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*This section is provided as a quick reference tool only.
(see disclaimer at the bottom)

Tips for Recognizing Fraud

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.

*This section is provided as a reference tool only. Benefit rates as well as State agency contacts, phone numbers and addresses may change periodically and are not guaranteed. Please send notification of any changes to support@workerscompensation.com