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Fraud Investigations

Field Surveillance + Itinerary Verification

INVESTIGATING WORKERS' COMPENSATION FRAUD

 

"I don't care if they get a hundred doctors to examine you. If you say your back is killing you, they can't prove it isn't. That's what we call pain and suffering. And the money you get is tax free."


Walter Matthau to Jack Lemon in the movie "The Fortune Cookie"

 

A claimant who was collecting more than four hundred dollars a week because of "soft tissue" damage was videotaped driving a tractor from a pole barn to an out-building at a remote corner of his farm property. Piled on a sled, which the tractor was towing, were several stacks of logs. When he arrived at his destination, he was observed "leaping" from the tractor then unloading the logs by himself. As a result of the videotape, the man was ruled physically able and ordered to return to work.

 

Surveillance is the most effective tool that can be used to investigate workers' compensation fraud. With cameras, some small enough to fit on a pair of common eye glasses, irrefutable evidence can be obtained to authenticate or contradict the claimed injury.

 

Faced with an overwhelming number of disability claims, and rising costs, a self-insured company implemented a "Trust but Verify" policy that included surveillance on anyone going out on a workers' compensation claim. The company was making a simple statement to it's employees: "...we want to help you, but we won't be taken advantage of". In less than two years time the company experienced a drop of 66% in "open" workers' compensation claims.

 

As a matter of rule, companies considering similar policies should understand that deployment of an investigator, or surveillance team, should never be a one-time application. Several random observations are necessary to expose and identify a pattern of behavior contrary to what the injured worker's limitations may be.

 

The following list of Red Flags will help expose worker's compensation fraud in your business:

  • The claimant refuses diagnostic procedures to confirm the injury

  • Date, time and place of accident is unknown

  • Claimant's is seen with calluses on his hands and grease under his fingernails

  • Claimant's only injury is "soft tissue" damage

  • Claimant can never be reached

  • Tips from co-workers about the claimant's activities

  • Claimant moved out of state

  • There were no witnesses to the accident or injury

  • The claimant is in line for early retirement

  • Specific details of the injury cannot be recalled

  • The injury coincides with proposed layoffs, down-sizing, etc

  •  When you telephone, the claimant is always "sleeping" and cannot be disturbed

 

By identifying fraudulent claims, and obtaining information about the claimant's activities, any or all of the following objectives can be accomplished:

 

  • Discover the claimant is not injured

  • Uncover co-conspirators within the company

  • Obtain evidence of medical fraud

  • Gain enough evidence to support a conviction of fraud in a criminal or civil proceeding;

  • Ultimately, reduce worker's compensation premiums