Workers’ Compensation Fraud Perception v Reality Who’s Fooling Who?

Perception If the employee can travel for vacation – why can’t they come to work? MUST BE FRAUD! How can they sit in their car for a two hour drive, but they can’t sit at their desk more than 30 minutes? MUST BE FRAUD! Hey, they were out drinkin’ and dancin’. Didn’t seem to be in pain. MUST BE FRAUD! Its all over her FACEBOOK, she planned this accident. MUST BE FRAUD! She shops at Costco. Those packages are BIG! How can she lift that and not do her simple desk job? MUST BE FRAUD!

Reality Most injured workers are REALLY injured. Medically determined physical or mental restrictions determine the ABILITIES of the employee. Your IDEA of what the employee should be able to do is not evidence.

What is Fraud? Insurance Code Make or cause to be made any knowingly false or fraudulent material statement or misrepresentation to obtain or deny compensation. Must be material. If the lie or falsehood does not pertain to the provision of benefits – it is not fraud. There must be evidence – suspicion is not enough.

Resources Available Start with your ICS Adjuster Discuss with your WC Program Manager Investigative Companies can be assigned by the Adjuster to obtain statements, and gather evidence which may include undercover films Only the District Attorney and the Dept of Insurance can determine if there is sufficient evidence of fraud to prosecute

Does A Picture Tell the Whole Story? Is This Fraud? The Story of Dave – Dave’s claim is for a neck and shoulder strain. Work Restrictions - Precluded from working at his desk computer for more than 15 minutes without a break. Work restrictions have been explained to Dave. Dave has stated to his physician: This injury has severely restricted his life. He spends most of his time at home, watching TV. He is unable to use his home computer or ride his bike without pain in his shoulders and neck.

Does A Picture Tell the Whole Story? Is This Fraud? The Story of Adrienne – Adrienne’s claim is for right upper extremity pain. Work Restrictions – Unable to move her right arm above 90 degrees. Her doctor has cautioned her to not raise her arm above shoulder level. Adrienne has told her boss: She is so unhappy this has happened. She really wanted to compete in the Housing Authority’s hula hoop contest. She has been practicing and “maybe if she doesn’t use the right arm much”, she can join in.

Does A Picture Tell the Whole Story? Is This Fraud? The Story of Lisa – Lisa’s claim is for psychiatric stress as the result of a hostile work environment. Work Restrictions – Lisa is unable to return to any type of work on a permanent basis due to her stress related condition. She is considered 100% disabled. Lisa tells EVERYONE she is so stressed out she has to spend her days in a darkened room at home. She is unable to be around public places or loud noises because she is always afraid. Lisa is seeking reimbursement for purchase of an assistance dog to enable her to at least walk to the mail box.

Does A Picture Tell the Whole Story? Is This Fraud? The Story of Jose – Jose has an undisputed claim for injury to his back. With the knowledge of his employer and claims adjuster, Jose is actively involved in a retraining program requiring classroom attendance. Work Restrictions – Unable to lift more than 10 pounds. Jose has been informed of his work restrictions and understands he is not to lift any thing over 10 pounds. He is very excited about his training program and returning to work.

Does A Picture Tell the Whole Story? Is This Fraud? The Story of Nancy – Nancy has an injury to multiple body parts. She is unable to care for her grandchildren who live with her and has requested Home Health Care assistance in the form of childcare. Nancy has submitted invoices from her neighbor for providing childcare services 7 days a week, 4 hours a day for a total of $90,000. In her deposition, Nancy has testified she requires childcare assistance everyday around the house, but particularly when she has to take the children outside.

Does A Picture Tell the Whole Story? Is This Fraud?

But... Come On! I Know Something Is Going On! REMEMBER if the evidence isn’t there, there is no case to present for fraud. DON’T let your frustration with the employee or situation become your focus.

F ORWARD any information which may involve fraud to your ICS adjuster. R ELY upon your ICS adjuster to guide any investigative activity. A CQUIRE any evidence that can be shared. U NDERSTAND that what you may view as fraud, may be a simple misunderstanding. D ISCUSS any concerns you may have regarding an employee’s activities with your ICS adjuster. The Key Points

DigiStream Investigations for use of their video. CHWCA and ICS Staff for sharing their photos and willingness to participate: Dave Beal Adrienne Beatty Nancy Broadhurst Jose Mederos Lisa Miller THANKS AND ACKNOWLEDGEMENTS