Workers’ comp fraud is painful but often preventable

Workers’ compensation fraud robs American workers of millions of dollars each year. Bogus claims made by employees are the most widely known, but these workers aren’t always the perpetrators. Workers’ comp scams can be instigated by health care providers and insurance carriers, as well.

Employee-perpetrated scams

The greater part of workers’ comp claims are genuine. However, invalid claims can be an expensive headache for employers to sort out.

To determine whether an employee’s workers’ comp claim is fraudulent or not, pay attention to certain anomalies: accidents with no witnesses, or incidents that occur just before an anticipated strike, layoff or termination. Be on guard against suspicious injuries that are inconsistent with your business or the worker’s position. Also be skeptical if the employee:

  • Can’t remember any details about the injury or accident,
  • Refuses or continues to postpone diagnostic procedures,
  • Is never home or is reported to be sleeping and unable to be disturbed, or
  • Relocates out of state.

You can potentially expose the worker-initiated scam by merely questioning coworkers or stopping by the injured worker’s home for a surprise visit.

Leave it to the professionals

When the perpetrator isn’t an employee, it can be much harder to uncover the fraud. Health care providers — including doctors, nurses, pharmacists, physical therapists and rehabilitation providers  — may bill for medical care or services they never administered. They might also submit duplicate bills for a single service to more than one insurer.

In general, red flags will be raised when providers commit fraud. For instance, they might:

  • Submit nearly identical medical reports that are for different patients with different conditions,
  • Report that employees are unable to work for longer periods than would normally be expected for the type of injury involved,
  • Bill for office services provided on weekends or holidays,
  • Charge higher-than-anticipated fees for treatment, or
  • Prolong handing over requested records.

On the insurance side, those involved in the scam sometimes accept gifts from health care providers to settle claims or gain referrals. These co-conspirators may alter evidence on a legitimate claim so that benefits are granted or denied, depending on the type of scam being conducted. To help expose these acts, look carefully for improper or incompetent claims management.

Abuse means higher costs

Keeping workers’ comp abuse from happening is in your company’s best interest and is worth the effort it takes. Please contact us at 949-860-9891 or click here for help. We will help you figure out what is going on with any suspected fraud.