Red Flags are alerts based on common patterns or behaviors found among fraudulent workers’ compensation claims. These Red Flags help you spot early on possible exaggerated or falsified information. Once you notice one or multiple Red Flags in a claim, further investigation is needed. But, before you call your private investigation firm (P.I.), what do these suspicious claims show?
By familiarizing yourself with these Red Flags you can quickly identify scam patterns and spot potential workers’ comp fraud.
10 Red Flags to Identify Workers’ Compensation Fraud
1) History of Claims
The employee has filed multiple claims over the years with multiple employers. If the claimant knows the game, and has success getting away with past workers’ comp fraud, he or she is more than willing to exaggerate his or her claim again.
2) Suspicious Providers
Claimants use medical providers or legal consultants who have a history and reputation of handling fraud claims. Proof of fraudulent behavior becomes increasingly difficult when a claimant is able to secure an advocate in one of these professions.
You may start to notice the same doctors or attorneys used by groups of claimants.
3) No Witnesses
If a claimant falls at work and no one is around to see it, did the injury happen?
No witnesses for an employee's injury claim is a Red Flag. If the claimant’s ‘word’ is the only proof of the incident occurring, then he may be exaggerating or falsifying his story.
4) Conflicting or Varying Descriptions
Similar to ‘No Witnesses,’ the claimant provides a description of her injury that conflicts or varies with her medical history, conflicts or varies with the witness statements, or conflicts with the injury report.
In these cases, inconsistencies can range from the date and time of the injury to the location of the injury.
5) Treatment Refusal
Refusing to receive treatment for an injury is certainly suspicious behavior. Often an employee simply doesn’t want to work and has no desire to seek treatment or promote healing.
6) Frequent Changes
Frequent changes in physicians and attorneys may indicate that the claimant is attempting to search for an attorney or physician who will support his case.
The claimant may also change addresses frequently in order to make it difficult to contact them and to observe his or her activities.
An immediate investigation, starting with witness statements, is a great way to get the story documented early. When changes occur, you can compare them to an initial report.
7) Late Reporting
The claimant delays an injury claim. In this case, the claimant may try to convince you that after the alleged incident she felt fine, but after some time passed, her injury progressed. Witness accounts of the incident combined with surveillance of the claimant’s activities are suggested for this Red Flag.
8) Monday or Friday Incidents
Similar to late reporting of the injury, be wary if the alleged injury occurred on a Monday morning or a Friday afternoon. This Red Flag may suggest the injury was a result of a non-work related accident over the weekend, or may suggest the claimant desires an “extended” weekend.
9) Claimant Grudge
The claimant may be reacting to a personnel action, a denied vacation, termination, or denied promotion. Suspicious claims are also filed when the claimant is about to retire. Essentially, the claimant has a grudge and is finding a way to extend his or her income, make a silent protest, or has lost his will to work.
10) Claimant is Hard to Reach
Despite multiple efforts, the claimant cannot be found or reached at home. When the claimant is allegedly recovering at a certain location (such as his or her home) and cannot be contacted, it raises a Red Flag. Surveillance can discover if the claimant is playing cat and mouse, may be working, or even on vacation.
Red Flags are a great first step to determining the legitimacy of a claim. These alerts help you quickly identify claims that need to be investigated. Paying a claimant who is committing fraud costs more than an investigation ever will.