The news is constantly full of stories about people busted for workers compensation fraud.
Maybe they were discovered doing things that a medical diagnosis said they shouldn’t be doing, such as physical labor after they were determined to be disabled.
Perhaps they made a noticeable amount of money, when they’re required to live on their workers compensation benefits.
Recently in Florence, when a former Transportation Security Administration employee was sentenced to federal prison and required to pay nearly $150,000 in restitution. He was injured on the job in 2004 but made reportable income at a job from 2009 to 2020.
It can be tempting to many of us at times, especially on bad days, to consider creating a workers compensation claim especially if you’re unhappy at a job and like the idea of not having to work anymore.
Perhaps pretend your back or other body parts hurt more than they actually do, convince a doctor, and fill out paperwork. Never work again and collect a check.
Unfortunately, this not a recommended career growth strategy. Not only are there federal fraud investigators, but every state labor and insurance departments have their own fraud teams who keep an eye on workers compensation recipients. Medical boards also are on the lookout for health care providers who may be misdiagnosing patients or even colluding with them for a portion of a settlement.
There’s another group that also monitors recipients: investigators from private insurance companies. Although taxpayers pay a certain amount, insurance companies are also on the hook for other amounts, so they want to make sure their funds are spent correctly, especially sizeable payoffs.
This not only includes the possible monitoring of individuals who have received claims but employers to make sure they’re properly paying and reporting premiums. (Like painting company owners in California who created various methods to avoid paying or under paying their workers.)
Investigators can perform simple surveillance as part of their efforts – is someone raking their lawn or playing with kids without visible pain when they reported a full physical disability?
Workers compensation surveillance tips can include following them throughout their day. Are they going to a job site and appear to be working? Investigators can also look at financial information. Are they making substantial amounts of money? Do they have unusual signs of wealth, like a fancy car on a regular basis?
Medical records can also be examined that can give information about someone’s specific condition, general prognosis and possible treatment plan.
Insurance investigations don’t have to be covert either. They can interview the person to learn about their condition and future outlook.
A workers compensation investigation may be encouraged after a claim is filed but could be done years later. For those depending on how long does workers comp investigation take, it could be a few months to a few years.
While many insurance fraud investigators don’t share the specifics of everything they look for, some are willing to share why one recipient may attract attention by an investigator more than another.
- Did anyone witness the injury? A visible on-the-job accident, such as forklift collision in the busy warehouse, may make someone’s claim easier to verify. But if they claimed the injury happened after hours and no one else is around, it could potentially be more suspicious.
- Timing of a claim. Is it made after a period of sickness or injury? Could there be other health matters that could lead to someone filing a potentially false claim? Are there rumors of layoffs or buyouts coming that can be avoided? Is their performance declining? Any of these could be motivation for someone to look for a different exit strategy.
- Financial instability. A successful claim could be welcome to someone with a spotty financial situation. Certainly anyone can be injured, but the lure of money could be a temptation.
- Past claims. Someone “already in the system” for past injuries and past claims might attract red flags as a potential abuser of the system vs. someone with their first claim. It’s always possible someone with a partial disability might have their condition aggravated over time or receive new injuries – that’s what investigations are for!
Employment experts that the COVID pandemic could potentially see an increase in workers compensation claims and therefore more investigations. Reduced staff at some businesses could mean more challenging working conditions for existing employees.
Some employees, including health care workers, are also working in potentially physically and mentally hazardous conditions.