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SNIFFING OUT WORKERS’ COMPENSATION FRAUD. Putting a Leash on Workers’ Compensation Fraud. ARMED ROBBERY WITH A DANGEROUS WEAPON. The ink pen. Workers’ compensation fraud occurs when an employee knowingly lies to obtain benefits. THE RIFF-OFF. Workers’ Compensation Fraud results in:

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sniffing out workers compensation fraud

SNIFFING OUT WORKERS’ COMPENSATION FRAUD

Putting a Leash on Workers’ Compensation Fraud

armed robbery with a dangerous weapon
ARMED ROBBERY WITH A DANGEROUS WEAPON
  • The ink pen.
  • Workers’ compensation fraud occurs when an employee knowingly lies to obtain benefits.
the riff off
THE RIFF-OFF

Workers’ Compensation Fraud results in:

  • An increase in premiums.
  • Withholding of employee raises.
  • Cuts to employee benefits.
  • Job loss.
fraud rap sheet
FRAUD RAP SHEET
  • Insurance fraud costs the average family between $400 and $700 each year in increased premiums.
  • Workers’ compensation fraud cost $80 million in Louisiana alone.
    • A legitimate claim can easily turn fraudulent.
not your usual suspects
NOT YOUR USUAL SUSPECTS
  • Summer baby sitter.
  • Deer hunter.
  • Home for the holidays.
  • No vacation time on the books.
  • Got on my last nerve.
  • The pregnant claimant.
  • The husband and wife tag team.
not your usual suspects7
NOT YOUR USUAL SUSPECTS
  • Doctors.
  • Pharmacists.
  • Therapists.
  • Attorneys.
could it be fraud
COULD IT BE FRAUD?
  • Disgruntled employee.
  • Financial or domestic hardship.
  • Misses medical appointments.
  • Injured worker wants to control the time he can meet with the adjuster or doctor.
  • Applies for unemployment benefits.
  • Physical appearance:
    • Tanned.
    • Calloused hands.
    • Grease under fingernails.
rumors
RUMORS
  • The accident never happened.
  • The injury did not occur at work.
  • The employee can return to work.
  • The employee is working somewhere else.
injured worker is never home
INJURED WORKER IS NEVER HOME
  • The injured employee is difficult to reach.
  • Voice mail always picks up when trying to reach employee by phone.
can t get story together
CAN’T GET STORY TOGETHER
  • Conflicting descriptions of the accident.
  • Not clear on the details of the accident.
  • Provides vague responses to questions.
method of operation
METHOD OF OPERATION

Employee has filed past workers’ compensation claims.

headquarters
HEADQUARTERS

THE EMPLOYER’S ROLE

sound hiring practices
SOUND HIRING PRACTICES
  • Conduct criminal background checks.
  • Drivers’ license and MVA checks.
  • Verify references.
  • Maintain current addresses for all employees.
no excuses
NO EXCUSES
  • Employee education.
  • Employer education.
    • Knowledgeable supervisors and managers.
  • Online claims reporting capability.
  • Fraud hotline.
  • Online fraud reporting capability.
  • Maintain a working relationship with the adjuster.
know fraud indicators
KNOW FRAUD INDICATORS
  • Rumors.
  • Late reporting.
  • Doctor shopping.
  • Voice mail / answering machines.
  • Can’t get the story straight.
  • Friday / Monday accidents.
  • No witnesses.
investigate all accidents
INVESTIGATE ALL ACCIDENTS

Use sound investigation techniques.

  • Obtain accurate information about job-related accidents.
  • Review video surveillance of accident scene.
  • Interview injured workers and witnesses as soon as possible.
    • Separate witnesses.
promote a fraud free workplace
PROMOTE A FRAUD-FREE WORKPLACE
  • Develop a policy statement about WC fraud.
    • WC fraud is a crime.
    • Show employees how fraud affects benefits.
  • Discuss WC policies and procedures with employees.
    • What to do when an accident occurs.
    • Return to work program.
      • Transitional duty employment deters fraud.
        • Find a place for the injured worker to come back to.
periodic safety checks
PERIODIC SAFETY CHECKS
  • Maintain a safe work environment.
  • Have regular inspections of work areas and equipment.
  • Fix hazards immediately.
  • Document all safety checks and repairs.
    • Safety records are evidence.
exit interviews
EXIT INTERVIEWS
  • Discourage post-termination claims.
  • Obtain a signed statement from employee about any unreported injury at work.
fraud proof the workplace
FRAUD- PROOF THE WORKPLACE
  • Complete the first report of injury.
    • Incidents.
    • Near-misses.
  • Report the injury to the carrier immediately.
  • Obtain prompt medical attention.
  • Stay in touch with injured workers.
the precinct
THE PRECINCT

-THE ADJUSTER’S ROLE

special investigation unit
SPECIAL INVESTIGATION UNIT
  • Take recorded statements.
    • Injured worker.
    • Supervisor.
    • Witnesses.
  • Accident Reconstruction.
  • Scrutinize medical documentation.
watch for claim patterns
WATCH FOR CLAIM PATTERNS
  • Symptom magnification.
  • Injured worker is never home.
  • Injured worker always wants medication.
  • Excuses to get out of medical appointments.
  • Doesn’t return state required forms.
  • Will not cooperate with voc rehab.
  • Injured worker is knowledgeable about the comp system.
outside resources
OUTSIDE RESOURCES
  • Medical case management.
  • Vocational rehabilitation.
  • Claims clearinghouse (index system).
  • Surveillance.
surveillance
SURVEILLANCE
  • Coordinate with defense attorney.
  • Same day of a doctor’s visit.
  • Evenings, nights and weekends.
  • Regional and local festivals.
  • Question injured worker about activities seen on the surveillance video.
  • Have the treating physician question the injured worker about his pain level and physical activities.
play it safe
PLAY IT SAFE!
      • DO NOT GIVE THE VIDEO TO THE DOCTOR!
        • Lose right to privileged information.
          • Plaintiff has a right to the video as well.
        • Hold video until after the deposition.
  • Attorney
    • Show surveillance video to defense attorney.
    • Schedule deposition after surveillance.
once you suspect fraud
ONCE YOU SUSPECT FRAUD
  • Get a second medical opinion.
  • Utilize surveillance.
  • Involve law enforcement agencies.
    • Attorney General.
    • District Attorney.
  • Involve professional oversight boards.
    • Pharmaceutical Board.
    • Board of Medical Examiners.
questions to ask
QUESTIONS TO ASK
  • What lie did the injured worker tell to receive benefits?
  • Did the injured worker lie knowingly or intentionally?
  • Was the lie made to obtain or deny benefits?
fraud is a crime
FRAUD IS A CRIME

Workers’ compensation fraud is costly and it’s illegal.

  • Employees who knowingly lie or help someone else provide false information in order to receive benefits
    • 5 years in prison.
    • $5000 fine.
  • Employers who lie to pay lower premiums face
    • 10 years in prison.
    • $10,000 fine.
fraud line up33
FRAUD LINE UP
  • Three comp claimants caught with side jobs in Texas.
  • New York roofer accused of collecting benefits after returning to work.
  • Five years prison for executive convicted of comp fraud.
fraud line up34
FRAUD LINE UP
  • Brooklyn doctor charged with workers’ compensation fraud.
  • Business owner in Massachusetts accused of premium fraud.
  • Ex-paramedic charged with false reporting.
fraud line up35
FRAUD LINE UP
  • Ft. Lauderdale business owner convicted in federal court in July for workers’ compensation employer fraud.
  • $4,600,000 fraud.
  • 60 months in prison with restitution.
help take a bite out of wc fraud
HELP TAKE A BITE OUT OF WC FRAUD
  • Know what to look for.
  • Know what to do.
  • Don’t be afraid to prosecute.
  • Work with law enforcement agencies.
  • Work with professional oversight boards.
references
REFERENCES
  • www.lwcc.com
  • www.nicb.org
  • da.la.ca.us/workers compensation fraud
  • Coalition Against Insurance Fraud
  • www.LAWORKS.net
  • dogthebountyhunter.com/downloads
  • business-insurance.suite 101.com
  • www.tdi.state.tx.us/fraud
  • claimsadvisor.com