No. 4 TOP TEN FRAUD INDICATORS

Some things to know before you give the talk:

Do not assume that every accident is fraudulent or faked.

If you suspect an accident to be fraudulent, the burden of proof will be on you to prove the claim fraudulent. Keep in mind that it is difficult to dispute a doctor’s professional opinion that states an employee is injured. Most successful fraud claims are proven because the employee told someone before the alleged event occurred that a fraudulent claim would be filed.

In most States, lying to obtain an insurance company benefit is considered fraudulent and a crime. Successful prosecutions do occur, but they are rare. Almost always, when an individual is successfully prosecuted, they usually meet a very light sentence, as insurance company fraud does no rank as high as a murder, rape or other serious crime. None-the-less, in some jurisdictions, insurance fraud can be considered a felony, which could result in high fines and serious time in jail, up to five or ten years, depending on the circumstances of the fraudulent act. In addition, courts can order the convicted individual to pay restitution.

Be sure to choose a meeting place that is adequate and affords no interruptions.

Keep your meeting to no less than five minutes and no longer than twenty minutes.

Employees are more receptive to talks that are informal, rather than “canned” or read. Read the subject matter to be discussed, and then formulate your discussion points.

If you choose to select someone else to conduct the meeting, give him or her a week’s advanced notice to prepare for the meeting.

The moderator for the meeting must make sure that he or she maintains control over the meeting. Tell everyone at the beginning of the meeting how long the meeting will last and stick to the topic and time schedule announced. (There is nothing worse than a long safety meeting that is not relevant. Always value the employee’s time, especially if they are attending the meeting on their normal time off from work). Some employees will want to be more actively involved in discussions than others and it is not fair that one employee dominate a discussion. It also helps to let everyone know that they will be asked a question in the meeting and that their active participation is expected when they are called upon.

What to discuss in the safety meeting:

Filing a false claim for occupational injury benefits is a crime. Every year, insurance companies go after workers who file false workers’ compensation or occupational injury benefit claims. The company is not in the business of determining whether or not a claim is fraudulently filed. We do, however, provide information, to our insurance company that allows them to assess each claim for fraud possibilities. There are fraud indicators that insurance companies consider when a claim for benefits is filed. Some of the indicators are as follows:

1. A delay of more than 24 hours in reporting a claim.

2. Claims filed immediately before or after a weekend or holiday. (Monday-Friday Rule)

3. Changing details on how the accident occurred.

4. Claims that are not witnessed.

5. Witness statements or supervisor statements that differ from the claimant’s version.

6. Claims for employees who have less than 30 days on the job.

7. A previous history of filing workers’ compensation or occupational injury benefit claims.

8. Doctor medical evaluations do not match claimant’s version of the accident.

9. Employee does not attend doctor appointments as scheduled.

10. Employee refuses to return to work when allowed by a treating physician, or suddenly takes other employment after filing for claim benefits.

Not all of the indicators always points to a fraudulent claim. There are always mitigating reasons as to why the indicators exist. If an employee has a legitimate injury claim, and it is filed appropriately within the allowable timeframe, then the injured worker has very little to worry about should an investigator call to inquire about the validity of the claim.

Insurance companies state that as much as 30 per cent of filed claims are fraudulent. Facts bare out that a far fewer number are actually determined to be fraudulent. In most instances, the issue is more related to whether or not the injury was really sustained in the course and scope of work.

Some employees pretend that their injuries are far worse than they actually end up being after all the medical evaluations are completed. This is not fraud, in as much as it is the “acting out” for sympathy or time off from work by the injured employee. For the employer who has to pay higher insurance premiums, as a result of higher dollar amounts tied to specific claims, this is a serious concern. For this reason, your employer is committed to a strong return to work program for those employees who have been hurt on the job.

Fraud claims cost millions dollars every year. If you know of an incidence of fraud, we expect that each employee would do the right thing and speak up. Insurance costs are already high and only increase when a fraudulent claim is perpetrated.

To reduce the risk of fraudulent claims, we expect any and all work injuries to be immediately reported to a supervisor.

Questions to Get Employees Talking:

· If an employee is unsure how the injury occurred, what should the employee do?

· If a minor injury occurs and is “first aid only”, does the claim have to be reported to the insurance company?

[Short answer: No. But the supervisor should follow-up within a few days to insure the injury has healed sufficiently and that no medical attention from a doctor will be needed. If the injury is a soft-tissue injury, it should always be reported to the insurance company, as soft tissue injuries tend to get worse over time if not properly treated at the on-set of first symptoms. Employees who suffer a sprain or soft-tissue injury should always make a precautionary visit to a doctor].

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