Presentation on theme: "2009 STRIMA SNIFFING OUT WORKERS’ COMPENSATION FRAUD Putting a Leash on Workers’ Compensation Fraud."— Presentation transcript:
2009 STRIMA SNIFFING OUT WORKERS’ COMPENSATION FRAUD Putting a Leash on Workers’ Compensation Fraud
2009 STRIMA ARMED ROBBERY WITH A DANGEROUS WEAPON The ink pen. Workers’ compensation fraud occurs when an employee knowingly lies to obtain benefits.
2009 STRIMA THE RIFF-OFF Workers’ Compensation Fraud results in: An increase in premiums. Withholding of employee raises. Cuts to employee benefits. Job loss.
2009 STRIMA FRAUD RAP SHEET Insurance fraud costs the average family between $400 and $700 each year in increased premiums. Workers’ compensation fraud cost $80 million in Louisiana alone. A legitimate claim can easily turn fraudulent.
2009 STRIMA NOT YOUR USUAL SUSPECTS Summer baby sitter. Deer hunter. Home for the holidays. No vacation time on the books. Got on my last nerve. The pregnant claimant. The husband and wife tag team.
2009 STRIMA NOT YOUR USUAL SUSPECTS Doctors. Pharmacists. Therapists. Attorneys.
2009 STRIMA COULD IT BE FRAUD? Disgruntled employee. Financial or domestic hardship. Misses medical appointments. Injured worker wants to control the time he can meet with the adjuster or doctor. Applies for unemployment benefits. Physical appearance: Tanned. Calloused hands. Grease under fingernails.
2009 STRIMA RUMORS The accident never happened. The injury did not occur at work. The employee can return to work. The employee is working somewhere else.
2009 STRIMA INJURED WORKER IS NEVER HOME The injured employee is difficult to reach. Voice mail always picks up when trying to reach employee by phone.
2009 STRIMA CAN’T GET STORY TOGETHER Conflicting descriptions of the accident. Not clear on the details of the accident. Provides vague responses to questions.
2009 STRIMA METHOD OF OPERATION Employee has filed past workers’ compensation claims.
2009 STRIMA SOUND HIRING PRACTICES Conduct criminal background checks. Drivers’ license and MVA checks. Verify references. Maintain current addresses for all employees.
2009 STRIMA NO EXCUSES Employee education. Employer education. Knowledgeable supervisors and managers. Online claims reporting capability. Fraud hotline. Online fraud reporting capability. Maintain a working relationship with the adjuster.
2009 STRIMA KNOW FRAUD INDICATORS Rumors. Late reporting. Doctor shopping. Voice mail / answering machines. Can’t get the story straight. Friday / Monday accidents. No witnesses.
2009 STRIMA INVESTIGATE ALL ACCIDENTS Use sound investigation techniques. Obtain accurate information about job-related accidents. Review video surveillance of accident scene. Interview injured workers and witnesses as soon as possible. Separate witnesses.
2009 STRIMA PROMOTE A FRAUD-FREE WORKPLACE Develop a policy statement about WC fraud. WC fraud is a crime. Show employees how fraud affects benefits. Discuss WC policies and procedures with employees. What to do when an accident occurs. Return to work program. Transitional duty employment deters fraud. Find a place for the injured worker to come back to.
2009 STRIMA PERIODIC SAFETY CHECKS Maintain a safe work environment. Have regular inspections of work areas and equipment. Fix hazards immediately. Document all safety checks and repairs. Safety records are evidence.
2009 STRIMA EXIT INTERVIEWS Discourage post-termination claims. Obtain a signed statement from employee about any unreported injury at work.
2009 STRIMA FRAUD- PROOF THE WORKPLACE Complete the first report of injury. Incidents. Near-misses. Report the injury to the carrier immediately. Obtain prompt medical attention. Stay in touch with injured workers.
2009 STRIMA SPECIAL INVESTIGATION UNIT Take recorded statements. Injured worker. Supervisor. Witnesses. Accident Reconstruction. Scrutinize medical documentation.
2009 STRIMA WATCH FOR CLAIM PATTERNS Symptom magnification. Injured worker is never home. Injured worker always wants medication. Excuses to get out of medical appointments. Doesn’t return state required forms. Will not cooperate with voc rehab. Injured worker is knowledgeable about the comp system.
2009 STRIMA OUTSIDE RESOURCES Medical case management. Vocational rehabilitation. Claims clearinghouse (index system). Surveillance.
2009 STRIMA SURVEILLANCE Coordinate with defense attorney. Same day of a doctor’s visit. Evenings, nights and weekends. Regional and local festivals. Question injured worker about activities seen on the surveillance video. Have the treating physician question the injured worker about his pain level and physical activities.
2009 STRIMA PLAY IT SAFE! DO NOT GIVE THE VIDEO TO THE DOCTOR! Lose right to privileged information. Plaintiff has a right to the video as well. Hold video until after the deposition. Attorney Show surveillance video to defense attorney. Schedule deposition after surveillance.
2009 STRIMA ONCE YOU SUSPECT FRAUD Get a second medical opinion. Utilize surveillance. Involve law enforcement agencies. Attorney General. District Attorney. Involve professional oversight boards. Pharmaceutical Board. Board of Medical Examiners.
2009 STRIMA QUESTIONS TO ASK What lie did the injured worker tell to receive benefits? Did the injured worker lie knowingly or intentionally? Was the lie made to obtain or deny benefits?
2009 STRIMA FRAUD IS A CRIME Workers’ compensation fraud is costly and it’s illegal. Employees who knowingly lie or help someone else provide false information in order to receive benefits 5 years in prison. $5000 fine. Employers who lie to pay lower premiums face 10 years in prison. $10,000 fine.
2009 STRIMA FRAUD LINE UP Three comp claimants caught with side jobs in Texas. New York roofer accused of collecting benefits after returning to work. Five years prison for executive convicted of comp fraud.
2009 STRIMA FRAUD LINE UP Brooklyn doctor charged with workers’ compensation fraud. Business owner in Massachusetts accused of premium fraud. Ex-paramedic charged with false reporting.
2009 STRIMA FRAUD LINE UP Ft. Lauderdale business owner convicted in federal court in July for workers’ compensation employer fraud. $4,600,000 fraud. 60 months in prison with restitution.
2009 STRIMA HELP TAKE A BITE OUT OF WC FRAUD Know what to look for. Know what to do. Don’t be afraid to prosecute. Work with law enforcement agencies. Work with professional oversight boards.