Common Signs of Workers’ Comp Fraud

Although the majority of Workers’ Compensation claims are valid, there is a very small percentage of individuals that invent symptoms, cancel medical appointments, and are insincere about getting back to work. This directly affects employers and the malingerer’s fellow employees. The working employees typically carry an extra workload to make up for the malingerer’s absence. And by forcing the payment of wages for no work and wasting money on medical treatment, employers are forced to tighten the budget on other benefits. Ultimately, the costs associated with workers’ comp fraud affects every tax payer.

These are common signs of malingering and possible workers’ comp fraud:

1) New hires that report injuries. Abusers have no intention of doing any actual work, and they don’t spend any more time than necessary on the job.

2) Injury is reported immediately before a work stoppage of some kind. While everyone else has to struggle through a strike, layoff, or shutdown without regular pay, the malingerer continues to collect without interruption.

3) Injury is reported Monday morning, and there are no witnesses. People who get hurt over the weekend sometimes try to turn their injuries into cash by faking an accident at work.

4) Missing work history. Malingerers frequently get caught and have to move on. Look for periods of unexplained idleness in their work records.

5) Employee is difficult to reach. An employee who is disabled from an on-the-job injury should be at home during the day. An employee who can’t be reached by telephone could be working another job or even away.

6) Frequent change of care providers. The malingerer changes physicians, hoping to extend disability payments before the physician catches on.

Report claims promptly to your insurer, and be sure to notify the insurer or your attorney if there is reason to believe that a claim is not based on a valid injury. Alert the insurer to any signs of malingering.

In California, Labor Code section 3823 requires any insurer, self-insured employer, third-party administrator, workers’ compensation administrative law judge, audit unit, attorney, or other person that believes that a fraudulent claim has been made by any person or entity providing medical care, as described in Labor Code section 4600, to report the apparent fraudulent claim in the manner prescribed by the reporting protocols adopted by the administrative director of the Division of Workers’ Compensation.

In California, we at Medical Legal Experts Medical Inc. work directly with the DWC fraud unit to identify and report fraud.