5 Common Indicators of Workers’ Compensation Fraud

As most workers’ compensation adjusters will tell you, sometimes the facts of a claim just don’t add up. In those instances, it is up to the file handler to dig a little deeper to determine whether or not they are dealing with a case of workers’ compensation fraud.

However, this task becomes much easier if you know ahead of time what you should be looking for. Here are five common indicators for spotting workers’ compensation fraud.

#1: Refusal to See a Medical Provider

One of the biggest indicators of fraud in workers’ compensation claims is when someone refuses to see a medical provider for their condition. Often, this means that there is no valid claim and that a doctor would be unable to corroborate whether or not the injury actually happened. Another variation of this red flag is a claimant that refuses to turn over medical records related to the incident. Both scenarios indicate that there is a reason why the person doesn’t want you to see that report and should be explored further.

#2: Reporting Delays

Another way to spot a fraudulent workers’ compensation claim is by determining if the claimant waited to report the injury after the incident. This is especially true when it comes to overexertion or soft tissue injuries. In most cases, it an injury is real, parties will file with an insurer either immediately or within a few days. Waiting weeks or filing a claim after a weekend can sometimes be an indicator of fraudulent activity.

#3: Selecting Certain Providers

Many habitual perpetrators of workers’ compensation fraud are smart—or at least think that they are. They opt to use certain attorneys or providers on a regular basis to ensure they are getting the maximum payout of a claim. Often, this is continued with claims against different insurers either simultaneously or in succession. Some workers’ compensation insurers allow adjusters to run C.L.U.E. reports on individual parties or providers, which can sometimes offer insight into whether this practice is happening.

#4: History of Changes in Personal Information

One more way to help detect a fraud claim is by looking at a claimant’s history. If they’ve moved around suddenly, changed phone numbers frequently, or recently switched jobs, there is certainly a need for further investigation. They may also be hard to reach at home when they are supposedly recuperating and out of work. This is one of those situations that could turn out to be harmless, but definitely needs a second look to see if this is a regular pattern for the person.

#5: Conflicting Descriptions

Another instance that could indicate insurance fraud is a conflicting description of what happened in the incident. For most people who experience a significant injury, they should be able to tell you directly what happened to cause the incident. If the story varies, there is a good chance that it is either false or mostly false. Many adjusters even opt to print out copies of the workers’ compensation transcriptions from recorded statements and compare them side by side to help spot discrepancies.

Why This Matters to Workers Compensation Adjusters

So, why do these indicators matter to workers’ compensation adjusters? Insurers pay out millions of dollars each year in fraudulent workers’ compensation claims. These payouts take away money from the company’s bottom line—which includes your bonuses, pay raises, and other company-funded benefits. Having a good eye for spotting false claims is one way to protect the firm you work for and ensure job security over the long run.