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Workers’Comp Fraud: 23 Red Flags

1. The alleged injury occurs prior to or just after a strike, layoff, plant closure, job termination, completion of seasonal or temporary work, or notice of employer relocation.
2. Applicant reports an alleged injury immediately following disciplinary action, notice of probation, demotion, or being passed over for promotion.
3. Applicant has a history of personal injury, workers’ compensation claims, and/or of reporting “subjective” injuries.
4. The alleged injury relates to a preexisting injury or health problem.
5. Applicant uses addresses of friends, family, or post office boxes; has no known permanent address and moves frequently.
6. Applicant’s family members know nothing about claim. Applicant has a high-risk activity, such as skydiving, as a hobby.
7. The applicant’s version of the accident has inconsistencies. There are no witnesses to the accident, or witnesses to the accident conflict with the applicant’s version or with one another.
8. Applicant fails to report the injury in a timely manner.
9. Accident or type of injury is unusual for the applicant’s line of work.
10. Facts regarding accident are related differently in various medical reports, statements, and employer’s first report of injury.
11. Applicant refuses to or cannot produce solid or correct identification.
12. Applicant avoids use of U.S. mail; hand-delivers documents.
13. Applicant cannot be reached at home during working hours although he or she claims to be disabled from working; or message taker is vague and noncommittal.
14. Applicant is otherwise unavailable and elusive.
15. Applicant refuses diagnostic procedures to confirm injury, or refuses to attend a scheduled defense medical exam.
16. Applicant changes version of accident after learning of inconsistencies.
17. Applicant frequently changes physicians, or does so after being released to return to work.
18. Medical treatment is inconsistent with injuries originally alleged by employee.
19. Applicant undergoes excessive treatment for soft-tissue injuries.
20. Applicant cannot describe either diagnostic tests or treatment for which employer was billed.
21. Various reports by a doctor on different applicants’ cases read identically or similarly.
22. Medical reports contain inaccurate terminology, spelling errors, variations in physician’s signature or are rubber-stamped with the doctor’s name.
23. Medical facility uses multiple names or changes name often. 

Source: Fighting Working Compensation Fraud: A Training Series For Industry.California Department of Insurance.

riskVue | The webzine for risk management professionals
June 1999