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A critical part of controlling workers’ compensation costs is to put into place solid investigation techniques. No matter how severe or minor a workplace injury, each case needs to be reviewed to identify any fraudulent claims and take appropriate action.
When communicating with employees, make it clear that the company will:
- Immediately investigate each accident when it occurs to determine the root cause
- Identify corrective measures
- Watch for minor extensions of days out of work and outright fraudulent claims.
Review these Red Flags of Fraud and request an investigation if you suspect a claim is illegitimate or exaggerated.
Injured Worker Red Flags:
- Injury reported late, to an attorney or to the state commission before reporting it to the employer.
- Fails to attend weekly meetings.
- Is uncooperative, e.g., refuses to try a transitional duty job.
- Is never home when you phone, especially during regular workday hours.
- Has only a postal box rather than a home address.
- Misses doctor appointments.
- Is known to perform seasonal activities, hobbies, or work.
- Has moved out of town or out of state.
- Disputes average weekly wage due to additional income.
- Files for benefits in a state other than the main location.
- Disputes information supplied by the employer on “First Report of Injury” notice.
- Refuses to cooperate in claim investigation.
- Has an unstable work history.
- Has recently been terminated, demoted, or passed over for promotion.
- Has a prior history of injury management or liability claims.
- Makes excessive demands or is pressing for a quick settlement.
- Carries little or no health insurance.
Medical Flags:
- Medical reports are repetitive, indicating continuing, constant pain with conservative medical treatment
- The word “disproportionate” is used in medical reports
- The doctor mentions there is “facial grimacing”
- Positive “Waddell Tests” (test for low back pain) are mentioned
Workplace Flags:
- Employer experiencing labor difficulties (i.e., layoffs, strikes, walkouts).
- Tips from fellow workers, friends, or relatives.
- The insurance company wants to settle the claim for a considerable amount of money.
“Things” just don’t ADD UP! Trust your gut, and if something seems off, be sure to check it out.
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