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

---

Using Keywords to Find Legitimate Telecommuting Job Leads

Many people are choosing telecommuting as an option to bring... Read More

Need a Job? Put a Gun to Your Head

A legendary marketing genius once said that, if he had... Read More

Any Job is an Honorable Job

Seeing your job as an honorable job, adds more meaning... Read More

Job Search Blurts

I coined this word to draw attention to the nervous... Read More

Stacking The Deck In Your Favor

Many people do not bother to look at their own... Read More

Avoid Your CV Always Ending Up in the Bin

Cover Letters must grab the reader's interest so that they... Read More

5 Things You Need To Know Before Deciding On A Certification Training

The right certification trainingTrainings vary a lot when it comes... Read More

Ebook Review: Winning a Job is Easier with Job Secrets Revealed

IntroductionThere are literally thousands, if not tens of thousands of... Read More

Minding Your Own Business

Think you have gone as far as you can in... Read More

Analysing Adverts for the Creative Response

The fundamental rule is: if you are going to apply... Read More

Top 5 Tips for College Grads Entering the Working World

1) Build a Relationship With Your Boss:Like it or not,... Read More

How You Can Find Freelance Writing Employment

How can you find writing jobs? Do you have proven... Read More

20 Ways to Advance Your Career

To survive and thrive in today's competitive environment, it is... Read More

10 Keys to Getting Paid What You?re Worth!

Asking for money is so taboo in our culture that... Read More

Avoiding Tire Kickers as Job Seekers

With the economy heating up and employment prospects opening up... Read More

Building Your Army of Supporters: How to Build Strategic Relationships in the Work Place!

Once you have accomplished your task of getting in the... Read More

Factual Employment Screening Part 1

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

Learn How To Succeed At Career Fairs

This career article will give you some great tips on... Read More

A Peek at Nursing as a Career

We need more people to choose nursing as a career.... Read More

Job Offers and Pay Negotiations

When you first get the job offer it will often... Read More

The 5 Essential Telecommute Résumé Components

1. An attractive layout that is easy to read and... Read More

Background Checks: How They Can Determine Whether You Get Hired or Not!

Background checks are utilized by companies today to decide whether... Read More

5 Ways to Combat Job Burnout

Job burnout happens when the stress or prolonged frustration of... Read More

Telecommuting Resumes

Your resume needs to outline your skills and experience, as... Read More

Cover Letter Sample -- For the Corporate Flight Attendant

Writing a cover letter to send with your résumé can... Read More

Why You Need To Be An Intrapreneur

When a client asks me if I think he or... Read More

Work In Dubai

Dubai is home to an exciting, diverse, multi-cultural blend of... Read More

Lost Your Job? Ten Ways to Bounce Back!

Whether you've been right-sized, downsized, underutilized, or just plain fired,... Read More

How to Give Job-Winning Answers at Interviews

Human Resources personnel, professional recruiters and various other career experts... Read More

The 6 Stages of Modern Career Development

Career experts say that people will change careers (not jobs)... Read More

Searching for an IT Job

Looking for an IT job is one of the easiest... Read More

Have You Been Fired? Laid Off? No? You Will Be!

It's true. Things have changed. You need to know the... Read More

Resume 101

Whether you've been downsized, are looking for a career change... Read More