What Constitutes Workers’ Compensation Fraud?
Workers’ compensation fraud is that act of an individual knowingly and willingly falsifying a claim of injury to take advantage of insurance coverage or benefits from their employer. To make a conviction, there must be evidence that concealment or misrepresentation has occurred intentionally on the part of the individual who filed the claim.
The Most Common Forms of Workers’ Compensation Fraud: Advantage and Premium
When someone has won a worker’s compensation settlement and is working an undocumented full-time job, but is not supposed to work due to their injuries, they are committing what is called advantage fraud. In these instances, a lawyer or healthcare provider may have also taken part in this scheme by double billing or billing for services that were not given.
Premium fraud can occur when a worker misrepresents their wages, their position in the company, or tries to avoid certain insurance risk modifiers that might reduce the amount that workers’ compensation will pay.
An insurance provider will investigate the claims and note any signs that there has been intentionally falsified information submitted. These indicators do not mean that fraud has occurred, but it will lead to a deeper investigation into the claim. Some signs of this type of fraud are:
- Wrong categorization codes;
- Duties that are not normally related to the position or unusually high pay for position;
- No witnesses to the incident;
- Injuries happening early on Monday or late on Friday;
- Claims made a week or more after the incident;
- Injury before a strike or vacation;
- Injuries that occur when there is an expectation of termination.
Some practical examples of fraud are:
- A secretary that files a workers’ compensation claim for an injury caused by lifting an unusually heavy object, while other witnesses’ stories do not match with the report;
- The worker making the claim has a history of worker’s compensation claims;
- A diagnosis from a doctor that does not coincide with the worker’s claim;
- Any evidence that the individual is working another job while still drawing benefits from their claim.
Some signs that could mean a lawyer or a doctor is involved in the fraud could be:
- Benefits or advantages being offered to the business;
- Bills from attorneys, doctors, or insurers that unwarranted, seem to be fraudulent, or appear to be copies of previously submitted documents;
- Doctor’s visits that occurred during vacation time or were not for emergency treatment;
- Bills from lawyers or healthcare professionals that indicate an unreasonable amount of time for treatment;
- Unusual relationships between the medical professional and the lawyer when managing workers’ compensation cases.
Steps to Take to avoid false Workers’ comp claims
As an employer, it is a critical part of your job to ensure that your staff is both efficient and productive, but it is equally as important to create a safe and secure environment for them. In the event of a workplace accident, it is important to care for and aid an employee who has been injured. Sadly, this type of compassion can be taken advantage of in the case of workers’ compensation fraud. Fortunately, there are some steps that can be taken to help prevent employees from exploiting their employer.
Regardless of an employee’s position in a company or the type of job they are performing, there is always risk for workplace injury. Because of this, there is a chance that any employee could try to take advantage of this system. Here are some steps that can help to prevent scams from happening:
- Require your staff to take security and safety training in regards to their job. This can help your employees be more aware of the validity of a workers’ compensation claim, but it will help to prevent accidents in general.
- Have equipment easily available that will help with physically strenuous jobs. Make sure your staff is aware of this equipment and insist upon them using it to avoid any personal injury. By having this equipment, you reduce the likelihood of injury and the chances that someone will be able to make a fraudulent claim.
- Inform your staff of the negative effects that can occur from workers’ compensations scams. By explaining how productivity and even jobs could be affected, employees will be more likely try and prevent accidents, and will be more willing to come forward if they know another employee has made a false claim.
By doing these few things you can effectively reduce the chances of mishaps and accidents on the job. These steps can prevent the number of false workers’ compensation claims being filed. In the instance that you do receive a claim that seems to be fabricated, it is of the utmost importance that you find proper legal representation to protect not only yourself, but also your business.
How the Insurance Company Can Assist in Uncovering Fraud
Your insurance agent, with the assistance of their firm’s underwriter, will determine what categorization codes an employee’s position falls in and other risk points to be aware of when determining your premium rates. There have been cases where certain mistakes or oversights have been found in these kinds of policies. So, take time to thoroughly review the policy, preferably with and skilled expert in insurance policy. Just accepting the policy without further review could end up costing you a lot of time and money, which no employer wants to lose.
If your company employs independent contractors, you need to even more diligent in choosing the right policy. If the policy you have does not cover independent contractors, and they end up being injured while on the job, your company will most likely be responsible for 100% of the compensation the injured party is owed.
When a workers’ compensation claim comes across your desk remember to look for any signs of fraud. Even if you happen to find signs that fraud might be occurring, keep an open mind and treat the injured party with compassion. However, you should contact the insurance company as soon as possible to ask them to send in an investigator to examine the situation. It is common for an insurance provider to send out an investigator regardless of signs of fraud to protect their own interests, but your request could speed up their investigation.
Be fair, but also be cautious with any claims that involve you or your company. Attempt using preventative education and equipment, be aware of the insurance policy in use, and have proper representation. Following these simple steps can keep you, your business, and your employees safe and secure. Call our determined Greenville, SC work injury claim attorneys today for help with your claim!
Dan Pruitt is a Personal Injury Attorney who practices in Greenville, SC. He graduated from University of Georgia, and has been practicing law for 25 years. Dan Pruitt believes in fighting for the injured. Learn more about his experience by clicking here.