Workers' Compensation "Red Flags"

May 2016
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Workers' Compensation Premium Fraud is very real. Over the years, patters have developed that can help claims handlers discover the "red flags" that are common in workers' compensation premium fraud. Here is a list of 10 "red flags" that should raise suspicions and trigger an investigation.

  1. Monday morning report of injury The alleged injury occurs first thing on Monday morning, or the injury occurs late on Friday afternoon but is not reported until Monday.
  2. Employment change The reported accident occurs immediately before or after a strike, job termination, layoff, end of a big project, or the conclusion of seasonal work.
  3. Suspicious providers An employee's medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.
  4. No witnesses There are no witnesses to the accident and the employee's own description does not logically support the cause of the injury.
  5. Conflicting descriptions The employee's description of the accident conflicts with the medical history or injury report.
  6. History of claims The claimant has a history of a number of suspicious of litigated claims.
  7. Treatment is refused The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.
  8. Late reporting The employee delays reporting the claim without a reasonable explanation.
  9. Claimant is hard to reach The allegedly disabled claimant is hard to reach at home.
  10. Changes The claimant has a history of frequently changing physicians, addresses or jobs.