Using various databases, your company can find investigative leads to follow according to Arthur J. Gallagher Risk Management Services, Inc. Looking for problems in the research you pull up could help you find holes in injury claims.
Often injuries are legitimate and certainly something a good company wants to take responsibility for. But occasionally red flags come up that prompt further investigation. In our modern age of information, there are some amazing resources available that can help investigate the veracity of a claim.
Ten Databases to Look Into When You Suspect Fraud
1. Use local, state and federal databases.
2. Go to regional courthouses to look for information that might mitigate the claim.
3. Work with claims handlers to establish what would add value to the file.
4. Research using databases to determine past injuries or pre-existing claims.
5. Does the claimant have Uniform Commercial Code filings? This means the claimant is borrowing money for a business. For example if the claimant cites a workplace burn injury but also owns a pizza parlor, this could encourage additional investigation.
6. Does the address history provide additional leads that could turn up previous claims from this employee?
7. Remember that almost everything is available on the internet such as EBay stores.
8. Look at www.pipl.com, www.spokeo.com or www.dirtsearch.org and other multiple search engines to help check many sites on one name, for example.
9. www.Bowl.com shows who is involved in bowling – if someone has a great bowling record but is supposed to be home due to injury, this site can be very helpful. (workersxzcompxzkit)
10. Use state fraud bureaus to access information and to help in prosecution.
"FRAUD PREVENTION" PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agen about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
The relatives of three dead Quebec sealers and the pair of lone survivors of a boat that capsized during a towing operation are suing the Canadian Coast Guard and Fisheries and Oceans Canada for $2.7 million. According to The Canadian Press, four hunters from Iles-de-la-Madeleine, Quebec, were killed when the L'Acadien II sank in March 2008 off Cape Breton as the rudderless ship was being towed through the thick ice by a coast guard vessel. The captain and three fellow sealers drowned when their 12-metre-long trawler capsized after it slammed into thick ice. The boat flipped and water rushed into the cabin of the overturned vessel, where most of the men had retired to their bunks to get some rest. Two other sealers survived after being rescued from frigid waters. Nineteen people, including the two survivors of the tragedy and 17 relatives of the victims, allege the coast guard was negligent and didn't do enough to ensure the safety of the L'Acadien II crew. The plaintiffs are also asking that the case be heard in Gaspe, the closest judicial district to the remote archipelago where the families and survivors still reside. The $2.7-million lawsuit, filed in Federal Court in early November, alleges a number of errors were made by the Canadian Coast Guard the night the Sir William Alexander was dispatched to assist the sealing boat. The suit alleges that communication lapses resulted in delays in the icebreaker getting to the L'Acadien II. The suit also alleges the coast guard did not follow procedure by allowing the doomed crew to stay aboard the vessel. "Despite the fact an agent with the Joint Rescue Coordination Centre (JRCC) told the captain of the (Sir) William Alexander that the crew should be removed, this possibility was never discussed between the captain of L'Acadien II and the officer of the Sir William Alexander,'' the statement of claim reads. "While the safety and the lives of the crew (of the L'Acadien II) were threatened, the officers aboard the Sir William Alexander decided the priority was to focus on the administrative procedure of getting a liability waiver instead of insuring the security of the L'Acadien II's crew.'' The suit also alleges that lookouts who were supervising the tow were on a radio frequency unknown to the L'Acadien II and that no communication link was established with the disabled ship. In addition, it's alleged the lookouts didn't move quickly enough in alerting the bridge and severing the line when the boat swerved and flipped. Finally, the suit alleges the coast guard made arrangements in English only, while the L'Acadien II crew spoke only French, and that it took search and rescue divers took too long to get to the scene. (workersxzcompxzkit) A number of reports have recommended the coast guard adopt changes to procedures and protocol when it comes to towing small vessels through ice.
Author Robert Elliott can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.
"FRAUD PREVENTION" PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
The Insurance Educational Association (IEA), announced the release of its latest online self-study course for the workers’ compensation claims professional.
“Permanent Disability and the AMA Guides,” builds on the online learning foundation IEA has constructed over 10 years, and on the experience IEA has in preparing workers’ comp professionals to master the intricacies of this challenging insurance line. Permanent Disability and the AMA Guides is the seventh online self-study workers’ comp course released this year. Each course has been authored by a leading specialist in the workers’ comp claims community.
Beginning with an overview of the rating process, Permanent Disability and the AMA Guides includes relevant terminology, anatomical terms, and medical descriptions and measurements in conjunction with the mechanics of rating disabilities per the AMA Guides, 5th edition. Emphasis is placed upon the most common injuries and becoming adept in the use of the AMA Guides to correctly categorize and rate Permanent Disability.
Although oriented towards the California workers’ comp system, IEA believes that claims administrators working in states other than California will get gain practical knowledge from the course’s extensive training in the proper reading and use of the AMA Guides and the author’s practical advice in dealing with claimants, attorneys and members of the medical community.
Permanent Disability and the AMA Guides completes IEA’s development of an online, self-study path to the Workers’ Compensation Claims Administration certification. While many students take one program per semester to complete the certificate within two years, online self-study students can complete the program much faster. Permanent Disability and the AMA Guides is rated at 30 hours credit for California claims examiner continuing education or initial training needs.
It is one of eight online courses which will allow motivated claims adjusters to achieve quickly their 5-course certificate in Workers’ Compensation Claims Administration and to go on to complete IEA’s full 8-course Workers’ Compensation Claims Professional designation. (workersxzcompxzkit)
For more information and to see a demo of IEA’s online courses, go to IEA’s website www.ieatraining.com or call 800-655-4432.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
I. Concepts Underlying Conflict Management (Pushback)
In a perfect world, you implement a workers’ comp management program and there is no pushback. Everyone in your perfect world is as excited as you are about the program because workers’ comp management strategies and processes work.
BUT in the real world it isn’t a question if you’re going to have pushback, it’s a question when pushback comes and how you’re going to deal with it. Pushback is inevitable.
The Push and Pull of Pushback
Pushback is defined as opposition or resistance to an idea, plan or strategy. You can plan on being on the receiving end of push back at one time or another in your career from management, peers, and subordinates.
Pushback I s also defined as the act of forcing the enemy to withdraw – to cause to move back by force or influence. This sounds pretty scary, but this is pushback from the giving end.
Pushback boils down to conflict. Conflict is pain; people feel threatened. Regardless of whether the threat is real or perceived, pain is often expressed in pushback. Perhaps the cause is professional jealousy. Perhaps it is change. There are a variety of reasons for pushback but it always comes back to some psychic pain the individual is feeling and manifests as fighting back, stonewalling, or resorting to back biting and backstabbing.
Can We Manage Pushback?
To manage pushback we must first understand it as it occurs in various levels of management relative to our own. We must develop different conflict management strategies for dealing with superiors, peers and subordinates.
1. Superiors – It’s About the Bottom Line
Management isn’t interested in the details of a workers’ comp management program. Management is interested in cost and cost savings. Create a brief presentation to show them how they’re losing money now and how they can save actual dollars and cents with the new program initiative. When you talk to their bottom line, chances are, management will be delighted to come on board.
2. Subordinates
Manage conflict from employees by creating positive incentives such as gift certificates to the company store for successful participation in the new program’s initiatives. Practicing active conflict management techniques helps to bring employees on board. (See 7 Common Management Themes)
3. Peers
Managing pushback from peers is the most difficult because power is equal. Backing from senior management helps manage give you the edge you need to implement a corporate wide workers’ comp management program.
II. Managing Conflict From a Procedural Level
7 Common Management Themes
Several important common conflict management themes emerge at every level because you want everyone in the company to own workers’ management program goals, to participate willingly and not sabotage your workers’ comp management program.
1. Consensus Building
Your ultimate goal is to find those areas you agree on and agree to compromise on the areas you don’t. This can be a slow, arduous process. But it can be worth it because people have buy-in to the new program, and they feel invested. They have internalized program initiatives and taken ownership. So building consensus among individuals is a powerful tool for moving the group ahead.
2. Careful Listening
When practicing active conflict management — such as when someone is in your face, what do you do? Listen carefully, then repeat back to the individual what they said. In this way, when the individual hears you voicing his own words, he feels heard. This is a powerful technique for calming angry individuals.
Sample Conversation:
Them: “I just don’t feel I can handle another program initiative with my current workload. I am overburdened as it is.”
You: “Okay. So you’re telling me you feel overburdened and cannot handle another program initiative. Is that right?”
Them: “Yes, we’re already running safety initiatives, and these are getting in the way of production numbers. If we were just left alone to do our work we would meet quota!”
You: “Okay, help me to understand. You are attempting to participate in safety initiatives but find you are running under production quotas, is this right?”
Them: Yes, that’s right.”
You: “Well, I hear you, and I’m going to write down your concerns, is this okay? Let’s follow up with representatives from your group, perhaps a short series of meetings will help bring us all come up to speed and put us on the same page. You’ll be getting an invite from me later this week and we can pursue your concerns.”
Them: “Okay, I’ll wait for your email.” (workersxzcompxzkit)
You: “You can expect an email later this week, and I’ll matrix the concerns. At the first meeting, we can begin to discuss solutions.”
When they share their concerns, tell them what you can and cannot do up front. Tell them, you can share their concerns, you can plot their concerns on a matrix and help organize them into immediate, short/long term goals, and tell they what things you have no control over.
Make sure you speak in a neutral tone and maintain a serious expression of concern and respect. People must perceive they have been heard. By listening and neutrally repeating what an irate individual said, you have moved them from an angry stance to a more open, “well, what are we going to do about it” stance.
3. Always Show Respect
Resist the temptation to patronize or belittle the opinions of others — even privately. As much as you may disparage or even dislike someone, you must always show respect especially for peers and people with less power than you. Human beings have an innate capability for sensing when they are being talked down to and patronizing them will alienate them forever. You will never gain consensus, and your program will struggle if you do not listen whole-heartedly and respond to the concerns of your fellow employees.
This doesn’t mean taking abuse. This means listening carefully, repeating what is said, noting it, allaying concerns. If an employee turns abusive, gently redirect that person onto the topic, or disengage yourself by saying, “Perhaps we can talk about this another time.”
4. Be a Person of Your Word
This goes a long way to ensure credibility, and sometimes credibility is all you’ve got. If you promise something by a certain time, deliver it. If you cannot perform some task, admit it up front. Always be honest but diplomatic.
5. Be constructive
If you can’t think of anything good to say, say something constructive anyway. If you are called on to critique another’s work or contribution, build on what they have created, do not tear it down. Find something positive to say. Couch your opinions as questions, as if you were asking their advice, after all, it is their work or contribution. They are sure to have opinions about it. This is all about consensus building and investing ownership.
6. Think in Terms of Possibilities and Solutions
Even if something is obviously inferior in quality, turn it into an opportunity for growth.
7. Be a Positive Thinker
Do not allow negativity to enter into your thinking or you will be unable to solve conflicts effectively. Believe the outcome will benefit everyone.
Author Robert Elliott can be contacted at: Robert_Elliott@ReduceYourWorkersComp.com or 860-553-6604.
“FRAUD PREVENTION” PODCAST click here: http://www.workerscompkit.com/gallagher/mp3
By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
From the November 6, 2009 Fraud Blotter
Criminal complaints and indictments are accusations only.
Defendants are presumed innocent until proven guilty.
The North Carolina Industrial Commission, its deputy commissioners and appellate courts have taken the unusual step of directing Mission Hospital to pay employees’ attorney fees as a penalty for the way in which it handled at least six disputes over injuries to its workers this decade. The hospital failed to turn over key evidence in workers’ compensation cases, gave employees blatantly incorrect information about the law and repeatedly denied benefits without basis, state officials found.
A local attorney representing employers in workers’ compensation cases, said it is possible that Mission “has been sanctioned more than any other employer in the state in the past five years.”
“This is not usual (for employers) and there’s no reason that it ought to be going on,” she said, adding the cases reflect “a long-term situation that needs cleaning up.”
Mission’s conduct came to light following a September 22, 2009 ruling by Deputy Commissioner George Glenn II in which Glenn referred Mission’s handling of a case to the state Department of Insurance and the state attorney general’s office. He ordered Mission to pay the attorney fees of a former employee “Mrs. Swanson”, as well as an additional penalty of 10% of the benefits due her because of Mission’s “bad faith denial and fraudulent actions.”
A spokeswoman for Attorney General Roy Cooper said attorneys at the Department of Justice and Department of Insurance have been discussing how to handle what she called “an unusual case.”
Mission said earlier this week that it had not been contacted by either agency. It is appealing Glenn’s decision in the “Swanson” case.
In a written response to questions from the Citizen-Times, Mission did not directly contradict allegations that it has deliberately sought to deny valid claims. It has said it welcomes any investigation by the state.
Repeated Problems
State workers’ compensation laws provide that employees are entitled to costs of their medical treatment and two-thirds of their lost wages while out of work because of job-related injuries. Workers cannot collect damages for pain and suffering or punitive damages, but the system is supposed to resolve their cases quickly in return.
Cases in which employees challenge their employers’ denial of workers’ compensation benefits generally go first to informal mediation under the direction of the Industrial Commission, a state agency. Either party can then seek a hearing before one of the commission’s deputy commissioners, whose status is comparable to that of an administrative law judge. Appeals from those rulings are heard by panels made up of three members of the Industrial Commission. From there, either party can appeal to the state Court of Appeals. Cases occasionally go on from there to the state Supreme Court.
A review of decisions in disputed cases suggests that Mission does not always play by the rules when handling cases in which it and the injured employee do not agree. For example:
1. In the “Swanson” case, Glenn found that a Mission employee knowingly made a false statement to “Swanson” as part of an effort to mislead her and deny her benefits. He also wrote that Mission’s decision to deny “Swanson” continued benefits came “in spite of the overwhelming evidence to the contrary.”
2. In a different case, a deputy commissioner found that a Mission official would not authorize payment for medicines prescribed by a physician to combat depression despite knowing the injured employee was entering the psychiatric ward.
3. In a 2002 ruling in another case, a deputy commissioner found that Mission ignored the “unequivocal” findings of its own expert when it denied continued benefits to a medical records clerk who was injured by mechanized shelving that closed on her in a records room. The clerk said she thought she would be killed by the shelves. Mission’s contention that the experience did not cause subsequent psychological problems was based on “no competent medical evidence,” the ruling says.
4. The commission found in 2005 that Mission had withheld videotaped evidence that showed an employee crying after unsuccessfully attempting to return to work.
How Unusual?
Mission, which has about 6,000 employees, said in its statement that employees filed 4,406 “occurrence” reports of incidents in which injuries could have occurred between April 2005 and October 15, 2009.
The statement says that among those incidents, it found 1,094 instances when an employee was injured on the job and that “only 26 claims or 2.3% were determined not to be compensable” under workers’ compensation rules.
Mission said it has become more common for a deputy commissioner or the Industrial Commissioner to award attorney fees to the losing party in general and that “the awarding of attorney fees does not necessarily suggest an employer has acted in bad faith.” A local attorney who has won attorney fees from Mission, said the fees are assessed “not when someone has fought a case but (when) they’ve fought them unfairly.” The attorney is also chairman of the Buncombe County Board of Commissioners.
State law says attorney fees can be assessed if there is a finding that a case “has been brought, prosecuted, or defended without reasonable ground.”
Mission pointed out that officials have sometimes disagreed over whether fees were warranted in its cases. It says that overall it has won eight cases before the commission since 1995 and lost eight.
The Industrial Commission does not keep statistics on how often attorney fees are awarded. Some attorneys who practice workers’ compensation law in the state said losing parties do have to pay attorney fees more often than in the past, but that it is still rare. (workersxzcompxzkit)
Attorneys representing plaintiffs in workers’ compensation cases agree assessing fees is very unusual and a rare occurrence, saying these sanctions very serious. There is also concern there may be many unknown cases because Mission told injured employs they could not file a workers’ comp claim.
The statistics also do not explain the hospital’s conduct in cases in which it was sanctioned as the hospital, failed to improve their claims handling process.
Mission Hospital Comments
In an October 2009 statement Mission Hospital said: Mission “has been subject to sanctions by three other Deputy Commissioners, based upon unfounded litigiousness. . . . (Its) prior behavior shows (a) pattern and practice of unreasonable defense of these claims and poor responses and conduct regarding injured employees.” – Kim Ledford, deputy commissioner, N.C. Industrial Commission, July 2004
Mission “has a long and well established history in workers’ compensation claims before the Industrial Commission and Court of Appeals wherein they have been found to have unreasonably denied workers compensation cases and sanctioned with attorney fees, and their actions in denying this claim (are) consistent with such practices.”
- George Glenn II, deputy commissioner, N.C. Industrial Commission, September 2009
“We continually evaluate our process and handling of workers’ compensation, and have periodic reviews by outside consultants.”
Reposted with Permission: Visit LexisNexis Workers’ Comp Law Practice Center for more information and full reports.
TRY OUR FREE TOOLS:
WC Calculator: www.reduceyourworkerscomp.com/calculator.php
WC 101: www.ReduceYourWorkersComp.com/workers_comp.php
Follow Us On Twitter: www.twitter.com/WorkersCompKit
View the Entire Blog: http://blog.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.
©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com
Posted in
