The following are considered to be ‘red flags’ of work comp
fraud. Just because your file has some of these indicators doesn’t guarantee
that the claim is fraudulent, but perhaps it should receive closer scrutiny.
Some of these indicators indicate fraud regarding attorneys or doctors, more so
than the claimant.
Injury reported by employee on a Monday that allegedly occurred the week
Employee reports the injury three to four months after it allegedly
The injured worker is a new hire.
Immediately, or soon after disciplinary action or notice of probation,
or being passed over for promotion, employee reports an injury.
The application took unexplained or excessive time off prior to claimed
The alleged injury occurs prior to or just after a strike, layoff, plant
closure, job termination, completion of seasonal or temporary work, or
notice of employer relocation.
A pattern of claims from the same employer by a group of employees such
as same injury, same circumstances, use of the same medical provider, or use
of the same attorney.
Employee has a history of claims with the same employer, personal
injury, workers’ compensation and/or reporting ‘subjective’ injuries.
Applicant’s job history shows many jobs held for fairly short periods of
Employee who has been taken off work due to an injury complains that
he/she hardly moves around, but is hardly ever home when you call.
The injured worker becomes employed while receiving temporary
disability, but fails to tell anyone.
When rehabilitation issues surface, the injured worker is engaged in
schooling of some sort, but reports that he/she is not taking any type of
The alleged injury relates to a pre-existing injury or health problem.
Applicant’s family members know nothing about the claim.
The injured worker is overly pushy and demanding for a quick settlement,
commitment, or decision.
The injured worker is unusually familiar with claim handling procedures,
worker’s compensation rules, laws and proceedings.
The claimant was experiencing financial difficulties and/or domestic
problems prior to submission of the claim.
The claimant indulges in a high-risk activity, such as skydiving or
bungee jumping as a hobby.
The claimant’s version of the accident has inconsistencies, is not
credible, or is different from witness statements.
There are no witnesses to the accident.
The accident or injury is not consistent with the type of work performed
by the claimant
The claimant gives different versions of how the accident occurred or
the severity of his/her injuries to doctors, attorneys, investigators or
The claimant’s identifying information is incorrect or he refuses to
The claimant fails to keep scheduled appointments and is generally
Surveillance efforts document the claimant’s activities are inconsistent
with stated restrictions given to his/her physicians.
Background investigation reveals the claimant has previous related
injuries due to prior non-work related or work related accidents and the
claimant reports to treating physicians that he/she has not sustained a
previous related injury to the same body part(s) as the current claim.
The claimant avoids the use of US Mail and hand delivers documents.
The claimant’s life style is not consistent with reported known income.
Members of claimant’s family are receiving workers’ compensation,
unemployment, Social Security, Welfare or Disability assistance.
The claimant has other disability policies which were recently obtained.
The claimant receives a release to return to work, then quickly changes
New or additional medical problems are alleged and attributed to the
Specific ‘soft tissue’ injuries develop psychiatric overtones.
Claimant’s co-workers advise that injury is not legitimate or didn’t
occur at work.
Claimant changes version of how injury occurred.
Claimant is described as being muscular, well tanned, has calloused
hands, grease under fingernails or other signs of outside or additional
The claimant alleges he obtained a clinic or doctor through a ‘hot
The claimant advises a ‘friend’ whose name he/she doesn’t remember
referred him/her to an attorney or clinic.
Claimant’s doctor/attorney work together on a large volume of claims.
The attorney’s letter is dated the same day or shortly thereafter the
alleged injury was reported.
An attorney’s Notice of Representation or letter from medical clinic is
first notice of claim.
Claimant is unable to define medical ailments as listed on claim form.
Medical facility has consistently billed both WC carrier and auto,
health, or insurance carrier and has received multiple payments.
Adjuster receives bills for unnecessary or services not rendered.
RVS/CPT ( Relative Value Scale/Current Procedural Terminology) codes
show evidence of upgrading level of services.
Medical or legal provider uses multiple names or changes name often.
Medical reports contain inaccurate terminology, spelling errors,
variations in physician’s signature or are rubber-stamped with the doctor’s
Diagnostic tests are performed by an out of area vendor, vendor uses
P.O. Boxes on all documents or cannot supply diagnostic records.
Physician or medical clinic has ownership share in diagnostic group. +
Various reports by a doctor are similar on different applicant’s cases, or
the doctor uses a Post Office box instead of a street address.
Medical reports appear to be second or third generation photocopies.
Medical reports are second or third generation copies.
Doctor’s report identifies claimant by wrong gender or not at all.
Medical treatment is inconsistent with alleged injuries.
Doctor ordered diagnostic testing that is not necessary to determine
extent of claimant’s injury or diagnostic testing s performed that was not
requested by doctor.
Claimant can’t describe diagnostic test or treatment for which employer
or carrier was billed.
Claimant lives a long distance from medical facility but receives
Claimant submits medical reports that appear to have been altered.
Claimant’s description of treatment indicates non-medical personnel
rendering medical treatment.
Claimant advises seeing doctor for a brief period of time, but billing
reflects a lengthy visit.