Important Times to Use Surveillance in Workers’ Comp Claims

Effectively managing workers’ compensation requires careful oversight and proactive measures to identify and prevent fraudulent or exaggerated claims. Surveillance serves as a powerful tool in validating claims, protecting your organization’s financial health, and ensuring resources are dedicated to genuinely injured employees. Here are critical situations in which using surveillance can significantly strengthen your workers’ compensation strategy:

1. Claimant Claims Total Disability

Surveillance is particularly valuable when an employee claims total disability, meaning they cannot perform any work-related activities whatsoever. In such cases, even minimal documented evidence of the employee engaging in ordinary activities could be sufficient to dispute the claim.

Video or photographic evidence of the claimant performing physical tasks like gardening, driving, or lifting objects can significantly strengthen your case, highlighting discrepancies between the reported disability and the claimant’s actual capabilities.

2. Verification of Information and Anonymous Tips

Act promptly when anonymous tips or workplace rumors suggest that an injured employee might be involved in activities inconsistent with their claimed disability. Even if you suspect what the surveillance will reveal, obtaining concrete evidence is essential.

Credible documentation provided by surveillance can confirm or refute these suspicions, enabling informed decision-making and potentially saving your organization significant costs.

3. Financially Devastating Claims

If a claim has the potential to be financially devastating or catastrophic to your organization’s fiscal health, immediate and consistent surveillance is imperative. Large claims can have significant long-term impacts on premiums, experience modification factors, and overall workers’ compensation costs.

Thorough surveillance can mitigate risk by ensuring only legitimate claims receive payment, protecting your financial stability.

4. Claims Lacking Solid Proof

Before authorizing payment for a substantial claim, ensure a thorough investigation through surveillance. Sub-rosa investigations—undercover surveillance designed to discreetly document claimant activity—provide evidence to substantiate or challenge the severity of reported injuries.

Without concrete proof of disability, substantial payments based merely on assertions or incomplete medical reports could lead to unwarranted financial losses. Surveillance delivers verifiable information crucial to accurately assess the claim’s true value.

5. Ambiguous Situations

Some claims simply don’t add up or leave unanswered questions regarding the claimant’s activities and true physical condition. Surveillance can be indispensable in these ambiguous situations, as a detailed video or photographic record provides clarity and prevents confusion or exploitation of uncertain circumstances.

The evidence collected through surveillance often conveys far more effectively the actual scenario than written documentation alone—truly demonstrating how a picture can be worth a thousand words.

Update Surveillance Regularly

It is essential to recognize that investigations conducted months or even years prior to settlement may no longer accurately reflect the claimant’s current condition. Frequent updates through regular surveillance, particularly close to settlement decision times, provide the most accurate and up-to-date portrayal of the claimant’s capabilities and condition.

Consistent monitoring helps ensure settlements accurately reflect present circumstances, rather than outdated or irrelevant information.

Pay Attention to Workplace Indicators

Remain vigilant within your organization for common fraud indicators, such as frequent inconsistencies in employees’ accounts of their injuries or recovery, lack of medical corroboration, delayed reporting, or employees who are difficult to contact or frequently miss medical appointments. Early recognition and rapid response to these indicators via surveillance and investigation can significantly curtail fraudulent claims and associated expenses.

Conclusion

In summary, strategic surveillance is a critical component of a comprehensive workers’ compensation management strategy, essential for protecting your organization from exaggerated, fraudulent, or catastrophic claims. Recognizing these key situations and acting decisively ensures your organization’s resources are used appropriately, supporting employees who genuinely require assistance while preventing exploitation and unwarranted financial loss.

Michael Stack, CEO of Amaxx LLC, is an expert in workers’ compensation cost containment systems and provides education, training, and consulting to help employers reduce their workers’ compensation costs by 20% to 50%. He is co-author of the #1 selling comprehensive training guide “Your Ultimate Guide to Mastering Workers’ Comp Costs: Reduce Costs 20% to 50%.” Stack is the creator of Injury Management Results (IMR) software and founder of Amaxx Workers’ Comp Training Center. WC Mastery Training teaching injury management best practices such as return to work, communication, claims best practices, medical management, and working with vendors. IMR software simplifies the implementation of these best practices for employers and ties results to a Critical Metrics Dashboard.

Contact: [email protected].

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Injury Management Results (IMR) Software: https://imrsoftware.com/

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