Work Comp Fraud

Here are a few tips to detect WC fraud

  • Injury was not reported promptly to a supervisor
  • No one witnessed the accident
  • Task that caused the injury is not consistent with job duties
  • Injury occurred late on Friday or early on Monday
  • Employee had been recently reprimanded, put on probation or laid off
  • Alleged injury coincides with personal problems
  • Employee immediately hires an attorney
  • Injured worker is familiar with claim procedures and workers’ compensation law
  • Employee changes physicians when a release for work has been issued
  • Letter from injured worker’s attorney is dated the day of the reported accident
  • Attorney threatens legal action unless a quick settlement is reached
  • Inappropriate and expensive treatment is prescribed for minor injury
  • Documentation doesn’t support services listed on medical bills

Fighting Fraud

The industry is currently fighting back against the problem of fraud, focusing on two major antifraud efforts: fraud awareness and investigation/enforcement. In regard to fraud awareness, insurers are placing greater emphasis on fraud training for claims adjusters and underwriters to help them identify signs of suspect behavior or claim patterns. Furthermore, support for public fraud awareness and education has been broad, involving not only insurers but the CAIF, consumer interest groups, and the NICB as well.

In Florida, the Department of Financial Services Division of Insurance Fraud reported that in fiscal year 2009-2010 it received and reviewed 12,820 insurance fraud referrals that resulted in 1,234 cases presented for prosecution and 1,042 arrests. The 706 convictions resulted in court-ordered restitution totaling $63,061,289.

Of the total number of fraud referrals, 13 percent—or 1,676 referrals—were for suspect workers’ compensation cases.

According to a 2007-2008 report from the CAIF, Florida’s Division of Insurance Fraud leads the nation in the recovery of insurance fraud-related losses through court-ordered restitution. In fiscal year 2008-2009, cases presented for prosecution by the Division of Insurance Fraud resulted in more than $34 million in court-ordered restitution. According to the Coalition’s 2007-2008 statistics, Florida ranks in the top four among all states’ fraud divisions and bureaus in key measurements of success, including:
◦Second in the number of arrests
◦Third in the number of cases presented for prosecution
◦Fourth in the number of referrals

During 2009 and 2010, the Florida Bureau of Workers’ Compensation Fraud was restructured and now is a completely independent unit within the Division of Insurance Fraud. According to the division, the restructuring will enable a more focused approach to combating various types of workers’ compensation insurance fraud. It will also make the bureau more responsive to changing trends, since all fraud referrals are channeled through one contact point within the division

Click here to report suspected cases of fraud to the Florida Division of Insurance Fraud.