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SNIFFING OUT WORKERS’ COMPENSATION FRAUD

SNIFFING OUT WORKERS’ COMPENSATION FRAUD. Putting a Leash on Workers’ Compensation Fraud. ARMED ROBBERY WITH A DANGEROUS WEAPON. The ink pen. Workers’ compensation fraud occurs when an employee knowingly lies to obtain benefits. THE RIFF-OFF. Workers’ Compensation Fraud results in:

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SNIFFING OUT WORKERS’ COMPENSATION FRAUD

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  1. SNIFFING OUT WORKERS’ COMPENSATION FRAUD Putting a Leash on Workers’ Compensation Fraud

  2. ARMED ROBBERY WITH A DANGEROUS WEAPON • The ink pen. • Workers’ compensation fraud occurs when an employee knowingly lies to obtain benefits.

  3. THE RIFF-OFF Workers’ Compensation Fraud results in: • An increase in premiums. • Withholding of employee raises. • Cuts to employee benefits. • Job loss.

  4. FRAUD RAP SHEET • Insurance fraud costs the average family between $400 and $700 each year in increased premiums. • Workers’ compensation fraud cost $80 million in Louisiana alone. • A legitimate claim can easily turn fraudulent.

  5. FRAUD ALIASES

  6. NOT YOUR USUAL SUSPECTS • Summer baby sitter. • Deer hunter. • Home for the holidays. • No vacation time on the books. • Got on my last nerve. • The pregnant claimant. • The husband and wife tag team.

  7. NOT YOUR USUAL SUSPECTS • Doctors. • Pharmacists. • Therapists. • Attorneys.

  8. FRAUD STAKE OUT

  9. COULD IT BE FRAUD? • Disgruntled employee. • Financial or domestic hardship. • Misses medical appointments. • Injured worker wants to control the time he can meet with the adjuster or doctor. • Applies for unemployment benefits. • Physical appearance: • Tanned. • Calloused hands. • Grease under fingernails.

  10. RUMORS • The accident never happened. • The injury did not occur at work. • The employee can return to work. • The employee is working somewhere else.

  11. INJURED WORKER IS NEVER HOME • The injured employee is difficult to reach. • Voice mail always picks up when trying to reach employee by phone.

  12. CAN’T GET STORY TOGETHER • Conflicting descriptions of the accident. • Not clear on the details of the accident. • Provides vague responses to questions.

  13. METHOD OF OPERATION Employee has filed past workers’ compensation claims.

  14. HEADQUARTERS THE EMPLOYER’S ROLE

  15. SOUND HIRING PRACTICES • Conduct criminal background checks. • Drivers’ license and MVA checks. • Verify references. • Maintain current addresses for all employees.

  16. NO EXCUSES • Employee education. • Employer education. • Knowledgeable supervisors and managers. • Online claims reporting capability. • Fraud hotline. • Online fraud reporting capability. • Maintain a working relationship with the adjuster.

  17. KNOW FRAUD INDICATORS • Rumors. • Late reporting. • Doctor shopping. • Voice mail / answering machines. • Can’t get the story straight. • Friday / Monday accidents. • No witnesses.

  18. INVESTIGATE ALL ACCIDENTS Use sound investigation techniques. • Obtain accurate information about job-related accidents. • Review video surveillance of accident scene. • Interview injured workers and witnesses as soon as possible. • Separate witnesses.

  19. PROMOTE A FRAUD-FREE WORKPLACE • Develop a policy statement about WC fraud. • WC fraud is a crime. • Show employees how fraud affects benefits. • Discuss WC policies and procedures with employees. • What to do when an accident occurs. • Return to work program. • Transitional duty employment deters fraud. • Find a place for the injured worker to come back to.

  20. PERIODIC SAFETY CHECKS • Maintain a safe work environment. • Have regular inspections of work areas and equipment. • Fix hazards immediately. • Document all safety checks and repairs. • Safety records are evidence.

  21. EXIT INTERVIEWS • Discourage post-termination claims. • Obtain a signed statement from employee about any unreported injury at work.

  22. FRAUD- PROOF THE WORKPLACE • Complete the first report of injury. • Incidents. • Near-misses. • Report the injury to the carrier immediately. • Obtain prompt medical attention. • Stay in touch with injured workers.

  23. THE PRECINCT -THE ADJUSTER’S ROLE

  24. SPECIAL INVESTIGATION UNIT • Take recorded statements. • Injured worker. • Supervisor. • Witnesses. • Accident Reconstruction. • Scrutinize medical documentation.

  25. WATCH FOR CLAIM PATTERNS • Symptom magnification. • Injured worker is never home. • Injured worker always wants medication. • Excuses to get out of medical appointments. • Doesn’t return state required forms. • Will not cooperate with voc rehab. • Injured worker is knowledgeable about the comp system.

  26. OUTSIDE RESOURCES • Medical case management. • Vocational rehabilitation. • Claims clearinghouse (index system). • Surveillance.

  27. SURVEILLANCE • Coordinate with defense attorney. • Same day of a doctor’s visit. • Evenings, nights and weekends. • Regional and local festivals. • Question injured worker about activities seen on the surveillance video. • Have the treating physician question the injured worker about his pain level and physical activities.

  28. PLAY IT SAFE! • DO NOT GIVE THE VIDEO TO THE DOCTOR! • Lose right to privileged information. • Plaintiff has a right to the video as well. • Hold video until after the deposition. • Attorney • Show surveillance video to defense attorney. • Schedule deposition after surveillance.

  29. ONCE YOU SUSPECT FRAUD • Get a second medical opinion. • Utilize surveillance. • Involve law enforcement agencies. • Attorney General. • District Attorney. • Involve professional oversight boards. • Pharmaceutical Board. • Board of Medical Examiners.

  30. QUESTIONS TO ASK • What lie did the injured worker tell to receive benefits? • Did the injured worker lie knowingly or intentionally? • Was the lie made to obtain or deny benefits?

  31. FRAUD IS A CRIME Workers’ compensation fraud is costly and it’s illegal. • Employees who knowingly lie or help someone else provide false information in order to receive benefits • 5 years in prison. • $5000 fine. • Employers who lie to pay lower premiums face • 10 years in prison. • $10,000 fine.

  32. FRAUD LINE UP

  33. FRAUD LINE UP • Three comp claimants caught with side jobs in Texas. • New York roofer accused of collecting benefits after returning to work. • Five years prison for executive convicted of comp fraud.

  34. FRAUD LINE UP • Brooklyn doctor charged with workers’ compensation fraud. • Business owner in Massachusetts accused of premium fraud. • Ex-paramedic charged with false reporting.

  35. FRAUD LINE UP • Ft. Lauderdale business owner convicted in federal court in July for workers’ compensation employer fraud. • $4,600,000 fraud. • 60 months in prison with restitution.

  36. HELP TAKE A BITE OUT OF WC FRAUD • Know what to look for. • Know what to do. • Don’t be afraid to prosecute. • Work with law enforcement agencies. • Work with professional oversight boards.

  37. HELP TAKE A BITE OUT OF WC FRAUD

  38. REFERENCES • www.lwcc.com • www.nicb.org • da.la.ca.us/workers compensation fraud • Coalition Against Insurance Fraud • www.LAWORKS.net • dogthebountyhunter.com/downloads • business-insurance.suite 101.com • www.tdi.state.tx.us/fraud • claimsadvisor.com

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