Workers’ Compensation Fraud Is Not a Victimless Crime

Author, Jim Malone, Workers’ Compensation Claims Advocate, Rancho Mesa Insurance Services, Inc.

Fraud can happen in every industry, including workers’ compensation. According to standard definitions, “in law, fraud is intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right. Fraud can violate civil law, a criminal law, or it may cause no loss of money, property or legal right but still be an element of another civil or criminal wrong. The purpose of fraud may be monetary gain or other benefits, for example by obtaining a passport, travel document, or driver's license, or mortgage fraud, where the perpetrator may attempt to qualify for a mortgage by way of false statements.”

Within workers’ compensation claims, fraud is a term that can be overused by employers who may not agree with a claim, or a condition that has been considered work-related/work-aggravated. Many times, instead of fraud, there is simply a difference of opinion as to whether a specific work incident caused an injury. For these disputes, it usually comes down to a medical opinion addressing whether something is work-related or work-aggravated.   

Examples of Workers’ Compensation Fraud

A claim can become fraudulent when the employee lies about how the injury occurred or about their ability to work. The treating physician may be asked to provide their opinion as to whether the injured worker mislead them about how their injury occurred, and the significance of their complaints or physical capabilities. The doctor is provided records or sub rosa videotape contradicting information previously provided by the injured worker. Fraud can also occur when the injured worker lies under oath during a deposition, thus becoming a felony. 

Workers’ compensation fraud is not limited to employees, but others within the system can also knowingly participate in the fraud. Physicians can be fraudulent in their billing for services not rendered, for accepting kick-backs, or realizing financial benefit for referrals to and from other physicians, vendors or other entities. Employers can commit insurance fraud by understating their number of employees, under-reporting payroll or misclassifying employees into cheaper job/class codes in order to secure cheaper insurance policy rates and premiums. Vendors can commit fraud by billing insurance carriers for products or services never provided. Attorneys can use illegal capping schemes to retain injured workers for clients. 

Combating Workers’ Compensation Fraud

Each insurance company is now required to have a Special Investigative Unit (SIU) that provides ongoing monitoring and investigation of questionable activities related to claims. Fraud continues to cost tax-payers millions of dollars (some estimates are up to $80,000,000) per year. The money and resources the employers and insurance carriers are spending to combat fraud are also increasing each year. 

In the event of a fraud conviction, fines or assessments, prison sentences, or restitution can be ordered. Workers’ compensation fraud is not a victimless crime; from the losses caused by fraudulent activities, to the money used to combat and prosecute fraud. The money lost to workers’ compensation fraud can never be replaced, but we are all responsible to do our part in remaining vigilant and reporting suspected fraud to the appropriate person or agency. 

Fraudulent Claims Could Be on the Rise

Author, Casey Craig, Account Executive, Rancho Mesa Insurance Services, Inc.

California is in the middle of a construction boom. There is more work than qualified employees and contractors need people on their job sites. While fraudulent workers’ compensation claims are relatively low right now, California contractors are asking what will happen when there is not enough work to keep everyone busy?

Fraudulent workers’ compensation claims peak when steady work dries up and opportunities diminish. When an employee doesn’t know if they will be employed next week, they can panic and consider making a fraudulent workers’ compensation claim to ensure a compensation check. Regardless of the size of your company, consider how you may be able to create growth opportunities for your employees. Even if an employee is with your company for a short time, it is important to show them there are opportunities for promotions and pay raises. Keeping your employees happy and goal oriented is extremely effective in reducing fraudulent workers’ compensation claims.

According to Chris Dill, Special Investigations Unit Manager for ICW Group Insurance Companies, millennial’s are two to three times more likely to commit workers’ compensation fraud compared to older employees. That is not to say you shouldn’t hire a millennial, just make sure they know there is a path to move up in the company, have job descriptions, and promotions available with new titles. This is essential to keeping their interest and dedication to your company. Make sure to have meetings where every employee can speak freely in an open forum, so their voices are heard. If an employee feels valued and a member of a cohesive team, they are less likely to create false claims, which can lead to a more profitable company.

When bidding for a job, it is next to impossible to account for injuries that may happen and how those injuries will cut into your net profit. If your only goal is revenue, profit is hard to attain and growth is only sustainable if your profit remains consistent. Keeping workers’ compensation claims to a minimum is a contributing factor to achieve consistent profit.

There are many ways to decrease the likelihood of fraudulent workers’ compensation claims. Rancho Mesa Insurance Services offers strategies to help clients stay ahead of this problem, including our upcoming workshop “Fighting Fraud in CA Workers’ Compensation System” on September 19, 2019. Please contact us at (619) 438-6889 or ccraig@ranchomesa.com for more information on how to prevent fraudulent claims, or with any questions you have regarding your policy.

Employers Beware! Ten Red Flags You May Have a Fraudulent Workers’ Comp Claim

Author, Jeremy Hoolihan, Account Executive, Rancho Mesa Insurance Services, Inc.

Workers’ Compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue their employer for the tort of negligence. 

While most people would agree with the idea of a workers' compensation system, unfortunately, there are people who try to defraud it in an effort to earn an extra buck. These individuals include both employers and employees. For this article, I will focus solely on the most common workers’ compensation fraud, claimant fraud (i.e., when an employee commits the fraud).

Claimant fraud includes false claims and exaggerated claims. These claims typically involve soft-tissue symptoms, such as headaches, whiplash, or muscle strain, which are all very difficult to disprove. In order to increase the value of the claim, claimants will also include multiple body parts. The most common types of claimant fraud includes reporting fake claims, injuries not received on the job, exaggerated injuries, and claimants working for another employer while collecting benefits from an injury claim.

Claimant fraud causes extreme frustration, animosity, and can lead business owners to question all claims, including those that are legitimate. Employers can feel helpless, especially when the system gives the benefit of the doubt to fraudsters. There are, however, red flags that both employers and insurance companies can pick up on to fight against these individuals seeking easy money.  

Ten Red Flags

The top ten red flags employers can look for on a possible fraudulent claims are: When the claimant;

1. Hires an attorney the day of the alleged injury.

2. Has several other family members also receiving workers’ compensation benefits.

3. Exhibits a strong familiarity with the workers’ comp system.

4. Has been disciplined several times or is disgruntled and fears termination.

5. Was engaged in seasonal work that is about to end.

6. Continues to cancel or fails to keep medical appointments or refuses a diagnostic procedure to confirm an injury.

7. Changes doctors when the original suggests they return to work.

8. Is seen working at another job while collecting total temporary disability.

9. Is reluctant to return to work and shows very little improvement.

10. Has problems with workplace relationships.

Contact me to learn strategies for combating fraudulent claims before and after it is reported.