In 2012 there were 196 instances of confirmed employee fraud, totaling an estimated $523,451.00 dollars.

10 Warning Signs Of Fraudulent Workers’ Compensation Claim*

fraudseasonIt’s that time of year again and according the Association for Certified Fraud Examiners (ACFE), scammers are hopeful. ACEFE conducted a survey back in 2012 on reported fraud claims and found that fraud cases had an increase of 20 percent throughout the holiday season compared to the rest of the year. Additionally, 61 percent of CFEs considered financial/economic pressure as the primary factor in the perpetration of fraud.

View our Worker’s Comp. Claims Reporting webinar here.

To assist you in identifying possible workers’ compensation (“WC”) fraud, experience shows a report of injury may be fraudulent if two or more of the following factors are present:

  1. Injury Reported Monday Morning, After A Holiday, Or Vacation:  The alleged accident occurs “first thing Monday morning,” or late on a Friday afternoon but not reported until the following Monday. Or the injury is reported after a holiday or vacation.
  2. Unwitnessed Accident:  No other employees witness the accident, and the employee’s own description of the accident does not logically support the cause of the injury.
  3. Late Reporting:  The employee reports the injury weeks after the alleged incident occurs and does not have a reasonable explanation for reporting the injury late.
  4. Treatment is Refused:  The employee refuses a diagnostic test or procedure (including a drug test) which would confirm the nature or extent of the injury.
  5. Employment Change:  The reported accident occurs immediately before or after a strike, layoff, reduction in force, transfer, or at the conclusion of seasonal or part time work.
  6. Job Termination:  An employee files a post-termination claim.
  7. Instant Lawyer Retention:  The employee hires an attorney within days of reporting an injury.
  8. Unusual Coincidence:  There is an unusual coincidence between the employee’s alleged date of injury and his/her need for personal time off.
  9. Extracurricular Activities:  The employee has a second job and/or hobby that could cause an injury similar to the alleged work injury.
  10. Family Plan:  A spouse or other family member is off of work due to a WC injury or other type of disability.

Employer Action

Report Fraud: If you suspect someone is committing insurance fraud it can be reported safely, easily and in some cases anonymously by contacting the insurance fraud bureau in your state.

*Note: These warning signs are possible identifiers only. If you are skeptical of a reported injury, please contact our Claims Department.

Claims, September 12, 2013, Employee Fraud Least Costly Workers’ Comp Fraud, By Denise Johnson
Risk Navigator, 15 Warning Signs of Workers’ Compensation Fraud, December 19, 2012, ‘Tis the Season – For an Increase in Fraud, By Scott Patterson