tecis

Fraud Investigation At-a-Glance Checklist

Pertinent Information

• Claimant's job duties
• Description of Accident
• Nature of Injury
• Has initial accident report been sent?
• Has any additional medical info been sent?

Details/Accuracy

• Physical description
• Medical limitations
• Complete residential address
• Any other information regarding lifestyle, hobbies, etc.

Prior Notification

• Are any medical appointments scheduled?
• Are any hearing set or due to be set soon?
• Will claimant be coming to plant soon to pick up a check, etc.?
• Has investigator been notified immediately of any postponements or cancellations?

Workers' Compensation Injuries Fraud Indicators

The indicators are listed below in order to ad in the detection of possible workers' compensation fraud. Please note that these indicators are meant to be a guideline and should not be construed as hard proof of fraud simply because they exist. Conversely, it should not automatically be assumed a claim is not fraudulent simply because it lacks evidence of any indicators.

General Points to Review

• Accident occurred just prior to claimant being laid off or terminated, or on a Friday afternoon or Monday morning
• There were no witnesses to the accident
• Claimant was hired as a temporary employee
• Accident occurred within a short period of time after claimant was hired.
• Claimant has an attorney, and subsequent claim forms list additional injuries never initially reported.
• Claimant has multiple prior claims

Medical Indicators

• Injuries described are subjective in nature
• Claimant goes "doctor-shopping" until he/she finds one who continues to extend leave time with little evidence to back it up
• Claimant continues to see physician even though no comprehensive medical treatment exists, and resists suggestions to obtain another opinion.
• Anxiety, depression or post-traumatic stress disorder are listed as medical conditions.
• Original injury/injuries and accident were minor in nature, but have "mushroomed" into major long-term problems.

Personality and/or Behavior of Claimant

• Claimant is unusually defensive or vague when asked questions about medical condition or mode of treatment
• Claimant is extremely knowledgeable regarding legal rights and workers' compensation system.
• Spouse or other close family member handles all phone calls or any related matters.

Fraud Investigation

Pertinent Information

It is vitally important that all pertinent background information is received regarding the claimant's job duties, medical history, accident description, etc. The easiest way to provide this information is to send a copy of the accident report. These reports often contain details that are easily overlooked or may seem unimportant and therefore are not relayed at the time a case is opened. Additionally, any information regarding the claimant's medical background or general lifestyle is essential.

Details/Accuracy

The accuracy of the information provided is almost as important as the information itself. Details about a subject's physical description for example, can save a considerable amount of time when the investigator is trying to initially identify the person. Sometimes circumstances dictate that several people answering to the same general description are present at the same time, thus making it extremely difficult to single out the subject. Any particularly descriptive information that saves time will ultimately save money. This holds true for residence determinations as well. When providing the investigator with the claimant's home address, it is vitally important to indicate specifically "north, south, east or west" prior to the street address, as well as whether it is a street, drive, lane, etc. Obviously, there may be times when you do not have current or correct information, but it is important that you are aware of these details so that you automatically provide the information when it is available.

Prior Notification

Another component that is crucial to the efficiency and success of any investigation is the ability of the client to provide the investigator with prior notification about an activity in which the claimant may be involved. Specifically, this would include such examples as medical appointments, hearings, meeting on company premises, etc. By knowing a claimant's specific whereabouts at any given date and time, the investigators can provide better surveillance in less time. Conversely, it is just as important to notify the investigator immediately if any pre-arranged appointment has been postponed or cancelled so that time is not wasted driving to a location only to find out that the subject will not be there as expected.