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 FRAUD ALIASES

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 FRAUD STAKE OUT

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 HEADQUARTERS THE EMPLOYER’S ROLE

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 THE PRECINCT -THE ADJUSTER’S ROLE

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

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.

2009 STRIMA HELP TAKE A BITE OUT OF WC FRAUD

2009 STRIMA REFERENCES    da.la.ca.us/workers compensation fraud  Coalition Against Insurance Fraud   dogthebountyhunter.com/downloads  business-insurance.suite 101.com   claimsadvisor.com