Some signs indicating possible fraud. The presence of any one by itself is not necessarily indicative of fraud, but it is a clue or lead to be further investigated for potential fraud.
Examples:
The injured worker is a new hire.
The applicant took unexplained or excessive time off prior to claimed injury.
The alleged injury occurs prior to or just after a strike, layoff, plant closure, job
termination, completion of seasonal or temporary work, or notice of employer relocation,
and so on.
Applicant reports an alleged injury immediately following disciplinary action, notice of probation, demotion, or being passed over for promotion.
Applicant has a history of personal injury, workers' compensation claims, and/or of reporting "subjective" injuries.
Applicant's job history shows many jobs held for fairly short periods of time.
The alleged injury relates to a preexisting injury or health problem.
Applicant uses addresses of friends, family, or post office boxes; has no known
permanent address and moves frequently.
Applicant's family members know nothing about the claim.
Applicant was experiencing financial difficulties and/or domestic problems prior to submission of claim.
Applicant has a high-risk activity, such as skydiving, or bungie-jumping as a hobby.
The applicant's version of the accident has inconsistencies, is not credible.
There are no witnesses to the accident, or witnesses to the accident conflict with the applicant's version or with one another.
Applicant fails to report the injury in a timely manner.
Accident or type of injury is unusual for the applicant's line of work.
Facts regarding accident are related differently in various medical reports, statements, and employer's first report of injury.
The Social Security Number provided does not belong to the applicant.
Applicant refuses to or cannot produce solid or correct identification.
Applicant avoids the use of U.S. Mail; hand-delivers documents.
Applicant cannot be reached at home during working hours although claims to be disabled from working; or message taker is vague and non-committal. Applicant is otherwise unavailable and elusive.
Applicant lifestyle does not coincide with reported known income.
Several of applicant family members are receiving workers' compensation, unemployment, Social Security, welfare, etc.
Income from workers' compensation and collateral sources (unemployment, Social Security, long-term disability, etc.) meet or exceed wages after taxes.
Applicant refuses diagnostic procedures to confirm injury, or refuses to attend a scheduled defense medical exam.
Applicant's co-workers express opinion that injury is not legitimate.
Alleged injuries are all subjective; i.e., soft-tissue, pain, and emotional injuries.
Applicant changes version of accident after learning of inconsistencies: misrepresentation or fabrication by any party.
Applicant frequently changes physician, or does so after being released to return to work.
Physical description of applicant indicates muscular, well-tanned individual, with calloused hands, grease under fingernails, or other signs of active work.
Medical treatment is inconsistent with injuries originally alleged by employee.
Applicant undergoes excessive treatment for soft tissue injuries.
Treatment as reported by applicant is different from doctor's statement in medical report.
Applicant is examined by several doctors when one doctor could have taken all the information and reached a diagnosis.
Applicant reports seeing doctor for a very brief period of time; however, reports and billing indicate a lengthy visit.
Applicant's description of treatment indicates nonmedical personnel rendering medical treatment.
Applicant sends in medical's or reports that appear to be altered.
Applicant lives far from medical facility, yet receives frequent treatment.
Surveillance shows applicant's activities are inconsistent with physical limitations related in medical reports and deposition.
Surveillance or "tip" reveals totally disabled worker is employed elsewhere (especially suspicious if employment conflicts with work restrictions given by treating doctor).
Applicant cannot describe either diagnostic tests or treatment for which employer was billed.
The doctor ordered diagnostic testing that is not necessary to determine extent of
applicant's injury; or, diagnostic testing is performed, yet there is no request by doctor in medical files.
Diagnostic tests are performed by a vendor not in close proximity to doctor's office or applicant's home, vendor uses post office boxes on all documents, or cannot supply diagnostic records.
Doctor or medical clinic has ownership share in diagnostic group.
Various reports by a doctor on different applicant's cases read identically or similarly.
Post office box used for a clinic/doctor address, instead of street address.
Medical reports appear to be second- or third-generation photocopies
Physician cannot be located at address shown on documentation.
Doctor's report never identifies claimant by gender of gets gender wrong.
New or additional medical problems are alleged and attributed to the original injury
Specific "soft tissue" injury develops psychiatric overtones.
Medical reports contain inaccurate terminology, spelling errors, variations in physician's signature or are rubber-stamped with the doctor's name.
Medical facility uses multiple names or changes name often.
RVS/CPT (Relative Value Scale/Current Procedural Terminology) codes show evidence of upgrading level of services.
Billings are received for unnecessary or not rendered services.
Medical facility has consistently billed both WC carrier and auto, health, etc., insurance carrier and has received payments from both.
Applicant is unable to define medical ailments as listed on claim form.
Lawyer's letter of representation or letter from medical clinic is first notice of claim.
The lawyer's letter is dated the same day as the reported incident or shortly thereafter.
There is a repeated pattern of doctor/attorney referrals; the same doctor and attorney work together on a large volume of claims.
Applicant states that a "friend," whose name is no longer remembered, provided reference to attorney/clinic.
Applicant alleges doctor or clinic found through a "hot line."
Applicant filed for unemployment or disability benefits before visiting attorney or clinic.
Applicant is overly pushy, demanding a quick settlement, commitment, or decision.
Applicant is unusually familiar with claims-handling procedures, workers' compensation
rules, and proceedings
