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Red Flags of Fraud

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 before.
  • Employee reports the injury three to four months after it allegedly occurred.
  • 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 injury.
  • 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 time.
  • 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 schooling.
  • 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 employer.
  • The claimant’s identifying information is incorrect or he refuses to produce it.
  • The claimant fails to keep scheduled appointments and is generally uncooperative.
  • 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 medical providers.
  • New or additional medical problems are alleged and attributed to the original injury.
  • 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 employment.
  • The claimant alleges he obtained a clinic or doctor through a ‘hot line’.
  • 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 name.
  • 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 frequent treatment.
  • 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.

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