Identifying fraudulent injury claims

Every leader dreads getting the call that an employee has been injured on the job. After taking care of the scene and the injured employee comes the next hurdle: dealing with worker’s compensation claims. Unfortunately, leaders also have to be wary of fraudulent injury claims, which can complicate the compensation process.

While no one wants to deny their employees medical attention and time needed to recover from an injury, it’s still important to approach this process with concern. Learning how to identify and handle claims that might be fraudulent is an essential skill that all EHS professionals need.

Below are my best recommendations for how to go about this, especially given the sensitive nature of providing adequate care. Moreover, you’ll need to protect your business interests from potential cases of injury claims that are fraudulent.

Proactive injury case management

Most companies have insurance. When an injury happens, an adjuster from the insurance company partners with them to manage an injury claim. If your company is self-ensured, you’ll typically have to manage the claim in-house. Stay alert to any potential signs of claims that are fraudulent.

One of the biggest mistakes employers make when it comes to managing worker’s compensation claims is being too hands-off. Just because the insurance company assigns an adjuster to handle a case doesn’t mean that they’re going to manage the claim well.

As an employer, it’s in your best interest to aggressively manage your workers’ compensation claims for several reasons. When employees are out because of injuries, it can affect the morale in your company. It can also impact the bottom line, especially if any claims are suspected to be fraudulent.

How to spot fraudulent injury claims

Part of your job is ensuring that employees don’t take advantage of the workers’ compensation process. There are many signs, or red flags, when it comes to fraudulent work injury claims.

Here are a few of the more common ones:

• No witness to the injury/incident
• Injury occurred when the employee was not in their usual area/position
• Injury occurred while employee was doing something outside of their normal job duties
• Late reporting of the injury/incident (anything beyond a week and/or the company’s reporting policy)
• Injured employee has multiple on-the-job injuries/incidents
• Injury occurring early on a Monday or late on a Friday (or close to an employee’s scheduled time off)
• Inconsistent reports/statements from the injured employee
• Conflicting reports from medical professionals treating the injured employee

If you suspect that your employee is making a claim that could be fraudulent, the best thing to do is to aggressively manage the claim. While every state has different worker’s compensation laws, most of them categorize and classify injuries with standard treatment and recovery times. This can help in identifying specific fraudulent injury claims.

A quick Google search can usually tell you (in your state) how long your employee should be out or on restricted duties for their injuries. If you have an employee that is getting time off or on restrictions that exceed the standard, then the first thing you should do is request a second opinion. Ensure this is from a different medical provider.

Returning injured employees to work

Another important element in claim management is returning to work. If employees know that they’re not going to be paid to sit at home on the couch, then they’re less likely to engage in filing fraudulent claims.

As an employer, you should do everything possible to bring the injured employee back to work. Even if they can’t perform their usual job duties because of medical restrictions, do everything in your power to find something for them to do. Ensure it does not violate those restrictions.

Some examples of light duty work include filing or organizing administrative paperwork or performing light cleaning tasks around the property. It doesn’t matter if you have them sweeping the same 800 square foot area all day. If they’re at work and not at home, then you’re helping to lessen the motivation for injury claims. These claims could be fraudulent within your organization.