Identifying Workers’ Compensation Fraud
Consider these factors to detect potentially fraudulent claims.
While the majority of workers’ compensation claims are truthful, the National Insurance Crime Bureau reports that billions of dollars of false claims are submitted each year. To help you detect possible workers’ compensation fraud, experience shows a claim may be fraudulent if two or more of the following factors are present:
1. Monday Morning: The reported injury occurs first thing on Monday morning, or it occurs late on Friday but doesn’t get reported until Monday.
2. Employment Change: The reported accident occurs just before or after a strike, layoffs, the conclusion of a big project or the end of a seasonal job.
3. Job Termination: If an employee files a post-termination claim:
o Was the alleged injury reported by the employee prior to termination?
o Did the employee exhaust their unemployment benefits prior to claiming workers’ compensation benefits?
4. History of Changes: The employee has a history of frequently changing physicians, addresses and places of employment.
5. Medical History: The employee has a pre-existing medical condition similar to the alleged work injury.
6. No Witnesses: The accident has no witnesses and the employee’s description does not logically support the cause of injury.
7. Conflicting Descriptions: The employee’s description of the accident is significantly different from the medical history or first report of injury.
8. History of Claims: The employee has a history of multiple suspicious or litigated claims.
9. Treatment Is Refused: The employee refuses a diagnostic test or procedure to confirm the nature/extent of the injury.
10. Late Reporting: The employee delays reporting the claim without a reasonable explanation.
11. Hard to Reach: You have difficulty contacting a claimant at home when they are allegedly disabled.
12. Moonlighting: Does the employee have another paying job or do volunteer work?
13. Unusual Coincidence: There is an unusual coincidence between the employee’s alleged date of injury and their need for personal time off.
14. Financial Problems: The employee has tried to borrow money from coworkers or the company, or requested pay advances.
15. Hobbies: The employee has a hobby that could cause an injury similar to the alleged work injury.
Remember, these warning signs are simply indicators.
