Claims - August 2015

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.

•;Knowingly;presenting;multiple;claims for the same incident.

•;Knowingly;causing;or;participating;in 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 fraudulent claim.

A;few;caveats;are;in;order;here.;Each 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 stages.;The;first;step;is;to;look;for;red;flags. In;training;examiners,;Keenan;has;identi- fied;42;indicators.;They;include;things;like: • Claimant is exceedingly eager for a quick or discounted settlement.

•;Claimant;lists;P.O.;box;or;hotel;as;their residence.

•;Claimant;threatens;to;see;a;doctor;or;at-
torney if the claim is not settled quickly.

•;Claimed;injuries;are;disproportionate to the impact of the accident.

•;Claimant;has;financial;or;marital;prob-lems.

•;Claimant;wants;a;relative;or;friend;to pick up settlement check.

• Claimant will not provide a sworn statement or documentation to confirm loss or value.

•;Claimant;has;multiple;prior;claims;or lawsuits.

•;Claimant;“over;documents”;losses.

•;No;independent;witnesses;or;versions differ;significantly.

• Claimant recently purchased private disability;insurance;policy(ies).

•;Accident;is;not;the;type;in;which;the claimant should be involved.

• First Report of Claim differs significantly from description of accident in medical;report(s).

•;Claimant;reports;an;alleged;injury;im-
mediately following disciplinary ac-
tion, notice of probation, demotion or
being passed over for a promotion
•;Alleged;injury;relates;to;a;pre-existing
injury or health problem

Investigating suspected fraud

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
be;admissible;in;court.;And;when;docu-
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-
tor;(AME/QME),;technical;experts;and
laboratories, and independent appraisers
and analysts.

The;following;are;some;guidelines;on when to utilize telephone, on-site and sub-rosa investigation methods:

Telephone (least expensive)

•;Employer;disputes;the;injury.

•;Injury;was;not;reported;to;employee’s supervisor, who can be interviewed by telephone.

•;There;is;another;witness;to;the;alleged injury.

•;Circumstances;suggest;that;an;on-site inspection is not required.

•;Apportionment;or;preexisting;injury.

• Short-term employee with Monday morning injury.

•;Alleged;injury;reported;after;termina-tion.

•;Preliminary;subrogation;investigation.

On-Site (moderately expensive)

• Multiple witnesses, unable to or uncomfortable with being interviewed by telephone.

•;Content;of;investigation;is;too;exten-sive to be conducted by telephone.

•;Circumstances;of;alleged;injury;suggest 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.