Red Flags of Workers’ Compensation Fraud and Abuse

Red Flags of Workers’ Compensation Fraud and Abuse

If the injured employee:

  • Claims injuries that are inconsistent with facts about the accident
  • Provides multiple versions of how the accident occurred
  • Refuses medical tests or examinations to confirm an injury
  • Stays out of work longer than the doctor prescribed
  • Protests excessively about a modified position or returning to work
  • Has a prior history of suspicious claims involving subjective injuries
  • Works a second job or owns a business
  • Files a workers’ compensation claim with a different employer
  • Is in a motor vehicle or other accident just prior to the alleged work-related injury
  • Is retiring, on probation, involved in a labor dispute, disgruntled, a poor job performer, or subject to disciplinary action
  • Can’t be reached at home while on disability
  • Is unusually familiar with the workers’ compensation system
  • States they found the attorney, doctor, or clinic through a hotline or an unnamed friend

If the accident or illness:

  • Lacks witnesses
  • Occurs late on a Friday afternoon (especially if not reported until Monday) or early on a Monday morning
  • Is not associated with the employee’s job duties
  • Occurs in an area not frequented by the employee
  • Is not reported in a timely manner
  • Leads to rumors at work that the accident was staged or is illegitimate

If the medical provider and/or attorney:

  • Submits medical reports inconsistent with the employer’s first report of injury
  • Provides medical treatment inconsistent with injuries originally alleged by the injured employee
  • Submits billing records for treatment different than what was reported by the injured employee
  • Frequently treats an injured employee despite the fact the employee lives far from the clinic
  • Attributes new or additional medical problems to the original injury (i.e., added body parts)
  • Shows a pattern of working with the same doctor or attorney on a large volume of claims
  • Provides a letter of legal representation, or letter from a medical clinic, as first notice of claim

A red flag does not prove fraud even when several indicators are present. However, if you know what to look for, you might discover some troubling patterns. If this happens, we want to hear from you so our SIU can investigate further.

If you suspect fraud, call our SIU at 866-296-4748.

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