2009STRIMA

SNIFFING OUT WORKERS’ COMPENSATION FRAUD

Putting a Leash on Workers’ Compensation Fraud

2009STRIMA

ARMED ROBBERY WITH A DANGEROUS WEAPON

The ink pen.

Workers’ compensation fraud occurs when an employee knowingly lies to obtain benefits.

2009STRIMA

THE RIFF-OFF

Workers’ Compensation Fraud results in:

An increase in premiums. Withholding of employee raises. Cuts to employee benefits. Job loss.

2009STRIMA

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.

2009STRIMA

FRAUD ALIASES

2009STRIMA

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.

2009STRIMA

NOT YOUR USUAL SUSPECTS

Doctors. Pharmacists. Therapists. Attorneys.

2009STRIMA

FRAUD STAKE OUT

2009STRIMA

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.

2009STRIMA

RUMORS

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

2009STRIMA

INJURED WORKER IS NEVER HOME

The injured employee is difficult to reach. Voice mail always picks up when trying to reach employee

by phone.

2009STRIMA

CAN’T GET STORY TOGETHER

Conflicting descriptions of the accident. Not clear on the details of the accident. Provides vague responses to questions.

2009STRIMA

METHOD OF OPERATION

Employee has filed past workers’ compensation claims.

2009STRIMA

HEADQUARTERSTHE EMPLOYER’S ROLE

2009STRIMA

SOUND HIRING PRACTICES

Conduct criminal background checks. Drivers’ license and MVA checks. Verify references. Maintain current addresses for all employees.

2009STRIMA

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.

2009STRIMA

KNOW FRAUD INDICATORS

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

2009STRIMA

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.

2009STRIMA

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.

2009STRIMA

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.

2009STRIMA

EXIT INTERVIEWS

Discourage post-termination claims. Obtain a signed statement from employee about any

unreported injury at work.

2009STRIMA

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.

2009STRIMA

THE PRECINCT-THE ADJUSTER’S ROLE

2009STRIMA

SPECIAL INVESTIGATION UNIT

Take recorded statements. Injured worker. Supervisor. Witnesses.

Accident Reconstruction. Scrutinize medical documentation.

2009STRIMA

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.

2009STRIMA

OUTSIDE RESOURCES

Medical case management. Vocational rehabilitation. Claims clearinghouse (index system). Surveillance.

2009STRIMA

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.

2009STRIMA

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.

2009STRIMA

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.

2009STRIMA

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?

2009STRIMA

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.

2009STRIMA

FRAUD LINE UP

2009STRIMA

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.

2009STRIMA

FRAUD LINE UP

Brooklyn doctor charged with workers’ compensation fraud.

Business owner in Massachusetts accused of premium fraud.

Ex-paramedic charged with false reporting.

2009STRIMA

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.

2009STRIMA

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.

2009STRIMA

HELP TAKE A BITE OUT OF WC FRAUD

2009STRIMA

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