It is estimated that in addition to the billions of dollars of legitimate workers' compensation claims that are paid each year, there are approximately $7.2 billion dollars paid out each year in fraudulent claims. This makes workers' compensation one of the fastest growing segments of insurance fraud. Fortunately, not every employee who files a claim is committing fraud. Differentiating between the employees who are and who are not committing workers compensation fraud is not as difficult as you think. Those who are committing fraud will usually fall in one of two basic categories.
The Attention Seekers - These are those employees who have found ways to get attention by filing workers' compensation claims. They often report injuries that did not take place at work, and may file multiple claims compared to other employees. When attempting to identify the attention seekers you may want to look for the following clues:
- They often report injuries that occur unseen by any other employees
- Injuries occur in remote areas of your company that are not covered by a camera
- Their injuries are often not reported immediately after they occur
- Injuries may be reported following leave days, holidays, vacations, or other time away from work
The attention seeker will often require you to spend money on claims and expenses that should not have been filed to begin with. They will take time, attention, and benefits away from the employees who rightfully deserve them. They will require you to launch more in depth investigations into their claims, which may cost you more upfront money, but will save you money in the long run.
The Charlatan - The charlatan is the employee who has actually been injured on the job, but who pretends that their injury is more severe to get more benefits than they are entitled to. These employees are often your malingers. You can usually recognize them by the following symptoms:
- These employees are often non-compliant with their treatment plans by either cancelling, or failing to show up for scheduled doctors appointments or therapy
- Medical providers often have difficulty finding the source of all of their symptoms
- Their symptoms appear to be more severe than expected for the type of injury they incurred
- This employee often doctor shops, or seeks multiple medical opinions in an attempt to find a doctor that will agree they are disabled
- Their injury keeps them out of work much longer than other employees with similar injuries
- They are often unwilling to return to work when the medical providers deem them to be ready to do so
This employee is often more difficult to discern because they do have a legitimate injury. Fortunately, further investigation will often reveal them participating in activities that they should not be able to participate in based on their reported condition.
In your investigation of their claims, look for:
- Multiple injury claims filed with you, or other employers if they have not been with your company for a long period of time
- Secondary employment during the time they are drawing workers compensation benefits with you
- Social media posts showing them engaged in activities outside of their doctor's recommendations
- Verbal reports from co-workers, friends, and neighbors about outside activities that are not consistent with their restrictions
Once you have identified a case that you suspect is a case of fraud, you owe it to your company, as well as to your other employees to launch a full investigation. Failure to do so will not only cost you money that will increase the cost of your workers compensation claims and impact your bottom line, but it will also affect the moral of your other employees. Contact a local workers compensation attorney to find out how to proceed.