Fraud may be present if the accident itself is
unwitnessed, occurs just prior to a strike, immediately prior to job
termination, retirement or layoff, or at the end of seasonal work or
probationary periods. It may also occur if it happens just after workers return
from a leave of absence.
An employer should be alert for fraud if
the injured employee was disgruntled at the time of the accident, has been a
poor performer, has unexplained absences shortly before the injury, is new to
the company or job, has a history of frequent job changes, is in financial
difficulty, has other family members also receiving work comp benefits or other
social insurance benefits, earns extra money by moonlighting, is in college, or
is known to participate in contact sports or physically demanding hobbies.
Other signs may include someone who has a history of frequent injuries of a
subjective nature, receives income from workers' compensation benefits and
other collateral sources, is difficult to reach at home or returns calls with
incongruous background noises, frequently changes medical providers or
attorneys, has recently purchased one or more disability policies, demands
quick settlement decisions or commitments, is usually familiar with work comp
claims, and/or is consistently uncooperative.
Circumstances relating to treatment are
suspicious if the injuries are subjective, such as pain, headaches, nausea,
inability to eat or sleep, etc. Other treatment-related "red flags" are where
an injured worker refuses a diagnostic procedure to confirm injury, a lab
report or physician's report appears identical to those issued for other
individuals, any required testing by a third party appears identical to those
performed for other individuals, treatment or testing is performed by a lab or
separate facility where the physician has an interest, medical bills are
photocopies instead of originals, claimant requests reimbursement to self
rather than medical providers, the health care providers show reluctance to
release information over the phone and/or treatment dates occur on Sundays,
holidays, or other unusual times.
The employer should be suspicious if the
attorney/doctor combination was seen previously for similar claims. When an
attorney representation letter is dated within the same day or soon after the
accident occurred, this should draw suspicion. Also, when an attorney pushes
for quick settlement or lump-sum early in the life of the claim, or the
attorney bills the claimant clearly excessive fees or bills unnecessary or
unperformed activities, one should be suspicious.