- Do you know how to determine the appropriate length of REAL MEDICAL disability, i.e., how long an injured worker SHOULD be out of work?
- Does your company TAKE CHARGE of the injury process immediately after the injury — or are the employees in charge?
- Do you know the seven reasons to investigate a workers’ comp claim?
- Do your supervisors know the “red flags” of fraud?
- Are you using all SIX types of investigation?
- Do you know the FOUR times NEVER to use investigation?
- Are your adjusters able to identify medical terminology that signifies malingering?
Workers’ compensation claims are usually legitimate and companies are committed to paying compensable claims quickly; however, they have a duty to determine that each is legitimate. When fraud is suspected, employers must communicate their suspicions to the adjuster. Prompt reporting and thorough accident investigation are CRITICAL to reduce fraud.
Investigate a claim when the employer wants to:
- Verify the extent of the employee’s disability.
- Substantiate the ability of an employee to return to work or perform transitional duty.
- Verify whether the employee is engaged in outside employment.
- Prove insurance fraud.
- Reduce/increase the amount of a settlement.
Types of Investigation
- General
- Activity check
- Sub-rosa
- Virtual
- Medical records
When to Use Surveillance
Request an investigation when a claim is thought to be suspicious or exaggerated. Fraud control actions are needed when:
- Claimant claims total disability.
- To verify information and tips.
- The claim could be financially devastating to the company.
- And More
For more information about this chapter, see the Table of Contents
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