Do you know the signs of workers’ compensation fraud?
Workers’ compensation insurance – or workman’s compensation insurance, as it is sometimes called – is a type of insurance that protects employees who develop an illness as a result of their job environment or are injured on the job. It is designed to pay for medical expenses related to the illness or injury, and provide wage replacement during recovery.
Workers’ compensation settlements are often made in cases where treatment and/or recovery is likely to be extensive and a lump sum payout is appealing to both parties.
There are rules, of course, for what constitutes a workplace-related illness or injury. Illnesses and injuries cannot be in violation of a company’s policy and cannot be self-inflicted, as examples. But people determined to break rules for personal gain have numerous and creative ways of committing workers’ compensation fraud (and finding ways to score a tax-free settlement).
Fraudulent workers’ compensation claims can translate to significant financial and productivity losses. If you suspect workers comp fraud, look out for these 14 warning signs that your employee, or even a ring of employees, may be gaming the system:
1. No witnesses.
Bogus workers’ compensation claims often have no witnesses who can verify when, where, why and how the illness or injury occurred.
2. Unlikely scenario.
Anything may be possible, but some things just are not likely. If an employee reports an incident description that doesn’t add up, it may well be worth investigating.
3. Conflicting stories.
The first-hand account of what happened changes between tellings, or witnesses interpreted the scenario differently from the reportedly ill or injured person.
4. Monday reports.
Fraudulent workers’ comp claims typically describe an incident that occurred on Friday afternoon that wasn’t reported until Monday morning.
5. Telling social media posts.
A lot of employees follow their employers and/or don’t protect their social network profiles. If your employee went rafting over the weekend or gave details about an illness or injury that happened outside of the workplace, they may have documented it online.
6. Late reports.
Some claimants have no explanation for their tardy report. It’s just … late.
7. Conflicting reports.
The medical report and the employee report don’t match.
8. Declined treatment.
Those working hard to conceal the truth about the existence or severity of their illness or injury will likely decline medical attention or diagnostic treatment.
9. Suspicious providers.
Some medical providers are in on the act and will corroborate a claim to get a piece of the pie. They tend to have a reputation, so pay attention to who’s giving care.
10. New providers.
Employees who frequently switch primary care physicians may be up to something.
11. Frequent job transitions.
Similar to the strategy of changing health care providers, an employee whose LinkedIn profile or resume demonstrates frequent job transitions may be working a scheme.
12. Sudden job transition.
There’s nothing so convenient as confusion. Fraudulent workers’ compensation claims often come right before or after the conclusion of a seasonal job, a resignation/termination or furlough/layoff.
13. Claim history.
A major red flag is an employee whose claim history includes several workers’ compensation or other insurance-related claims.
14. Missing in action.
Be mindful of the employee supposedly convalescing from an illness or injury who is suddenly unavailable by phone or email.
We’re Here To Help.
Skidmore & Associates’ private investigators and intelligence professionals are licensed and credentialed to pursue workers’ comp fraud cases – and any other corporate and insurance-related investigations you may need to launch. Whether you need a highly experienced team to build a case from the ground up, or have an internal investigation division and need to eliminate any perception of bias, we can help.
Workers’ comp fraud is common, but it doesn’t need to be costly or controversial for your company.
We service the Carolinas and have offices in Rock Hill and Myrtle Beach. Connect with us. Let’s uncover the truth.
