Workers’ Compensation Fraud: What to Look For

Workers’ compensation insurance fraud can be committed by employees, employers, insurers, agents, doctors, lawyers or anyone else involved in the workers’ compensation process. But workers’ comp fraud primarily penalizes employers and their employees.

When someone fakes or exaggerates a job-related injury or illness to collect benefits, it often causes insurance rates to go up, which can leave employers with less money to provide employees with raises, paid vacations and other benefits.

While the majority of workers’ comp claims are filed in good faith, experts agree that a number of them are fraudulent and that employers should be on the lookout for the following warning signs.

Red flags include claimants who:

• Do not complain when their checks are late, or fail to show up to collect their checks.
• Present conflicting medical information.
• Change the frequency of communication with claims adjusters.
• Claim injuries that are not easily detected, such as back and neck injuries or carpal tunnel syndrome and other conditions related to repetitive motion trauma.
• Have prior workers’ compensation claims history.
• Present claims for non-labor intensive injuries.
• Present pain-related injuries but refuse to undergo surgery or physical therapy.
• Present claims related to mental health.
• Are uncooperative and argumentative.
• Present diagnosis changes after or during claims periods.
• Fail to keep scheduled medical examinations.
• Are experiencing financial difficulties.
• Have records of excessive absenteeism prior to filing workers’ compensation claims.
• Move out of state following an accident or use a post office box for a home address.
• Have worked in the same position for a lengthy period of time and have become bored with the job.
• Are never home when called, but return calls later in the day.

Employers should exercise extreme caution before confronting an employee they suspect of fraud. Uncovering a fraudulent claim can result in substantial savings, but a competent investigator and legal counsel should be consulted before any action is taken against an employee. Doing so will help you steer clear of false accusations that could lead to costly litigation.