A critical part of controlling workers’ compensation costs is to put into place solid investigation techniques. No matter how serious or minor a workplace injury, each case needs to be reviewed to identify any fraudulent claims and take appropriate action.
When communicating with employees make it clear the company Immediately investigates each accident when it occurs to determine the root cause and to identify corrective measures. And, will be on the alert for both minor extensions of days out of work and outright fraudulent claims.
Review these 25 Red Flags of Fraud and request an investigation if you suspect a claim is illegitimate, or exaggerated.
Claimant Flags:
Injury reported late, to an attorney or to the state commission before reporting it to the employer.
Fails to attend weekly meetings.
Is uncooperative, i.e., refuses to try a transitional duty job.
Is never home when you phone, especially during normal workday hours.
Has only a postal box rather than a home address.
Misses doctor appointments.
Is known to perform seasonal activities, hobbies, or work.
Has moved out of town or out of state.
Disputes average weekly wage due to additional income.
Files for benefits in a state other than the principle location.
Disputes information supplied by the employer on “First Report of Injury” notice.
Refuses to cooperate in claim investigation.
Has an unstable work history.
Has recently been terminated, demoted, or passed over for promotion.
Has a prior history of injury management or liability claims.
Makes excessive demands or is pressing for a quick settlement.
Carries little or no health insurance.
Medical Flags:
Medical reports are repetitive, indicating continuing, constant pain with conservative medical treatment.
The word “disproportionate” is used in medical reports.
The doctor mentions there is “facial grimacing.”
Positive “Waddell Tests” (test for low back pain) are mentioned.
Workplace Flags:
Employer experiencing labor difficulties (i.e., layoffs, strikes, walkouts).
Tips from fellow workers, friends, or relatives.
Insurance company wants to settle the claim for a huge amount of money.
“Things” just don’t ADD UP!
Author: Robert Elliott, J.D.
Try the WC Cost Calculator to show the REAL COST of work comp.
Look at WC 101 for the basics about workers comp.
Workers’ Comp Kit® is a web-based online Assessment, Benchmarking and Cost Containment system for employers. It provides all the materials needed to reduce your costs significantly in 85% less time than if you designed a program from scratch.
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.
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