Tribal workers’ compensation fraud: 38 signs that your employee’s claim may be bogus

Tribal workers’ compensation fraud is a fact of life – as are work injuries. Wherever you have employees, even if your tribal entity is comprised of low-risk white collar jobs, sooner or later you’ll experience a work comp claim. Eventually, you may also be the victim of tribal workers’ compensation fraud.

Whether your tribe has created their own workers’ compensation commission and laws, handles such claims through your tort system, or has chosen to be regulated by your state’s workers’ compensation system, there are a number of red flags that may indicate potential fraud. These red flags are not evidence of fraud; they are simply warning signs that an employee may be attempting to defraud you.

Typically they fall into four categories relating to the employee’s background, the work injury event, medical treatment and recovery time. Let’s dive into each.

Employee background

The employee is unusually knowledgeable on workers’ compensation terminology, laws or claims handling procedures.
The employee is brand-new on the job.
He has a fuzzy work history or wide gaps in employment.
The accident occurs near the end of a probationary period.
He or she is facing imminent firing or layoff, or is disgruntled, or will soon be retiring.
She is seasonal, and the work is about to end.
The claim is filed just after the employee has been laid off.
The claim is filed following disciplinary action, an announcement of impending layoffs, a plant closure announcement, a reduction in shift hours, or after any event the employee may perceive as a threat to his or her job security or finances.
Prior to the injury, he took unexplained or excessive time off.
The employee has been experiencing financial problems or difficulties at home.
He participates in contact sports or physically demanding hobbies.
She is known to have a second job or income-producing sideline.
The alleged injury is similar to a pre-existing injury or health problem.

The work injury event

The injury isn’t immediately reported to a supervisor; instead an excessive amount of time has passed (“I thought it would get better on its own, but it’s worse,” is commonly heard.)
The injury-causing event occurs on a Friday so that the person needs to leave early. Or it supposedly occurs on Friday, but she doesn’t notify you of the injury until Monday.
The injury occurs at the beginning or end of the work shift.
The injury occurs in an area of the facility where the employee wouldn’t normally be.
No one witnessed the injury, although there are always people in the area.
Other workers suspect the injury event is bogus.
The worker is performing a duty outside her job when she is injured, such as a clerical worker lifting heavy boxes on the loading dock.
Details of the accident are contradictory, vague, or keep changing.

Medical treatment

Injuries are vague and subjective, i.e. headaches, nausea, difficulty sleeping, anxiety.
Appointments are cancelled or not kept.
The story told to the physician is different from the story told to the supervisor.
Injuries don’t correlate to the employee’s first report of claim.
An additional doctor is seen by the injured worker, whose diagnosis conflicts with the earlier doctor’s, as to the worker’s condition and ability to return to work.
She insists on being seen by “her” doctor, whom you know owns the clinic or has a financial interest in it.
The employee-chosen doctor or clinic submits a medical report that looks suspiciously boilerplate.
The worker never seems to improve, even though you’ve been billed for extensive treatment.

Recovery time

When their physician releases them for work, they change doctors.
Although disabled, he appears to be as fit or more fit than before, more tanned, has grease under his fingernails or sports new calluses.
You receive a tip that the employee, though totally disabled and still in your employ, is working elsewhere.
Home visits are refused, or you’re asked to provide plenty of warning time before the visit.
If a home visit is made unannounced, you’re told the injured worker “just stepped out” and will call you back on a mobile.
When you call her home phone, you’re consistently told she’s asleep and can’t be disturbed.
When you call the employee’s cell phone, background noises indicate the person is not at home, recuperating.
Recovery time is inordinately long, and the employee is protesting a return to work even in a modified job status.
She has moved out of state or even out of the country.

What to do if you suspect tribal workers’ compensation fraud

Carefully document your concerns and then call your insurance agent and your adjustor. They will follow up with the claimant or put the injured worker under surveillance to verify the injury. Let the special investigations unit of your claims administrator be the “bad guy,” asking the difficult questions of the claimant and deflecting the heat from you. Just be sure to keep a copy of your detailed reports in your HR files.

How can you help prevent tribal workers’ compensation fraud?

We will address this issue in a future post, but for now, there are two things you should do to prevent work comp fraud, say claim experts: One, assure employees that if injured on the job, their medical care will be seen to, their job will be held, and they will be able to return to work in a lighter capacity as soon as they are released. Two, inform employees that you have a zero tolerance for work injury fraud. All workers’ compensation claims are fully investigated by your insurer, who employs special investigation units comprised of former police officers and detectives.

Sources:
Measuring the Value of Return to Work in a Recession
Native Americans and Workers Compensation
Is an Employee Filing a Fraudulent Workers’ Compensation Claim?
Workers’ Compensation Red Flags
10 ‘Red Flag’ Warning Signs of Workers’ Compensation Fraud

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