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The High Cost of Fraud
Workers’ compensation fraud is prevalent and is costing
employers and insurance carriers significant dollars each year.
There are many degrees of fraud. There are blatantly false
claims, such as someone faking a fall or accident, to more
subtle examples, such as complaining of false or lingering pain
“minor” claim turned into a large
An effective way to investigate
is by interviewing the employee.
Question him or her about exactly
how the incident happened, who
witnessed it and what could be done
to avoid it in the future.
Specifically ask them to name all
body parts that were injured. One
form of fraud is an attempt to add
non-related injuries to the claim as
time goes on.
Ask them questions about their
lives. What are their hobbies, do they
have other employment, and do they
have a spouse and children?
These questions help document
the accident and provide great
information if there is a need to
investigate the validity of the claim.
Having their version of the accident
in writing makes it less likely that the
facts will change.
NURSE CASE MANAGEMENT
Nurse case management is useful
in many ways to help ensure proper
treatment, mitigate costs and return
the worker to full duty. It is also a
way to help manage situations where
there is suspected claims fraud.
The nurse should attend medical
appointments and ensure the worker
is being honest with the doctor about
He/she should have a detailed job
description so there is no question
about what restrictions the doctor
should or shouldn’t place on the
injured worker. The nurse can also
give the doctor information about the
worker’s hobbies and lifestyle.
If an investigation reveals that
an employee is performing activities
that he/she states they cannot do, the
nurse can present this to the doctor
in the hope of getting a full-duty
There are numerous ways to
reduce or prevent claims fraud.
Initial investigation and nurse case
management are valuable tools.
While some fraudulent claims
are prosecuted, most are not. The
evidence of fraud can be used to limit
the exposure of the claim.
Use the information to bring the
worker back to full duty as soon as
possible. These tools can help shorten
the length of a claim and save the
SUSAN LABAR is the risk manager at Coach
USA/Megabus. She has more than 20 years
experience in handling nationwide liability and
workers’ compensation claims. She can be
reached at firstname.lastname@example.org.
● Susan LaBar
to get more time off of work.
All forms of fraud cost money.
Recognizing fraudulent claims and
controlling them can be difficult.
Below are two ways that workers’
comp fraud can be controlled.
GET THE FACTS
The initial investigation is one
of the most important steps in
preventing and controlling fraud.
Always ensure that an accurate injury
report is received.
Thoroughly investigate every
claim in detail, no matter how minor
the injury. How many times has a
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