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work comp fraud prevention tips - corinthian group


Before Accidents Occur:

1. Make certain each employee has received adequately training for their jobs and have signed the appropriate documentation indicating their compliance to your Safety policies.
2. Identify potential and or problem areas at your place of business and install video cameras as a deterrent.
3. Provide quarterly employee safety training/meetings and discuss how injuries could be prevented/avoided.

a. Educate your employees about negative consequences associated with workers compensation fraud. “Increased fraud means increased insurance premiums, which means the company will be forced to decrease and or eliminate employee incentives (IE-Company picnics, Christmas parties, promotions, bonuses) and or raises!
b. Identify unsafe work habits and have each employee sign documentation indicating that they understand all newly implemented safety procedures.

Once an accident has occurred:

4. Mandate that all injuries are immediately reported to their immediate supervisor and or to the proper department(s).
5. Usher the injured employee to your company’s health care provider that is familiar with work related injuries and who will not alienate the injured employee.
6. Mandate that an incident report has been completed by the employee as soon as reasonably possible and immediately obtain written statements from all witnesses.
7. Interview the employee for specific details of have the incident occurred, what injuries they sustained and note who observed the accident.
8. Ask the injured worker to identify their injuries on a skeletal diagram.
9. Conduct a thorough investigation and secure any evidence such as video recording of the incident and or the conditions prior to the accident.
10. Investigate the reported accident/incident scene for any corroborating or contradicting evidence.
11. Pay close attention to what employee are discussing about the incident. Honest employee won’t stand silently by while their co-workers defraud the system.

After an accident:

12. It is imperative that you demonstrate genuine concern for the involved employee(s). IE-Send “Get Well Soon” greeting card.

a.  Stay in contact with the injured employee/worker and show genuine concern about their speedy recovery.
b.  Ask if there is anything that you can do to for them. (You will quickly determine their desire to return to work and or their intentions to retain an attorney.)
c.  Try to answer any questions they may have and reassure them that they will have a job once they return…
d.  Let them know that they are a valuable commodity to the company’s success/productiveness and that you look forward to their return…

14. Determine if the medical diagnosis corroborates with the alleged injuries the employee reported.
15. Implement & enforce drug testing. Insure that your drug testing policy requires mandatory screening after all incidents, not just accidents!
16. Be watchful for any Red Flag indicators of possible fraud.
17. Communicate regularly with the medical provider.

a. Determine the severity of the employee’s injury and reasonable timeframe that the employee will be able to “Return to Work”.

b. Educate the treating physician about the employees current work duties.

c. Consider attending your employee’s medical appointment to show concern about their rehabilitation, progress and overall well being.

d. Determine if the employee will need to be retrained to work in a different position.

e. Determine if the employee will need modified work duties and what their work restriction & limitations will be in advance.

18. Utilizing worker compensation surveillance as 1 tool within your ”Return to Work” program for all lingering injuries will pay huge dividends!
19. Report all injuries to your claims adjuster/insurance company ASAP!
20. Remain involved for the duration of the claim!
21. Establishing modified duty programs will allow the employee to return to work much quicker, which decrease cost significantly!!!
22. Determine with the treating physician what modified duty would be appropriate for the injured employee’s current limitations/restrictions


Insurance Fraud Red Flags - corinthian group


(In no particular order of priority)

  • Accident occurs shortly after employee arrives at work (especially after a long weekend) or after they returned from a lunch or break.
  • Disgruntled employee
  • Potential employee layoffs, disciplinary action and or firings.
  • Retiring employees
  • Employee requested unexplained or medical time off prior to injury
  • Employee takes more time off than the injury warrants
  • Injured employee is new to the company
  • Injured employee purchased private disability insurance prior to the injury
  • Employee has prior work compensation claims
  • Employee avoids and or disputes ability to “Return to Work”.
  • Employee’s injuries never seem to heal or respond to medical treatment
  • Employee as history of changing their address, employer, and or treating physician
  • There are no witness and or occurred in security camera blind spots
  • Injury not reported in a timely fashion or according to established incident/accident reporting procedures
  • Injuries the employee sustained are not consistent with the employee’s regular job duties
  • Employee complains of symptoms not consistent with symptoms generally associated with specific injuries. (IE- Psychological: Fear, stress, sleep disorders, headaches, nausea, etc.)
  • Injury occurred in an area where the employee would generally not be
  • Employee retains an attorney or discusses retaining an attorney early in the claims process
  • Employee adds additional injuries allegedly related to their claim
  • Employee later develops additional injuries when the parties fail to reach a settlement agreement
  • Employee falsified information on their employment application
  • Employee has known or suspected chemical/drug/alcohol dependence
  • Employee is having marital problems and or other financial issues
  • Employee was denied a raise or promotion
  • Co-workers deny the claims validity
  • Injured employee moves out of the area or leaves the state
  • Injured employee request transportation assistance and or travel reimbursements
  • Employee obtains a treating physician/medical provider a long way from their residence
  • The employee does seasonal work
  • Employee reports the claim after they are no longer employed
  • The employees address is not consistent on all paperwork. (IE-Paycheck, initial incident/accident report, AOE/COE Investigation, medical bills, etc.)
  • Employees checks being mailed to a PO Box, PMB (Personal Mail Box), relatives address and or an address different from the residence.
  • Employee retains an attorney well known for handling fraudulent claimants
  • Employee using a medical provider well known for assisting fraudulent claimants and or who are claimant friendly…
  • Employee who repeatedly fails to show up for the scheduled medical appointment or who constantly change the date/time of the appointment at the last minute.
  • Employee fails to show up for scheduled depositions
  • The employee or the employee’s retained attorney inquires about a settlement early in the claims process
  • The employee’s statement obtained during the initial incident is different than what is obtained during the AOE/COE Investigator and or deposition.
  • Employee’s reported injuries are not consistent with the medical evaluation