Workers’ Compensation Fraud Printer friendly format
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 It’s Monday morning. One of your newer employees just called to say she would be out of work for a few weeks due to some back pain she incurred while moving offices last Friday. You helped her move her few boxes of work items across the hall Friday afternoon and frankly, you did all the heavy lifting. Her absence will lead into the holidays, and she has been complaining that work leaves her little time to enjoy the season. You are suspicious.

 
It reminds you of how you felt last spring when another employee was out for almost three weeks after cutting his hand badly over the weekend. Although he told you and HR that he injured his hand on the paper slicer when he came into the office on Saturday to catch up on some work, your instincts always told you that it was more likely that the employee was injured in his own comprehensive home wood shop in which he tends to spend every minute of his free time.
 
Have you just become cynical, or are you on to something? In both cases, the injured employees collected workers’ compensation while they recuperated. If indeed they were faking—not that they were—it offends in you some deep sense of justice and community. And on the practical side, having an employee out of the office unexpectedly for a few weeks really affects workflow within your small group.
 
As you may already be aware, workers’ compensation is a system designed to provide employees who are out of work due to a work-related illness or injury with benefits such as partial pay and compensation for related medical bills. Employers are required to have highly-regulated insurance plans that pay out to qualifying workers. An employee commits fraud when he or she lies about a material fact that affects his or her claim, whether in words or in writing. Examples of fraud include faking symptoms in a doctor’s office or claiming that an injury happened at work when it did not.
 
Other than your “gut instinct,” what are red flags for fraudulent claims? Investigators cite the following commonalities in many claims ultimately determined to be fraud:
 
·       Employee recently argued with supervisor
·       Illness/injury not reported immediately
·       Claim happens on Monday morning
·       Employee is vague about details
·       Details do not match witnesses’ report
·       There is no witness
·       Employee was recently denied vacation time
·       Employee decides not to pursue treatment for injury/illness
·       Employee is hard to reach during time off
 
Okay, are alarm bells sounding? As a manager, what do you do with your suspicions? Several things:
 
Talk to Human Resources. In many organizations, especially larger ones, HR manages workers’ compensation paperwork for managers. Make sure that you are candid with HR about your concerns so that the process doesn’t overlook your suspicions.
 
Write it down. The state paperwork to qualify for workers’ compensation typically requires a statement by the employer. Usually the form asks you to specifically weigh-in if you, as employer, believe the employee’s report is not entirely honest. Be sure to use that opportunity to write down your concerns.
 
Report. Workers’ compensation insurers usually have a group for investigating potential fraud. Typically, this group employs private investigators, as needed, to research the employee’s claims. If you do not know your carrier or otherwise need help with reporting, talk to HR.
 
Not being honest in the workers’ compensation process creates problems for almost everyone: organizations pay higher premiums, managers have additional administrative hassle while at the same time they lose one of their teammates, and fellow employees have to pick up the slack. Perhaps having a reputation of knowing what fraud looks like as well as how to respond to it will help hold your employees even more accountable.