HR Management & Compliance

Employment Law Tip: Red Flags for Workers’ Comp Fraud

Fraudulent workers’ comp claims cost employers millions every year. And while fraudulent claims can often be hard to prove, there are some red flags it can pay to look out for. Possible indicators of employee fraud include:

–Injuries where the only witness is the worker

–Injuries that occur on Friday afternoon or Monday morning

–Injuries that occur just before a strike, holiday, or anticipated layoff or termination

–Injuries occurring just after the worker has been disciplined

–Injuries occurring where the worker would not usually work

–Injuries that are unusual for the employee’s type of job

–Injuries that aren’t reported until a week or more after they occur

–The worker is observed in activities that are inconsistent with the reported injury

–The worker has a history of comp claims

–The worker is a new hire

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–Treating doctors have provided conflicting diagnoses

–There is evidence that the injured employee is working elsewhere while drawing benefits

–The worker, claiming to be disabled, can’t be reached at home during working hours

In addition, some possible indicators of fraud by attorneys or health care providers include:

–Receiving bills or explanations of benefits from health care providers, insurers, or attorneys for services that seem unnecessary; “boilerplate” medical reports; or reports that are merely copies of previously submitted reports

–Bills from a health care provider or attorney that reflect an unreasonably high dollar amount or hours per day

–Treatment dates on holidays for nonemergency situations

–Statements or complaints by the worker that the attorney is “never” available, even though the attorney is billing for services

–Attorney relationship with a health care provider that appears to be a partnership in handling workers’ compensation claims

These factors are not conclusive proof of fraud, but they may act as a tip-off to it. If you suspect fraudulent activity, promptly report the facts to your workers’ compensation insurer. 

Have you ever dealt with a fraudulent comp claim? Share your thoughts on this and other topics on the California Employer Forum.