Signs That May Indicate Worker’s Compensation Fraud

The National Insurance Crime Bureau (NICB) pegs worker’s compensation fraud as a fast-growing menace, resulting in damages of over $7 billion annually.

Certain early warning signs may point to fraudulent claims. Here is a look at the red flags that need further investigation to determine whether or not fraud is being perpetrated.

Employee fraud

1. Claimant cannot detail their injury properly

Claimants who have legitimately suffered an on-the job injury can recall details of the incident. If the claimant offers a vague description or cannot answer questions clearly, then it is not unreasonable for suspicion to arise. Also note how the claimant responds further on during the investigation: if he has changed his story quite a bit, then the claim is likely fraudulent.

2. Claimant does not report the incident immediately

Reporting the injury immediately to the supervisor is a workplace incident reporting protocol at many organizations. However, not everyone follows this protocol and herein lies another clue.

Late reporting is a pretty common feature of fraudulent claims. However, it should not be the deciding factor to pursue investigation. Sometimes, the effects of an injury may not be experienced until the next day. Employers typically give the claimant the benefit of the doubt and look at other red flags to make an informed decision.

3. There are no witnesses to the injury

If there are usually co-workers in the area where the claimant suffered the injury, yet no one witnessed the incident, the matter needs more probing. It is possible that the incident occurred at the beginning or end of the shift, when there was no one around. These factors should be considered in making judicious assessments.

If the claimant has a history of filing litigated claims, then there is a high likelihood that he may be behaving dishonestly.

Provider fraud

1. Duplicate/Double billing

Double billing occurs when the provider attempts to bill Medicare/Medicaid or the insurance company for the same treatment OR when two providers seek payment for services rendered to the same patient for the same procedure on the same date.

Another duplicate billing technique is when the provider attempts to charge more than once for the same service. This is done by billing on an individual code and again within a bundled set of tests.

2. Billing for services not rendered

The Association of Certified Fraud Examiners (ACFE) lists billing for services not rendered as a common type of healthcare fraud. A comparison of dates of service listed on claims forms should have documentary evidence indicating that the patient visited the facility on those dates. Documentation, the facility’s sign-in logs and even appointment calendars offer enough clues to objectively determine if the provider is attempting fraud.

3. Misrepresenting dates of service

Providers stand to benefit financially by reporting that they treated the same patient on two separate days rather than on one day. Here, the services are rendered but the dates of service stated on forms are intentionally wrong. The patient’s medical files should match the dates of service mentioned on claim forms.

A sudden increase in the frequency of visits to the provider’s facility/clinic also offers reasonable grounds for a probe. A similar situation is when medical treatment has been performed for several months without any improvement in the injury.

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