If something smells fishy . .
If something smells fishy . . .
One of the best ways to keep workers’ compensation costs down, not just at your agency but across the industry, is by reducing incidences of fraudulent reporting. Certainly not every workers’ compensation claim is fraudulent, and in fact, the vast majority are legitimate. So how do you tell the difference?
The following red flags are worthy of investigation, notes David Goetsch, PhD, professor of safety and quality management and provost for the joint campus of the University of West Florida and Okaloosa-Walton Community College in Niceville, FL:
-The claimant is never home, can never be reached by phone, or has an unlisted telephone number.
-"It doesn’t mean fraud automatically. But in order for someone to collect workers’ comp, he or she needs to freely give out information as to how they can be contacted," Goetsch explains.
-The injury claim coincides with a layoff, termination, business closing, or disciplinary action.
"We’ve learned that employees have learned to file workers’ comp claim to protect themselves," he notes.
-The person filing has another job.
There might actually be an injury in this instance, explains, Goetsch. "It just might not have occurred while the employee was working for you. The employee is thinking, I’m covered under this job but not the other, so I’ll make claim against the one that has coverage.’"
-The employee filing the claim is in line for early retirement.
"A workers’ comp claim can put it off and let them work longer at higher rate of pay because they will be collecting both, he says.
-There is a conflicting report from the employee’s health care provider that indicates the person is maintaining an active lifestyle at odds with the claim.
-The employee filing the claim receives all mail at a post office box.
"There’s nothing wrong with it, but they need to give the manager their home address," he says. "Otherwise it looks like they don’t want you to know where they live."
-There are no witnesses to the accident in question.
-This is a hot button, says Goetsch, especially with home health where there "probably aren’t going to be any witnesses and if there are, the patient receiving treatment will probably side with his or her nurse."
-The person files the claim and then relocates out of the state or country.
-Demands for compensation are excessive and out of proportion to the claimed injury.
-The employee filing has a history of filing claims.
It’s a matter of public record, explains Goetsch, and "while you can’t ask a potential hire if they have filed a claim before, you can make them answer questions such as, Do you have any disabilities or have you ever been injured?’ Your insurance company will tell you what to ask and how to state it so that these questions are legal."
-You have physicians’ reports that are contradictory.
-"Employees looking to file fraudulent claims will fish for a doctor that’s workers’ comp friendly," he says. For this reason, he advises having a health care provider already picked out for workers’ comp checkups. "Then, if the employee goes and thinks it’s a faulty diagnosis, you can give them the chance to go to another doctor. If the reports still don’t match, you’ll want a third opinion," he says.
As Goetsch explains: "You don’t want to proceed too fast with contradictory results but the third opinion will be the one acted on because immediate medical diagnosis and treatment are key — what if there is something wrong and it’s then aggravated by a delay? Then you are really in trouble."
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