Fraud Alert: Warning Signs of Workers’ Compensation Claims

Third in a series of installments on workers’ compensation coverage

Having covered the circumstances that make a workers’ compensation claim compensable in a previous post (see it here), let’s take a moment to look at the other side of the coin: signs that a claim might be fraudulent.

Various sources estimate that fraudulent claims cost employers and insurers from $6 billion to $7 billion annually, at least 10 percent of the total of $60 billion paid out in claims each year. So there’s a very strong motivation to root out cases of fraud.

Having said that, employers must tread carefully in leveling accusations of fraud for fear of opening themselves to legal repercussions should a claim turn out to be legitimate. None of the following warning signs necessarily constitutes a fraudulent action in and of itself. Rather, look for patterns and investigate further as necessary.

Here are some red flags indicating that a claim may warrant deeper investigation:

• Filing multiple claims
• Longer absences from work than initially expected
• An unwillingness to return to work
• Unwillingness to accept lighter-duty or partial-duty assignments
• Multiple medical appointments missed
• Incomplete details from employee on date, time or location of the incident that caused injury
• Employee has no recollection of services provided for related medical bills
• Lack of witnesses to an accident or incident
• Employee is unable to produce specific information about the nature of the injury
• Employee has a history of short-term employment

Again, these are indicators and do not necessarily constitute fraud, but these circumstances are often found in fraudulent claims.

Questions about workers’ compensation claims? Contact Consolidated Insurance.