Stopping Fraud with Video Proof
3 Action Steps to Use When Contacting Your TPA
Once you suspect an injured employee of lying about an injury, launch an investigation. With video proof the injured employee’s range of motion is not as stated, you document these facts with a doctor.
The next step is legal and it’s time to contact your third party-administrator (TPA).
1. Send a letter stating the nature of the employee’s fraud by:
Overnight priority mail.
With a confirmation receipt and tracking.
Enclose the investigation report and video.
Enclose a completed transitional assignment form.
2. Next the injury coordinator needs to include a cover letter detailing the situation. This letter must include the employee’s name, claim number, your company name and contact information, with an explanation:
That the company’s policy is to verify that employees who tell us they cannot perform a transitional duty job are actually unable to perform such work because you accommodate any restrictions provided to the company by the treating doctor.
Tell your TPA the company paid for this investigation directly and will keep a copy in the files in case there are any subsequent employment-related claims.
Explain the investigator’s report indicates Mr. X can do strenuous yard work for an extended period of time. Thus, he has more ability than he has told his doctor.
Note the company will make good on its offer to give Mr. X a transitional duty position in the transitional duty program based on the report.
Explain if Mr. X refuses the job offer, your company will notify the TPA immediately and request they file a Motion to Discontinue Benefits according to state law.
Note a copy of the new job offer is attached.
3. Lastly, you must ask your TPA about legal recourse. One way of phrasing this is as follows:
“We are also interested in pursuing any criminal and/or civil action and ask you to request the head of your Special Investigation Unit to contact me immediately to discuss whether this claim rises to the level of fraud in our state.” (workersxzcompxzkit)
4. Request a Meeting with the SIU (special investigation unit) at the carrier to see if additional evidence is likely to be needed.
Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: [email protected] or 860-786-8286.
WC Calculator: www.reduceyourworkerscomp.com/calculator.php
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WC 101: www.ReduceYourWorkersComp.com/workers_comp.php
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker about workers’ comp issues.
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