More than one-in-10 small business owners say they are concerned that one of their employees would commit workers’ compensation fraud by faking an injury or illness in order to collect benefits, according to a recent poll conducted by EMPLOYERS, a small business insurance specialist carrier based in Reno, Nevada. The survey also found that that nearly one-quarter of small business owners have admitted installing surveillance cameras to monitor employees on the job and that one-in-five business owners feel unprepared or unsure of their ability to identify workers who are just feigning injury.
Ranney Pageler, vice president of fraud investigations at EMPLOYERS, said they were, in the last 18 months, had three cases in California where workman’s compensation insurance fraud was proven through videos showing the claimant workers staging their injuries. “All were decided well within a calendar year,” he said. “What that (video) did was keep that claim from ever showing up on the policyholder’s experience rating. Workers’ compensation fraud is a serious crime that can strain business operations, lead to higher insurance costs for businesses, and even undermine honest workers who are legitimately injured on the job.”
Pageler, explaining further, said: “When we look at fraud cases that result in criminal convictions, about half of them are caught within the claims process itself and the other half are tip-offs from the employee’s co-workers, friends or family members, or from workplace surveillance video. There is no silver bullet when it comes to identifying claim-related workers’ compensation insurance fraud. Instead, you’re looking for a pattern of events or multiple indicators that suggest something may be amiss.” Some of these indicators he said are:
• Monday morning, or start of shift, injury reports. The alleged injury occurs first thing on Monday morning, or the injury occurs late on Friday afternoon but is not reported until Monday.
• Employment changes. The reported accident occurs immediately before or after a strike, job termination, layoff, end of a big project, or the conclusion of seasonal work.
• Suspicious providers. An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.
• No witnesses. There are no witnesses to the accident and the employee’s own description does not logically support the cause of the injury.
• Conflicting descriptions. The employee’s description of the accident conflicts with the medical history or injury report.
• History of claims. The claimant has a history of suspicious or litigated claims.
• Refusal of treatment. The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.
• Late reporting. The employee delays reporting the claim without a reasonable explanation.
• Claimant is hard to reach. The allegedly disabled claimant is hard to reach at home and does not respond promptly to messages.
• Frequent changes. The claimant has a history of frequently changing physicians, addresses or jobs.
Employers who suspect an employee may be committing claim-related workers’ compensation insurance fraud are advised to first alert the special investigations unit or fraud unit of their insurance company’s claims department. Depending on the outcome of the initial investigation, appropriate law enforcement authorities may also be called when found warranted.
If we may suggest, it would also help to make a nurse telephone triage an integral part of your workplace injury reporting protocols. A trained registered nurse has the needed medical background to determine whether a supposed on-the-job injury or occupational disease is real or just being faked.