushed her to the ground, where he took her wallet and fled.
Though she claimed ignorance as to his identity or motive beyond the robbery, Parker allegedly gave a detailed description of the assailant. This description led Transit Police to conduct an extensive investigation into who he might have been. After posting a composite sketch to the Massachusetts Most Wanted web site and circulating it among local businesses, Transit Police received a tip that led to particular scrutiny of a suspect in past offenses. He was eventually cleared of wrongdoing in the bus incident.
Parker also allegedly showed investigators her uniform jacket, which had three holes in it. Though she described them as bullet holes, she suffered no injuries from the shooting she described. She did, however, leave work and file a workers comp claim which amounted to $7,750.87, plus an additional $2,063.07 in payments to medical providers.
In a second interview with Transit Police, Parker allegedly stated that she had lied in her initial statement. This time she allegedly indicated that a former intimate partner had sent the gunman to collect a $5,000 debt Parker had incurred about 14 years earlier.
After interviewing that former partner, conducting further investigation, and attempting to contact Parker only to be met with evasiveness or, on one occasion, shouted profanities, Transit Police determined that her story was a fabricated.
Parker was first charged in Chelsea District Court on April 30, 2009. A judge dismissed the case of prosecutor objections in 2010. Conley’s office put the matter to a grand jury last year, leading to her Dec. 20 indictment. (WCxKit)
Her trial is now scheduled for Oct. 15, and she is due back in court soon.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Oklahoma Attorney General Scott Pruitt recently charged two men with workers compensation fraud. Charlie Jones, 45, of Norman faces one count of workers comp fraud.
According to charges filed in Oklahoma County District Court, Jones had filed a claim for injuries to his right arm and hand allegedly sustained while working. He was awarded permanent total disability (PTD) benefits. In a medical re-evaluation two years later, Jones claimed constant pain with limited mobility.
During the investigation, Jones was observed feeding animals and cleaning his pool with no clear signs of pain or lessened mobility. The fraud resulted in Jones receiving $11,385 in benefits to which he was not entitled.
Meantime, Johnny Lee Crowder, 42, of Lawton also was charged with one count of workers comp fraud. According to charges filed in Oklahoma County District Court, Crowder filed a claim for injuries to his left hand when he tripped and fell while working. Crowder sought medical treatment for an injury to his hand sustained while at home. (WCxKit)
During the investigation, investigators found discrepancies in Jones’ claim and medical records. On the day in question, the business was closed for holiday and the ambulance picked him up at home not at work as he originally stated.
Ohio Man Not Liking the Tune of Workers Comp Fraud
An Austintown (Mahoning County), Ohio man was sentenced recently for workers comp fraud after Ohio Bureau of Workers Compensation (BWC) investigators caught him on video entertaining partygoers and bar patrons as a disc jockey.
According to the BWC, Randall Schornack pleaded guilty and must repay more than $27,000 he collected illegally while receiving benefits for a workplace injury. (WCxKit)
BWC's Special Investigation Department (SID) received an anonymous tip on the fraud hotline that Schornack was working as a disc jockey at area bars under the name "DJ Randy Stevens."
SID's investigation determined that Schornack was working as a DJ for several bars in Mayfield and also for a professional DJ service in Girard while receiving temporary total disability benefits. The SID obtained video of Schornack unloading and carrying speakers and other equipment from his vehicle into different establishments on a weekly basis and performing work services as a DJ. (WCxKit)
Schornack was sentenced in a Franklin County courtroom and the judge ordered him to pay $27,202.62 in restitution He was also sentenced to 18 months in prison, suspended for five years of community control.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
A California roofing contractor was sentenced recently to one year in jail and was ordered to pay $510,000 in restitution for failing to provide workers compensation insurance for an injured employee and failing to pay insurance premiums for unclaimed employees, who were paid in cash.
According to the Orange County District Attorney’s office, Michael Amzie Holley, 43, Murrieta, pleaded guilty to a court offer to two felony counts of perjury by declaration, two felony counts of recording false and forged instruments, one felony count of misrepresenting facts to the State Compensation Insurance Fund (SCIF), seven felony counts of making a fraudulent statement, one felony count of presenting a fraudulent material statement to obtain compensation, one felony count of making a false statement to discourage an injured worker from claiming benefits, one felony count of willfully failing to pay taxes, one felony count of failing to file a return with the intent to evade taxes, and a sentencing enhancement for aggravated white collar crime over $500,000. [WCx]
At the time of the crime, Holley was a roofing contractor and owner of So Cal Roofing. The defendant purchased a minimum workers compensation policy from SCIF and failed to state that he employed subcontractors, paid workers in cash, hired unlicensed employees, and leased employees from other companies. Holley paid his employees in cash to hide the fact that So Cal Roofing had workers. He received insurance based on his false declaration and entered into a contract requiring SCIF to cover all workers employed by Holley, even those employees unknown to the insurance company. Holley submitted inaccurate payroll reports to SCIF, resulting in underpayment of insurance premiums. To hide the fraud, Holley failed to file an accurate tax return to avoid paying taxes to the State on the cash payments made to his employees.
One of Holley’s employees was injured when he fell off a roof, and subsequently filed a workers comp insurance claim. Holley denied that the injured employee worked for him, thus denying the injured employee his workers comp insurance benefits. Subsequently, Holley fraudulently signed under penalty of perjury that he had no employees at So Cal Roofing and filed these documents with the California State Contractor’s Licensing Board to make him exempt from securing workers comp insurance.
California law requires that all employers maintain workers comp insurance for their employees. Payroll records showing the number of employees and their income must be submitted to both the workers comp insurance company and EDD, who oversee the collection of payroll taxes. [WCx]
Workers comp insurance rates are determined by a formula, which takes into consideration the number and type of employees and the company’s history of injury claims.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
The Florida Department of Financial Services Division of Insurance Fraud reports that it has charged an Orlando man with workers compensation fraud and grand theft after an investigation claimed he fraudulently collected more than $115,000 in benefits.
According to the office of Florida Chief Financial Officer Jeff Atwater, Keith Jackson falsely reported that his injuries took place at the time of his employment as an Orange County corrections officer. Jackson could receive up to 30 years in prison if convicted.
“It is one of my missions as your CFO to root out fraud of all types,” CFO Atwater commented in a statement. “Those who are looking to game the system are ultimately putting the financial burden on all of Florida’s consumers. If you bilk the system, we will find you and put you behind bars.”
Atwater’s office reports that Jackson had claimed to have injured his back and foot while taking part in defense tactics training as an Orange County corrections officer.
“Jackson’s claim was initially deemed compensable; however, it was determined that Jackson made false statements and omitted material information about his medical conditions,” Atwater’s office reported. [WCx]
Anyone with information regarding suspected insurance fraud is asked to call 1-800-378-0445. Individuals who provide tips can remain anonymous and are eligible for a reward of up to $25,000 for information that directly leads to an arrest and conviction in an insurance fraud scheme.
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
These are dreaded words heard ‘round the locker room or break room table.’ They may start out as nothing, maybe a little one-liner about “some layoffs coming down the road” or maybe another guy said he saw Keith talking to Bob about “Immediate downsizing.”
Whether these are true or untrue, as a risk manager or someone involved in the claims process, be ready for the onslaught of the consequences of layoffs or downsizing. Not everyone will file a claim for workers comp, but bet the disgruntled employees will, along with a few unexpected employees to now report an injury of some sort in the past. (WCxKit)
How are these issues controlled and handled proactively? We discuss a few options below, and remember these may or may not apply in your jurisdiction.
Always consult counsel before implementing any of these ideas.
1. Go back to documentation
Keith just received his letter that his job was terminated and his last day of work will be in 10 days. Keith is nervous, because he has limited job skills, bills to pay. He lives in a small town and there are not a lot of jobs out there. Plus he does not have the greatest relationship with his supervisor, and he feels this is a personal assault coming directly from that supervisor who just does not like him.
What does Keith do? Well he decides to say he injured himself a month or so ago but was afraid to report it, because he heard that layoffs were coming. And he did not want to be one of the guys picked to be laid off.
This is a very common scenario. And this is where attention to documentation comes in to play. By now, everyone on the work floor should know that if any injury happens, whether they want treatment or not, the worker is to come to the risk manager’s office to complete some paperwork. And those who decide not to do this face the consequences associated with not reporting it.
The first question to Keith after he tells you he hurt himself a month ago should be “Why did you not tell me? You knew the procedure, right? Did you tell anyone? Did anyone witness your injury? Did you see your doctor? Why are you telling me this now?”
These are the first handful of questions to ask. Then call in his claim to the carrier/TPA immediately. And let them deal with it. If you still want to lay him off while his claim is under investigation, that is fine. If you want to wait until a decision has been made, that is fine as well. But documentation is key, and it always will be. You have to constantly tell the workers the responsibility to come tell you when something does not feel right, and an injury may have occurred. And if the employees do not do this then they face the consequences that can affect the claim’s compensability. Make it a reminder phrase every week.
2. Perform an exit interview
If a worker resigns from a position, or is laid off, chat with them a bit. Chances are the worker will come to you anyway to ask why it was them anyway. So now is a good time to see if the employee pulls out any angles to try and keep getting some income coming . Flat out ask if the worker is hurt, or had a workers comp claim, or is experiencing pain for example.
Common knowledge will reveal that this is a way to increase your own claims, since if it is not mentioned then why stir the pot? Actually, if employees are going to come forward and try being deceptive, better to confront it now versus 6 months from now. A claim will result regardless. Granted, most people will say “No” and move on, but there is always that handful of people that will try to claim an injury. Call the claim in to the adjuster, and let them handle it. That way you have performed your duty, and your responsibilities of reporting it are over and done.
3. Have a medical exam performed by an occupational medicine doc or a local clinic doctor to be safe
In order to be ultra-aggressive, get a doc to do an exit-exam. This will weed out all the fakers. It is not going to be free, but weigh the costs. If this is something to do to prove a point, then do it. Take time finding a doc that is also legit, and willing to do this. In the grand scheme of things I guess it is not fantastic to be laying off people due to expenses, and then have to spend $4,000 to have a doc say these workers are fine and show no signs of disability. This is about protecting your company from the unknown future of compensation claims, some of which can become incredibly costly no matter how insignificant they seem. So it is an option if that is preferred. Just make sure to have a credentialed doctor performing the exams in a private, professional setting (does this go without saying?), and that it is all HIPPA compliant.
4. Ask the employees to sign a release waiving liability (if legal in your jurisdiction)
Probably the most common is just the legal paper stating that the worker is not claiming any disability at this time. Depending on the jurisdiction, try inserting the word “future disability’ as well. But my advice is to thoroughly check with the employment counsel, as well as the workers comp counsel on permission. Or better yet have counsel draft the letter. Again it may cost something up front as far as expenses go, but it is all about protection down the road.
5. With a witness present, ask if the worker was or is hurt, or experiencing symptoms, and has been to the doctor for this. Ask is this is related to work or not.
This is similar to the doctor, but not as expensive. Have another HR person present for the exit interview, and ask the person about any disability relating to work. This will prevent the worker from coming back saying there were some problems swept under the rug and ignored. Check again with counsel on what can be and cannot be done, and then go from there. (WCxKit)
Summary:
With any type of employee reductions in the workforce, there are going to be some bitter feelings and resentment when reducing your number of workers. This article is about protecting your company, and protecting the future of potential comp claims. Any way to reduce exposure is always one worth researching, and implementing, sooner rather than later.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact
California Fraud Case
Manuel Perales, 50, of Fontana, Calif., has been charged with two counts of workers compensation insurance fraud, according to the San Bernardino County District Attorney's Office.
Recently, members of the DA’s Office, Workers Compensation Fraud Prosecution Unit, began an investigation into allegations of possible insurance fraud involving Perales. (WCxKit)
Perales reportedly sustained an industrial injury, while working for a local company. During the workers comp process, Perales withdrew his claim after being confronted with evidence that supported the incident was not true.
Although Perales withdrew his claim; he subsequently filed a second workers comp claim alleging that he sustained the same injuries, along with other industrial injuries, over a specific period of time, not including his original date of injury.
During this investigation evidence revealed that the allegations of workers comp insurance fraud were substantiated. As a result, an arrest warrant showing a bail amount of $100,000.00 was issued, charging Perales with insurance fraud. (WCxKit)
Later, Perales was located and arrested pursuant to the arrest warrant. He was transported, booked and housed at the San Bernardino County Sheriff’s West Valley Detention Center to await trial in this matter. Perales is scheduled for arraignment some time in 2012.
Ohio Fraud Case
A Cleveland (Cuyahoga County) woman was sentenced recently for fraud after Ohio Bureau of Workers Compensation (BWC) investigators found she was working for a veterinary hospital and a local charity while receiving benefits for a workplace injury. Nancy Palmer pleaded guilty and must repay more than $8,000.
BWC's Special Investigations Department (SID) reports it received an allegation that Palmer had been working at a local veterinary hospital. Investigators found she had returned to work as a veterinary assistant while receiving Temporary Total Disability benefits.(WCxKit)
According to the report, Palmer was performing duties such as office work, assisting during surgeries, cleaning and taking care of animals. It was also found that Palmer was working as a telephone solicitor for a local charity.
Palmer entered a guilty plea recently to a felony count of workers comp fraud. The judge ordered Palmer to pay $7,457.72 in restitution and $1,000 for investigative costs. She was also sentenced to seven months in prison, suspended for 18 months of community control.(WCxKit)
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He is an editor and contributor to Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: Info@ReduceYourWorkersComp.com.
WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
VIEW SAMPLES PAGES
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
The fastest growing area of workers compensation fraud is narcotics abuse. The fake workers comp claim for the purpose of feeding a drug addiction, or for the purpose of obtaining narcotics for resale, is a fast growing problem. Employers and claim adjusters should proceed with caution when an employee has been given a narcotic prescription, especially when there has not been a recent surgery.
The term “pill mills” has been used by law enforcement to describe medical facilities where the primary purpose of the medical facility is to write prescriptions for painkillers. The U.S. Drug Enforcement Administration (DEA) has been raiding medical facilities in Florida, Georgia, Ohio and other states with mixed results. They close down one pill mill only to have another one pop up. (WCxKit)
Pill mills often try to camouflage the activity as pain management clinics. There is however some red flags that distinguish a pill mill operation from a legitimate pain management clinic. Included below are some characteristics of pill mills.
-The physician(s) have little training / background in pain management.
-The facility sees a high volume of patients daily.
-The facility provides scant patient examinations before prescribing narcotics.
-The facility both writes the prescription and fills the prescription.
-The facility writes prescriptions for amounts that exceed the manufacturer’s recommendation for maximum usage.
-The price of the prescription is inflated over what the same dosage would cost at a chain drug store.
-The facility operates on a cash-only basis.
-The patients often travel long distances to the facility, even from out of state.
-The facility is often located near an interstate highway for convenience of patients traveling long distances.
-The facility advertises its “services” on Craigslist or other similar Internet sites.
The abuse of narcotics has gotten so bad that, per the Associated Press, drug overdose deaths have surpassed traffic accidents as the top cause of accidental death in Ohio, Colorado, Massachusetts, New York, Oregon and 11 other states. According to the Center for Disease Control, 20,000 people a year die from prescription drug overdose.
Pill mills like the Greater Medical Advance Clinic in Wheelersburg, Ohio are at the center of this epidemic. According to the arrest documents, the clinic owner, George Marshall Adkins, wore a handgun in the clinic while dispensing tens of thousands of painkillers at inflated prices.
Employers in Florida should be especially cautious of prescription drug abuse on the workers compensation claims. According to Florida state officials, 85% of all oxycodone pills sold in the United States come from Florida, with the top 50 medical prescribers of such drugs being located in Florida.
Carlos Gonzales in South Florida was arrested for his black market business of selling narcotics. Gonzales was not an ordinary street level drug dealer. He was a doctor operating a “pain management center” with numerous workers compensation patients. He lived in a multi-million dollar home with a Mercedes, a Bentley and a Lamborghini parked in the driveway. The DEA estimated he was making from $13,000 to $20,000 a week writing thousands of prescriptions.
There are steps an employer can take to stop workers comp fraud / drug abuse through pill mills. Among the ways the employer can fight workers comp fraud / drug abuse include
-Operate a drug free workplace – if the employees knows that drug testing for hiring and random drug testing is performed, the employees inclined to abuse drugs (and to file bogus workers comp claims to obtain drugs) will go somewhere else to work until they pull the workers comp fraud.
-Drug screen after each injury – a drug screen on the day of the injury should be a part of the immediate medical treatment. In many states a failed drug screen can be grounds for the denial of the workers comp claim. In the states where the workers comp claim cannot be denied due to the failed drug screen, the employer will at least know what the employee’s drugs of choice are.
-In the states where the employer is allowed to select the medical provider, be sure to do so. Check the reputation of the medical provider with local defense counsel to eliminate doctors known for over prescribing medications or known for referring employees to questionable pain management clinics.
-Whenever pain becomes a significant part of the employee’s complaints following an injury, especially pain without visible trauma, a nurse case manager should be assigned to the claim to prevent narcotics abuse.
-All prescriptions for the injured employee should be filled through a pharmacy benefit manager (PBM). Any time the employee is exceeding the manufacturer’s recommended maximum dosage, the PBM can review the requested dosage with the medical provider. (WCxKit)
By taking the above steps, the employer can significantly reduce the number of bogus workers comp claims for the purpose of obtaining narcotics, either for drug abuse or for resale.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
A Yolo County, California jury has convicted a West Sacramento resident and 25-year employee of The Sacramento Bee of workers compensation insurance fraud.
According to the Yolo County District Attorney's Office, Linda Vela, 58, was convicted of seven counts of workers comp fraud, three counts of presenting false statements concerning payment on an insurance policy and two counts of attempted perjury in connection with disability claims made over a two-year period. [WCx]
Vela, who was employed as a member of The Bee's finance department, left her position on disability and was diagnosed with bilateral carpal tunnel syndrome.
Vela, who had surgery on her right wrist, complained that she was still in pain after the surgery and that she could not go back to work despite the surgeon's recommendation that she return to work. Due to Vela's complaints of pain and her reported inability to use her hands, her physician kept her off work as "totally disabled."
As a result, Vela obtained workers comp benefits from The McClatchy Co., parent company of The Sacramento Bee, along with payment through Liberty Mutual Insurance Co.
Not long after starting to receive payments, Vela was nabbed on video doing many of the things that she told doctors she could not do.
An orthopedic surgeon who watched the surveillance video testified that Vela could go back to work with the restriction that she "avoids power gripping and torqueing." [WCx]
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.
Sometimes, despite an employer's best efforts, some employees just do not want to come back to work (not having to work for a steady paycheck is a pretty good deal). The usual way employees block their return to work is by exaggerating the physical demands of their job. When asked by the orthopedic doctor how much lifting the job entails, the employee remembers the one time in his 20 years of employment where he picked up a 90-pound bag of concrete mix. What the doctor hears is the poor employee is lifting 90-pound bags all day long. The orthopedic in an effort to avoid a malpractice claim, tells the employee you cannot do that, and keeps the employee off work for another month.
A lot of savvy risk managers and workers compensation coordinators are furnishing the medical provider with a copy of the employees written job description as soon as they know who the medical provider is or is going to be. This often helps to get the employee back to work as soon as the employee is physically able to return to work. However even with a written job description, there are times the doctor does not have a clear understanding of the employee’s job.(WCxKit)
With YouTube and all the other video display sites on the internet, the use of video to show and describe things is quite common. Video job descriptions are now easy to create, simple to watch and they make it much easier to understand processes when the medical provider is not previously familiar with them. There are also videos and photos on Facebook that are now commonly used to dispute claims on inability to work.
Before you start making a video of the employee’s job, stop and plans what you want to show. Read through the written job description. Does it cover everything the employee does? Ask another conscientious employee who does the same job how the written job description can be improved (no need to mention the other employee’s work comp claim). Be sure to make note of everything the currently working employee states needs to be added to, or taken out of, the existing job description.
Obtain a copy of the injured employee’s medical restrictions. Identify the limitations the medical provider has placed that are preventing the employee from returning to work (this will be important when making the video record of the job description).
Ask the working employee to allow you to video record the work routine, the daily task and the most difficult parts of the job. Be sure to capture on the video the way the working employee has to move, bend, stretch, twist, walk, sit, stand, etc. Show all repetitive motions. Show all lifting whether it is a 40-pound box of materials, or a feather-light single piece of material.
Be sure to have the sound turned on during the video of the job and ask questions. Some of the questions you will want answered in your video include:
1. How much does that item weigh?
2. How often do you have to pick up the item?
3. Is it easier to do your job sitting down or standing up?
4. How far do you have to reach?
5. How many times a day to you repeat that motion?
6. What can be done to make the physical demands of the job easier?
7. Show me the most difficult part of your job.
8. Without mentioning the injured employee, ask about each limitation that has been placed on the injured employee, for example:
a. “If for safety reasons we said not to lift more than 20 pounds, could you still do your job?”
b. “If you were unable to stand for more than four hours at a time, would you be able to do the job sitting down?”
c. “Would it make the job easier if you alternated between standing and sitting?”
d. “Would you be able to do your job if we limited the repetitive motion to XX repetitions per hour?”
Keep in mind there is the possibility that the conscientious employee will state “you cannot do this job if you cannot lift 40 pounds” or something similar that will validate the fact the injured employee is not malingering and really cannot return to work, yet.
If necessary, edit your video job description to keep the length down to about five minutes. That is about as much time as you can expect the doctor to take away from his/her many other duties to watch the injured employee’s video job description.
When you are satisfied the video record will answer all the potential concerns of the medical provider and properly portray the injured employee’s job, ask the nurse case manager to view the video job description. See if she has any concerns about the injured employee’s capabilities to return to work. If she does, determine how the job might be modified for the injured employee to return to work.(WCxKit)
The nurse case manager is a good way to get the video record in front of the medical provider. The nurse case manager can explain your desire to get the employee back to work and also explain how any necessary job modification will be accomplished to meet the injured employee’s restrictions. If necessary, add to the video any job description changes needed to accompany the employee’s restrictions, showing the way the modified job will be done. When the medical provider sees the employee can do the regular job, or a modified duty job, the formerly injured employee will soon be back to work.
Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com.
Contact: RShafer@ReduceYourWorkersComp.com.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.
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