temporary disability benefits as a result
of lying about outside employment, reemployment or ability to work. In billing
fraud, a provider submits a bill for services
never provided, for a patient who was never examined, or for more services or time
than;was;actually;provided.;Abuse,;as;op-posed to outright fraud, can include sending claimants to specific attorneys, doctors
or facilities; kickbacks for insurance reps
of employees; and rewards or gifts for
quick or favorable settlement of claims.
Here are some specific examples:
• Knowingly presenting, or causing to
be presented, any false claim for the
payment of a loss, including a loss
under a contract of insurance.
for the same incident.
a vehicular collision for the purpose of
presenting a false or fraudulent claim.
•;Knowingly;preparing,;making;or;sub-scribing any writing with the intent to
present or use it in support of a false or
case must be considered on its own merits. Do not designate people for special
attention simply based on their origins,
ethnicity, profession or area of practice or
because they do a large volume of business. Avoid generalized and accusatory
statements.;Beware;of;withholding;pay-ments or making accusatory statements
based on the serving of search warrants
or the filing of criminal charges.
Evaluating the potential case
Although;the;process;of;pursuing;Work-ers’ Compensation cases is fairly straightforward, attention to detail and the proper
resources are essential for success. Solid
experience and training on the part of the
examiner is essential in identifying things
that simply don’t feel right in the early
• Claimant is exceedingly eager for a
quick or discounted settlement.
torney if the claim is not settled quickly.
to the impact of the accident.
pick up settlement check.
• Claimant will not provide a sworn
statement or documentation to confirm loss or value.
• Claimant recently purchased private
claimant should be involved.
• First Report of Claim differs significantly from description of accident in
Investigating suspected fraud
mediately following disciplinary ac-
tion, notice of probation, demotion or
being passed over for a promotion
injury or health problem
If there appear to be grounds for a case,
an;investigator;is;engaged.;The;first;cri-terion, of course, is a valid and current license. Others include proven expertise in
investigation of Workers’ Comp claims;
a track record of well-managed, efficient
and cost-effective investigations; use of
state-of-the-art technology for surveillance; current knowledge on applicable
legislation; availability for courtroom testimony; online case management system;
and a process of internal audits.
The investigator will monitor the individual’s activities, talk to neighbors,
review;medical;conflicts;and;the;like.;Ob-servation, including video surveillance
and recorded statements, usually takes
place over a period of two to three days
to identify consistent behavior patterns.
Other resources include medical records, employment records, business/
asset records, and the ISO Index of
criminal records and previous injuries.
Confirm all information with authenti-
cated documentary evidence, which will
menting claim notes, do not use the term
“fraud,” but instead use “potential fraud”
or “alleged fraud.”
Professionals who can assist in this
process include defense counsel, regency
investigations, accident reconstruction-
ists, source/origin experts, agreed medi-
cal evaluator/qualified medical evalua-
laboratories, and independent appraisers
when to utilize telephone, on-site and
sub-rosa investigation methods:
Telephone (least expensive)
supervisor, who can be interviewed by
inspection is not required.
• Short-term employee with Monday
On-Site (moderately expensive)
• Multiple witnesses, unable to or uncomfortable with being interviewed by
•;Content;of;investigation;is;too;exten-sive to be conducted by telephone.
employee was not performing regular
job duties at time of injury, not supposed to be in the area, or not making
full use of available safety equipment.
medical problems, drug/alcohol abuse.
Activity Check/Sub Rosa (most expensive)
• Interview of witnesses discloses employee boasted about claiming to be
injured in order to collect Workers’
to support the severity of alleged injury.
•;Claimant;is;never;available;to;take;tele-phone calls at claimant’s residence.