10 Red Flags for Employee Work Injury Compensation Fraud

JODI MATHY
HNI Senior Claims Consultant

Work comp claims are no picnic for employers or employees.

Injured workers are laid up and stressed out about their health and livelihood. Their bosses are worried about the well-being of their people and liability of the employer for the incident.

A clear plan of action for handling work comp incidents — executed immediately after an injury — sets the stage for claims success. Part of this plan should include running through a list of red flags for employee work injury compensation fraud, elements that are easy to overlook in a stressful situation, especially if you don't handle many work comp claims.

Identifying the following red flags for employee work injury compensation fraud at the onset of a claim, and reporting them to an adjuster at first contact, is key to compensability and mitigating your exposure. Check them out:

1.) It's a Monday or Friday Incident

The alleged injury occurred Monday morning or on a Friday afternoon but was not reported until the following Monday. It could be that the injury is the result of some weekend hijinx, or the claimant could be itching to get off for the weekend.

2.) There's a Beef

Maybe the claimant had been passed over for a promotion, denied vacation, or laid off. Other motivations could include a strike, end of project, or end of seasonal work.

3.) There are No Witnesses

The claimant is the only witness to the event. This is especially suspect when a claim incident occurs in an area that's usually not lonely (factory floor, shop, etc.).

4.) There's a History

This isn't the claimant's first time at the rodeo. Be aware, though, that a history of prior claims won't come to light unless you get this intel through an enhanced physical (where the question is asked by a medical provider) or if an employee has a claim with you (the employer) and the insurance carrier can check records for other events.

5.) There Was a Delay

The claimant held off on reporting the claim. The most common reason for the holdup is, "I thought the pain would go away or get better." The more time that passes, the fuzzier the details get.

6.) Descriptions Vary

The straight story on what exactly happened isn't quite straight. Descriptions of the incident vary between what the supervisor was told, what the doctor was told, what's on the official record, etc.

7.) Can't Make Contact

It's tough to reach the claimant at home, where they are allegedly laid up with a disability. This begs the question, "Are they actually at home?" Some employers will make a visit to a home just to see if the claimant is there.

8.) It's an All-Too Familiar Lawyer or Doctor

There are some lawyers and doctors who have reputations for involvement in suspect claims. Be aware of these potentially toxic characters by doing your homework. Ask trusted work comp and occupational health pros if they've heard anything negative.

9.) There's a Different Doctor

The claimant changes doctors or medical providers after receiving a release for work, or the claimant frequently changes doctors. This could indicate that the claimant is telling different tales to different health care providers in hope of leveraging some personal advantage.

10.) There's a Third Party

If there's someone else involved in the incident, subrogation is a possibility. Employers and insurance carriers have subrogation interest, or a right to recover the money they spend because of the actions of a negligent third party. The employee stands to benefit by making a claim for pain and suffering which may cause some malingering.

Here's a big caveat: Assuming your injured employee is being less than truthful can erode a good relationship. Focus on the facts, and be transparent about how claims will be investigated before injuries occur. Employers and employees have the same goal: Get the injured worker recovered the right way for long-term wellness and back to work (even if it's light duty or modified) ASAP.

What surprises you about these red flags for employee work injury compensation fraud? Have these (or other) red flags clued you into a questionable work comp situation at your own organization? Please share in comments!