1- Provide each new employee with information on your workers’ comp program. This should include a clear statement noting that while you pay legitimate claims quickly and fairly, you will investigate all questionable claims thoroughly.
Click Link to Access Free PDF Download
“The 5Cs to Taking a Bulletproof Injured Worker Recorded Statement”
2- Immediately look for red flags if you receive a report that an accident has occurred. These can include accidents occurring with no witnesses and/or accidents occurring around the opening dates of local hunting season, school vacation, etc.
3- Talk with anyone and everyone who might have been or should have been in the area at the time of the alleged incident. Often, these people will explain they did not see an accident, or they may report that they did not see “any indication” of an accident actually occurring, which should raise a red flag. For example, a witness might see an employee right after an alleged accident and note an absence of anything unusual. This information is useful and indicates you need to investigate further.
4- Look for signs of potential fraud later on such as notes from the employee’s physician saying the employee needs to be out of work for an unreasonably long period of time while finding that the employee is never at home when you call, etc. Make sure to compare the proposed length of time out of work with disability duration guidelines. Signs of fraud can be seen at many times during the course of a claim, not just at the time the claim is filed.
5- Require every injured employee to visit your company physician or clinic to verify the extent of the injury. Your physician should then communicate directly with the employee’s physician unless precluded by state law. Often, when the employee’s physician receives this type of inquiry, he or she will release the employee back to work if the original directive for time off work was excessive. Explaining illogical medical reasons for excessive time out of work is more difficult when a doctor is speaking with another doctor.
6- Share your concerns about possible fraud with your adjuster and ask them to investigate the claims. Many adjusters do not investigate aggressively for a variety of reasons such being criticized for spending the extra money even though you have a cost reimbursable insurance program meaning your company pays for all expenses. Arrange to have surveillance conducted over a period of time, not just one day so you don’t have to defend against “good day, bad day syndrome.” It is important to work with your corporate counsel in arranging surveillance to make sure you do not violate any laws. If you have to, have corporate counsel hire an investigator directly so the company is in a better position to defend any other claims that may arise from this claim.
7- Don’t cut corners on the investigation of this claim. These claims can be large and costly. For example, if I am looking at a $100,000 claim that is suspicious, I may spend $10,000 on the investigation. I do not set an arbitrary cut-off number; I look at it as “investing” in the workers’ comp cost containment program. Take a “Can DO” approach. This is not the claim to reduce expenses on – reduce expenses on another claim rather than the phantom accident. Fortunately, there are not a lot of these claims, but you will need to work the few phantom claims you have aggressively. It is a huge deterrent to the next person that tries to file this type of claim.
For more cost-saving tips go to WC Cost Reduction Tips. Show the REAL cost of workers’ comp with the Real Cost Calculator. Workers’ Comp Kit® is a web-based online Assessment, Benchmarking and Cost Containment system for employers. Do not use this information without independent verification. All state laws are different. Consult with your corporate legal counsel before implementing any cost containment programs. ©2008 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.
