What is Workers Compensation Fraud

What is Fraud

Fraud occurs when a person knowingly or intentionally conceals, misrepresents, and makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit. The key to conviction is proving in court that the misrepresentation or concealment occurred knowingly or intentionally.

Premium fraud and benefit fraud are the most common types of workers compensation fraud.

Premium fraud is usually committed by an employer who misrepresents the amount of payroll or classification of employees, or who attempts to avoid a higher insurance risk modifier by transferring employees to a new business entity rated as a lower risk category.

Benefit fraud is usually committed by: a worker who works full time at an unreported job and draws benefits when he or she is supposed to be unable to work, or when a worker fakes an injury; a health care provider or attorney who assists the worker in fraudulent schemes, participates in double billing or bills for services not provided.

An insurance carrier commits fraud if documents are intentionally falsified in order to deprive benefits. Fraud Indicators Fraud indicators do not mean fraud has occurred, but they may require a closer review of the claim or application. Employer fraud indicators include but are not limited to: classification codes not consistent with duties normally associated with the employer's type of business, for example, a construction company that reports mainly clerical classifications payroll information on the insurance application inconsistent with payroll reported to the Workforce Commission, much larger premium paid for the previous year's policy small payroll reported by a large company or employee leasing company frequent addition and cancellation of coverage, especially if several business entities appear to be owned or controlled by the same person or group.

Employee fraud indicators include but are not limited to; injuries that have no witness other than the worker, injuries occurring late Friday or early Monday, injuries not reported until a week or more after they occur, injuries occurring before a strike or holiday, or in anticipation of lay off or termination, injuries occurring where the worker would not usually work, injuries not usually occurring in the particular job description, for example, a secretary injured when lifting a heavy object, worker observed in activities inconsistent with the reported injury, worker history of workers compensation claims, conflicting diagnosis from subsequent treating doctors, any evidence of working elsewhere while drawing benefits.

Attorney/health care provider fraud indicators include; receiving bills or explanation of benefits for services from health care providers, insurers or attorneys that seem unnecessary or fictitious boilerplate medical reports, or reports that are merely copies of previously submitted reports, treatment dates on holidays for non-emergency situations, bills from a health care provider or attorney that present an unreasonable amount of hours per day, complaints from the worker that the attorney is (never) available although the attorney files fee affidavits for services, attorney relationship with a health care provider that appears to be a partnership in handling workers' compensation claims.

Do not modify this article Workers Compensation Law Workers Compensation Law - information to help you understand your rights and obligations. webmaster@worker-comp-law.com

---

How To Find Writing Work

Are you looking for new writing work? It can be... Read More

Has ADHD Put Your Career in Danger? 3 Steps to Get You Back on Track

"Roger, you must get those contracts completed for this month's... Read More

Can You Tell Me Something About Yourself!

Interview Question, "Tell Me Something About Yourself?""Tell me about yourself"... Read More

Feng Shui Your Desk for Career Success

Have you used feng shui around your desk? It's a... Read More

5 Steps to a New Job

The economy is picking up, budgets are new, positions are... Read More

Troubleshooting Your Job Search

OK. You've posted your resume online. You've sent out a... Read More

What is Absolutely the Best Day to go on a Job Interview?

First of all, to fully understand and appreciate the answer,... Read More

How to Change Career Horses in Mid-Stream

You'll get wet but the reward just might be a... Read More

Networking Masterclass - Part 2 Practicing Altruism

Practicing Altruism The 'Golden Rule' occurred in the Greek and... Read More

The Perfect Resume

The perfect resume presents hiring managers with a... Read More

Take Charge of Your Job Search: 12 Steps to Success

Despite what many people may say, a job search does... Read More

Interview Thank-You Letters

The number one etiquette tip for interviews is writing a... Read More

Waiting for Lightening to Strike

Author and management guru, Peter Drucker says, "People adjust to... Read More

Sweeping Up Worms

With the opening of a new venture and numerous reporters... Read More

Creating a Feng Shui Power Office: 6 Easy Tips to More Successful Surroundings

More and more people are looking to gain an edge... Read More

How to Become a Real Estate Agent

If you're wondering how to become a real estate agent,... Read More

Mid-Life Crisis: Its Not Just for Men Anymore!

A recent story in Career Journal begins:"The "midlife crisis" has... Read More

Changing Careers? How to Get Around the Three Major Mental Roadblocks to Success

A part of you can't wait to dive into your... Read More

Tales from the Corporate Frontlines: Career Opportunity and Employee Retention

This article relates to the Career Opportunities competency and explores... Read More

Fun At Work Leads to More Success

Common sense at work: Such qualities as loyalty, energy, intelligence... Read More

Career Change Is Not For Wimps! 3 Powerful Steps to Do Work You Love

Tough words... but I truly believe that folks who make... Read More

Writing Resumes

Use a resume as a foot in the doorWhen you... Read More

Get In The Game With a Stellar Resume

During the job hunter's market of the 1990's, employers were... Read More

If Youre Fired, Will Past Employers Keep Your Secret?

Despite what some job seekers think, it is not illegal... Read More

War Time Hiring: 5 Steps to Attract Top Talent

A recent report, titled "The War for Talent" stated that... Read More

Making The Best Of Yourself At Interview

You are just about to leave university You are just... Read More

Tips for Terrific Telephone Interviews

Telephone interviews don't just happen; they are the result of... Read More

20 Powerful Tips For Advancing Your Career

You don't want to stay in your current position forever...... Read More

Ive Got the Big Bad B Word on My Job!

That "B" word---B O R E D O M.How did... Read More

Factual Employment Screening Part 1

We have all heard in recent years that the need... Read More

Who Should Write Your Resume?

This is a question we get a lot. It seems... Read More

Job Search Advice for Desperate Job Seekers

Another morning of job hunting lies ahead of you. You... Read More

The Interview - A Few Tips for Making a Great First Impression

Searching for employment is one of the most nerve-racking activities... Read More