• Menu
  • Skip to main content
  • Skip to secondary navigation
  • Skip to primary sidebar
  • Skip to footer

Before Header

  • Search
  • About
  • Contact
  • Privacy
 
CHOOSE BROADSPIRE

Amaxx Workers Comp Blog

Reduce Workers Compensation Costs By 20-50%

Header Right

  • Home
    • Training Center
  • Get Started
    • Newcomers Class for WC Professionals
    • Subscribe to Free Newsletter
    • Free Training Center Account
    • Return to Work Resources
    • WC Claims Mgmt. Resources
    • Insurance Advisor Resources
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login

Mobile Menu

Choose Broadspire

CHOOSE BROADSPIREBroadspire Delivers Meaningful Results to Our Clients and Their Claimants
  • Home
    • Training Center
  • Get Started
    • Newcomers Class for WC Professionals
    • Subscribe to Free Newsletter
    • Free Training Center Account
    • Return to Work Resources
    • WC Claims Mgmt. Resources
    • Insurance Advisor Resources
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login
  • Search
  • About
  • Contact
  • Privacy
You are here: Home / Claim Management / Fight Workers Comp Fraud & Abuse / Up to 39% of Work Comp Claims Involve Malingering

Up to 39% of Work Comp Claims Involve Malingering

July 9, 2015 By //  by Michael B. Stack Leave a Comment

Most workers compensation employees would not think or stoop to actual fraud for a workers compensation claim. Most studies have found actual fraud is 1 or 2 percent of all claims presented.

However, other studies show that malingering might be as high as 39 percent in some area of claims presented.  Sadly both fraud and malingering cases are on the rise.  The basic cause for perpetration is financial gain.

Periodically a workers compensation fraud case may appear in the daily news media.  This usually brings a momentary flurry of concern.   Occasionally, a legislature may be moved to legislative remedy if the cause is really unique or new.

Click Link to Access Free PDF Download

“The 5Cs to Taking a Bulletproof Injured Worker Recorded Statement”


Indications of Malingering:

Malingering is generally difficult to prove.  Workers Compensation courts generally favor employee testimony over employers if there is even the slightest of evidence to the employees.  This is in keeping with the general unwritten directives that the judges shall interpret most liberally in favor of the employee.

Substantial proof by video surveillance, activity checks, medical examinations, witnesses, and unavailability of the claimant are basics that will help employers prove a malingering case.

Adjusters and Employers need to be alert to the few following points that may suggest malingering:

  1. The employee is hard to contact.
  2. There are great gaps in treatment
  3. The claimant often misses treatments, physio therapy, and doctor appointments
  4. The employee resists Independent Medical Examinations or fails to show for one.
  5. The injury co-insides with reductions in force, vacations, holidays,
  6. Symptomology complaints are: vague, don’t connect with normally expected physical conditions, seem exaggerated, or do not co-inside with physical facts of the injury.
  7. Reports from doctors, nurse case managers, physio therapists that the employee appears in better physical condition than claimed.
  8. The claim was not reported until after termination.
  9. The injury occurred shortly after employment.
  10. Disability extends longer than normally expected recovery periods.
  11. There are no witnesses to corroborate the employee’s history of how the loss occurred.
  12. Disagreement between doctors as to disability.
  13. Premature or excessive demands for benefits or treatment by the employee.
  14. The employment was seasonal and the injury occurred shortly before the end of the employment period or was reported shortly after the employment ended.
  15. Lack of organic basis for symptom complaints.
  16. Tips from neighbors, fellow employees, doctors, therapists, nurse case managers.
  17. The employee has financial problems.
  18. Prior claims that may indicate exaggerations, malingering etc.
  19. Claimant changes doctors frequently or without authorization,
  20. Course of treatment is questionable or not in keeping with the expected injuries due to the mechanics of the injury description.
  21. The job performance was below par and the employee was not likely to have a favorable reference.
  22. The claimant has a history of multiple claims.

Defense Steps:

As soon as any of the preceding incidents appear the following procedures or more should be employed;

  1. Arrange for an immediate medical management by a nurse case manager.
  2. Arrange for a specialist Independent Medical Examination.
  3. File a petition for benefit and or medical termination. (This can always be withdrawn if facts change before a trial date.  However, if facts are ready by trial date there will be less delay to go forward.  Further non-compliance by claimant to appear for IME can be addressed.
  4. Arrange for activity and surveillance video at once.  Be sure the surveillance is set to co-inside with the times it is known the employee will be moving or active. I.e. Doctor appointments, benefit check mail arrivals, weekends, holidays, weather conditions, evening activities, and early morning visits to determine times that may indicate reporting to another job.
  5. Unscheduled visits by nurse case managers.
  6. Multiple daily attempts to reach the claimant by the adjuster or employer.
  7. Unscheduled visits by employer representative and claim adjuster.
  8. Explore claimant on all social media and background services.

    FREE DOWNLOAD: “The 5Cs to Taking a Bulletproof Injured Worker Recorded Statement “

Others that may be aiding in Malingering:

Plaintiff attorneys stand to have more income the longer the employee receives benefits.  Most jurisdictions limit fees to 20% of benefits.  While the attorney fee might be minimal frequent collections do add up fast.

Attending physicians may also have income for extra treatments.  Many doctors also have the same employee as a private patient.  That means reluctance to offend or question the employee’s motives.

Doctors may tend to over treat to avoid possible mal-practice charges.

Chiropractors, physiotherapists, and other medical practitioners gain by frequent visits and treatment.

Pharmacies may not pay attention to or watch for drug abuses.

Conclusion:

Malingering is hard to detect.  Close case management and monitoring is demand by adjuster and employer.  As soon as any indication occurs immediate and proactive defenses must be set in motion.

Author Michael B. Stack, Principal, COMPClub, Amaxx Work Comp Solutions. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool.  He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com, and Founder of the interactive Workers’ Comp Training platform COMPClub. Contact: mstack@reduceyourworkerscomp.com.

©2015 Amaxx LLC. All rights reserved under International Copyright Law.

SALES TO PAY FOR ACCIDENTS CALCULATOR:  http://reduceyourworkerscomp.com/sales-to-pay-for-accidents-calculator/

MODIFIED DUTY CALCULATOR:   http://reduceyourworkerscomp.com/transitional-duty-cost-calculators/

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

WORKERS’ COMP TRAINING: https://workerscompclub.com

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

FREE DOWNLOAD: “The 5Cs to Taking a Bulletproof Injured Worker Recorded Statement “

Filed Under: Fight Workers Comp Fraud & Abuse

Related Articles

Complete A Better Accident Investigation

Complete A Better Accident Investigation

One Critical Step To Start Any Injured Worker Investigation

One Critical Step To Start Any Injured Worker Investigation

Can You Spot the Workers Comp Fraud Red Flags?

Can You Spot the Workers Comp Fraud Red Flags?

Pro-Actively Stop Workers’ Comp Fraud Before It Starts

Pro-Actively Stop Workers’ Comp Fraud Before It Starts
workers compensation red flags of fraud

The RED FLAGS of Workers Comp Fraud

The RED FLAGS of Workers Comp Fraud

Surveillance in Workers’ Compensation

Surveillance in Workers’ Compensation

Responsibilities of a Workers’ Comp Claims Investigation Leader

Responsibilities of a Workers’ Comp Claims Investigation Leader
TEN Steps Every Adjuster Should Perform In a Workers Comp Claim Investigation

10 Steps Every Adjuster Should Perform In a Workers Comp Claim Investigation

10 Steps Every Adjuster Should Perform In a Workers Comp Claim Investigation

Detecting Workers’ Compensation Fraud

Detecting Workers’ Compensation Fraud

Surveillance is Often Used Incorrectly

Surveillance is Often Used Incorrectly
Five Clues an Injured Employee is Dragging Out a Workers Compensation Claim

Five Clues an Injured Employee is Dragging Out Their Workers Compensation Claim

Five Clues an Injured Employee is Dragging Out Their Workers Compensation Claim

Effective Workers’ Comp Claim Investigation Techniques

Effective Workers’ Comp Claim Investigation Techniques

Free Download

The 5 Cs For Taking A Bulletproof Injured Worker Recorded Statement - FREE Download Click Here Now!

Train to Succeed

BECOME CERTIFIED IN WORKERS’ COMPENSATION

Proven Course Catalog & WC Toolbox Give You The Power To Achieve Lower Costs and Better Injured Worker Outcomes

VISIT WORKERS' COMP TRAINING CENTER

Previous Post: « British Firm Sentenced, 4 Workers Suffer Injuries
Next Post: CDI Leads Statewide Multi-Agency Outreach Effort »

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

FREE DOWNLOAD

The 5 Cs For Taking A Bulletproof Injured Worker Recorded Statement - FREE Download Click Here Now!

Our Sponsors

Broadspire

Workers’ Comp 3rd-Party Administrator
 

Catastrophic Care Management, Complex Care, and Specialty Networks
 

Ametros

Post-Settlement Administration
 

Medicare Secondary Payer Services
 

Medcor

Injury Triage, Onsite Clinics

Read Our Award-Winning Blog

Blog Categories

Search Our Archive

Subscribe to Our FREE Newsletter

Footer

Search Our Archive

Search our continually growing archive of over 2500 articles about Workers' Comp issues.

Quiclinks

  • Calculators
  • Terms & Abbreviations
  • Glossary of WC Premium Terms
  • WC Resources
  • Best Practices
  • Industries

RSS Recent Blog Posts

  • Big Employer Mistake In Work Comp is No Employee Rapport
  • 20 Unfair Claim Practices For Your Adjuster To Avoid
  • Use Vocational Coordination When Employees Are Unable To Return to Work
SUBSCRIBE TO OUR FEE NEWSLETTER
Let Us Help You Stomp Down the High Cost of Workers' Comp!
Top of Page ↑
  • Home
  • Training Center
  • Get Started
  • Membership
  • Products
  • Blog
  • About
  • Contact
  • Subscribe
  • Login
Copyright © 2021 Amaxx, LLC. All Rights Reserved. · Privacy Policy / Legal Notice