Most employees injured at work are honest and want to recover and return to their jobs as soon as possible. There are workers, however, who are repeat workers’ comp claim offenders, creating headaches for their employers and those handling their TPA/carrier.
Repeat workers’ comp claim offenders are annoying at best and their claims can be extremely time-consuming and expensive at worst. Before casting aspersions on these employees with multiple workers’ comp claims, or giving up altogether, there are steps you can take to determine a) if the worker is committing workers’ compensation fraud and b) stop him from sustaining repeat injuries.
Legit or Not?
While it may seem obvious that a worker who has frequent injuries is trying to game the system that may not be the case. Diligent employees who are willing to do whatever it takes to get the job done may take safety shortcuts or act in others ways that place them at increased risk of injury; the person may be just naturally clumsy, or he may be unaware of the proper ways to undertake certain tasks.
It’s important to separate those who are intentionally getting injured (or claiming to get injured) from those who just need more and better training and education. Once that is done, you can address the issue(s) at play.
The key to determining why a particular employee has sustained multiple injuries and whether he is intentionally claiming injuries is to conduct a thorough investigation and let the worker know you are aware of it and concerned about him.
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Steps to Uncover Intent
You want to find out why the worker continues to be injured. Several strategies should be undertaken before you jump to the wrong conclusion.
- Resist your first temptation. All employees deserve respect — even repeat offenders. Dealing with the same worker multiple times for injuries can be frustrating. But you won’t uncover the problem unless you approach each injured worker the same and evaluate each claim on its merits. That means giving the worker the benefit of the doubt — at least until and unless you determine something untoward is happening.
- Investigate the injury. This is always important, but especially so if the person has a history of injuries. The steps should include
- Gather statements about the injury from the employee, supervisor, witnesses, and the treating physician. Try to understand how and why the injury occurred, the extent of the person’s injury and what he is or is not capable of doing during his recovery.
- Determine causation. Talking with the physician and other stakeholders will help determine if the workplace was the actual cause of the injury, or if it was something else. Several steps to determine causation include
- Evidence for a causal relationship – do studies support a link
- Evidence of exposure – highest quality data are quantified personal measurements of the worker’s tasks, while lowest quality are job title or self-report of exposure
- Other relevant factors – comorbidities, prior injuries, etc.
- Judge the validity of the testimony – make a judgment call on what is true or false
- Evaluate and conclude
- Talk to the treating physician. You might get some insights into whether there is a specific problem causing frequent injuries with the worker. You might also determine that the worker is physically incapable of doing the job without risking injury. Even if the employee was cleared to do the work initially, something might have changed in his physical abilities.
- Get peer reviews. If the treating physician is not forthcoming or if you suspect the physician is not providing the best treatment for the injured worker, have another physician intervene. The insurance carrier or TPA may have a medical provider who can speak directly with the treating physician and get answers.
- Consider root cause analysis. While a formal root cause analysis may be unnecessary, you want to look closely at all the circumstances surrounding the incident, especially if the worker gets repeatedly injured doing the same types of tasks. Rather than laying blame on the worker, you may uncover something else. For example, the worker may put the ladder he uses at the same height as another colleague who is much taller. That could force the worker to have to reach above his head, putting him at risk of injury. His physique may be such that the equipment he’s using is inappropriate for the specific task. Uncovering such a simple cause can be easily rectified.
- Talk to the injured worker. You may find there is a simple reason the person continually gets injured. Or you may get a sense the worker has something else going on
- Unhappy with supervisor
- Personal challenges at home. Problems with spouses and/or children can distract a worker, so he becomes sloppy with safety practices
- Psychosocial issues
- Anger at the company. The employee may feel overworked, or that he was unfairly passed over for a promotion
If your investigation leads you to believe the worker is truly a frequent claim filer, you should still treat him with respect but make his fraudulent actions more difficult. You want to investigate the claim aggressively. Also, any psychosocial issues of which you are aware should be shared with the claims adjuster and/or TPA.
You may want to find out if the worker has been a frequent claim filer at other companies. Doing an ISO claims search, for example, may point up other instances where the worker has filed multiple workers’ compensation claims.
Conclusion
Employees who file multiple workers’ comp claims can be a drain on money and other resources. If you have a worker who is often injured, you need first to determine if the person is experiencing legitimate injuries or abusing the system. Then determine how you can prevent further injuries or — in the case of a repeat offender — deal head-on with the worker and explain you will be watching him carefully and taking aggressive action up to and including termination.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .
Contact: [email protected].
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