Tag Archive for: workers’ compensation
So, you’re a private investigator on a stakeout. It’s a bright, sunny day. You’re in your car in a fixed surveillance position, and your fraudulent Subject somehow becomes aware of you, and now your client is upset. Did you get burned because of your window tint?
As a P.I., automotive window tints are a must – it keeps you out of view from neighbors, onlookers, and of course, your Subject. And, of course, it blocks visible light from entering your car’s interior.
But before slapping some on your windows, it’s important to know your state’s laws and general info.
Each state has laws for front, backside, rear windows, windshield, and reflectivity.
When you see data on window tint, you’ll see it categorized by percentage.
Here at Gravitas Investigations, we have a rule of thumb: The lower the percentage, the DARKER the tint, and the less sunlight can come into your car. The higher the percentage, the lighter the tint, and the more sun can come in.
I went ahead and linked to the window tinting laws in all 50 states (click here)
Let’s take Ohio, Kentucky, and Indiana, for example, the states where I’m licensed.
In Kentucky, the front side window must be 35%. This means you can’t have a tint that allows less than 35% of the rays on your front side window.
It’s 18% on both the rear side and rear back windows. So you can go darker tint there.
The windshield tint allows you to place a strip of tint to the top of the car manufacturer’s “AS-1” line. What is the as1 line?
The AS-1 line extends from the “AS-1” label on most motor vehicle windshields. An actual As1 label is found on the windshield and runs parallel to the top of the windshield or at about 5 inches.
Legal window tint in Ohio is at 50% on front side windows. But any level, even limo tint, is allowed on the rear side and rear back windows. So, we can go crazy there.
Indiana legal window tint is at 30%. Legal tint in Indiana for rear window tint is also 30%. Indiana window tint law also says 30% for side windows.
My two cents: if you can, get your rear side and back windows as dark as possible.
Especially if you have an SUV or minivan, when you add dark tint to the rear windows, they don’t seem to change the look of your car that much. That’s because most factory-made large vehicles come with a high level of rear tint as it is. But if you can match the front and back window tint, I tend to go that route.
It’s visually appealing, and it makes your car blend in well.
My cars also have had the 5” band across the top of the windshield. Though some installers won’t put it there if you have a “frit” band. Those tiny little dots around the edge of your windshield.
I avoid reflective tint because it stands out – it doesn’t blend in too well. I’m not against limo or blacked-out tinting. But if you’re parked for extended periods in your car in a suburban area, it might bring more attention than less.
When it comes to the law, though, I could receive a fine for my tint. I’d be willing to pay that fine. I’ve never been pulled over or cited in my 15 years of driving with an “illegal” tint. I chalk it up to the fact that police officers aren’t looking to cite someone for window tint. It’s a minor offense, and since so many already have it, it’s not worth it for them to stop me.
So, depending on how aggressive your local PD is, it’s up to you how “illegal” you want to tint your windows.
Also, some states allow exemptions. Under some state laws, private investigators can get exemptions on window tinting.
So check your local statutes and revised code for those details.
Even though you have window tint, the sun can shine, exposing your silhouette.
#1 – Ensure you angle your car to avoid direct sun glare.
I always like to park with the sun at the back of my car if I can and not blasting through the front window. In cold months, the sun is low and can do that to you.
#2 – Find some shade wherever you park.
When I find a stationary spot and park on the street, I usually try to park where there is an overhanging tree. It doubles the effectiveness of your car’s tint and prevents visible light transmission.
#3 – I always have a front window shade to block out any sun coming in the front window and any onlookers.
I get shades that you can pop in and out quickly into your front windshield.
#4 – In a van or larger vehicle, sitting in the rear seats and using window curtains are huge too.
Passersby only pay attention to who is in the driver’s seat and don’t notice people in the back seat. Curtains block out any silhouette. Also, some minivans come stocked with mesh shades that pull up from the sliding door. So you may not even need curtains on the side windows.
#5 – If you’re renting a vehicle and don’t want to use your own to save on mileage, I always ask for an SUV or minivan.
They come stocked with factory-level side windshield tinting and back window shade. The front windows aren’t tinted, but I assume I’ll be sitting in the rear of the vehicle anyways.
Over to you…
What percentage do you have in your windows? Go ahead and assess automotive window tints for all your surveillance vehicles.
Have you ever been given a ticket for illegal window tint?
Comment below. Let me know.
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The Reason You Got Burned: Driving By Too Slowly
So, you’re a private investigator on surveillance and you got burned and you don’t know why. Was it because you drove past your Subject’s house too slowly?
So, drive-by video. I learned this lesson early on in my career.
It became ingrained in my brain.
Because I was assigned to a two-person surveillance operation on workers’ compensation claimant in a rural area of Ohio. Like, we’re talking Amish country people. You’ve got horse and buggy, oxen plowing fields, and epic Amish beards.
But, the reason it was a two-man operation wasn’t that it was so rural, but because the previous investigative team (not from our firm) had been burned on it before.
So, our Claimant was already “heated up.”
And we knew why – the client had provided the previous report and video to us, so we knew what they had done wrong.
This Claimant lived on a country road, and the previous investigators had driven past the house too often, and, too slowly.
Eventually, the claimant, who had a residence with a huge bay window at the front of his house, caught on to the drive-bys.
I mean, he probably knew all his neighbors’ cars as it was, and seeing two cars he’d never seen before drive by every half-hour alerted him.
And this was all in the report – the claimant actually got into his own car and tailed the investigators out of the county.
Look, I get it. When you first get onsite to a residence, your natural inclination is to a good establishing shot. You wanna get a shot of the house, the layout, note the plates and vehicles on-site, on top of any action that might be going on.
But that doesn’t mean driving along the road at normal speeds and then all of sudden, dropping it down to a crawl to get some drive-by footage.
That’s a disaster in the making.
So, I’m here to help.
First, obviously, don’t ever drive by the house too slowly. There’s no reason for it.
When you do drive-bys, go at a normal speed every time. As if you were an average joe living in the area.
But when you’re shooting video, get the house in the frame early and pan left or right as you pass the house.
Also, while this is going on, zoom in at first and then zoom out wide as you pass by the house to frame everything up nicely.
It’ll take some practice to both stay on the road with one hand and pan and zoom with your camera hand.
The key is to keep it steady. Keep it level.
This isn’t shaky cam footage Jason Bourne.
If you wanna get really fancy you can get ahold of a window mount, one with a suction cup, and fix your camcorder or even a dash camera to the second-row window of your surveillance vehicle.
Press record, do the drive-by, and later edit out what’s unnecessary.
There’s a link below to a mount to get you started: https://amzn.to/2Yh1NWO
Second, especially in rural areas, limit your drive-bys to every hour or so.
You can certainly do drive-bys every half-hour, but only when you feel you need to.
Like if there have been multiple cars coming and going from the residential area, it’s lunchtime for the Claimant, or something similar.
And don’t just come back up the road in which you initially drove down. Give it time.
Driving by the house within a couple of minutes of each other is suspicious.
Instead, drive by the first time and “flank” back to your original surveillance position by going around the “block” assuming there’s another route to get to your original spot.
However, if the residence is in a hollow (like in Kentucky), like a no-outlet street, I’d limit my drive-bys to every two hours.
And, I know what you’re thinking – I could use drone footage or an unmanned surveillance camera hidden in a rock or safety cone to get static video.
Hold your horses, James Bond. That’s a video for another day.
For now, let’s just stick with the basics.
Third, hide your camera.
It may sound simple but what’s worked for me is to actually place my camera hand or monopod on the top of my left arm to stabilize and hide the camera.
I’ll do this if the residence is on my left side.
If the residence is on my right side, I’ll actually place my camera behind the passenger side headrest to get drive-by footage.
These simple methods help to prevent people from seeing my camera through my front windshield as I drive by.
This is me trying to be as casual as possible.
Lastly, and I can’t believe I have to say this but close your windows when filming drive-bys.
If you can’t get the footage because your windows are foggy or dirty, clean those things before getting onsite for crying out loud.
Overall, use the KISS method – keep it simple, stupid.
Drive by the residence like a normal person would (not too slowly!), limit drive-bys to every hour, hide your camera, and keep your windows up.
And, just in case you were wondering. Even with the knowledge of the previous investigation, we still couldn’t get much of anything on that Claimant in rural Ohio. But, at least he didn’t tail us.
Anybody wanna volunteer to take that case??
Over to you…
What ways can you prevent from getting burned?
Workplace Accident Investigations
Many workplaces equate a workplace accident investigation by identifying the party to blame for it. The actual goal of a workplace accident investigation is to prevent its re-occurrence.
While your firm may tackle the workers’ compensation process alone, we believe you better serve your company and its employees’ safety by including a private investigation firm in the total process. Your investigation needs to go beyond the party at fault and make prevention the focus of the investigation.
Accident Investigations and Safer Workplaces
The overarching goal of a workplace accident is to identify the cause of the injuries, followed by developing procedures and processes to prevent future injuries. This process starts with proper evidence collection and information gathering.
Certainly, in the US and Canada, workplace accident investigations form an integral part of legal compliance with Occupational Health and Safety Administration (OSHA) standards. They’re also vital for determining the accident’s cost, to process workers’ compensation claims, and to determine the level of compliance with OSHA regulations.
While OSHA’s focus will center on the incident report and the proper medical treatment of injured employees, your investigation should focus beyond that to the causal factors.
The quickest and easiest way to administer the investigation is to create and document the process before it is needed. Develop the paperwork and the process formats before their need arises. While the scope of an investigation may differ, the overall process remains the same. A process should remain the same from investigation to investigation to keep the value of any conclusions consistent.
The “Who” in the Investigation
Within your organization, the immediate supervisor of the injured worker should conduct the investigation. The risk manager or safe workplace practitioner may assist, along with any investigative or review committee in existence. Senior management personnel, engineering staff, and the firm’s attorneys may also join in an investigation involving a fatality. During the investigation, you should interview:
- any injured employees,
- accident witnesses,
- witnesses to events preceding the accident,
- the injured employees’ immediate supervisor unless they’re heading the investigation.
- The injured employee may have an employee representative present during their interview.
The “What” in the Investigation
The “what” in the investigation refers to the information you collect to determine the accident’s cause and those involved. The data you obtain will later enable your analysis to determine a preventative method for future occurrences. During the investigative process, you should collect:
- the employee characteristics such as age and gender, department, job title, experience level, job and company tenure, training records and their hiring status,
- the injury characteristics of each injured employee including an injury or illness description, severity, and body part(s) affected,
- an events sequence and a narrative description from each involved party and each witness,
- characteristics of all equipment involved in the accident,
- task descriptions featuring specific characteristics of its performed when the accident occurred,
- any factors related to time such as the time of day, placement within their shift, etc.
- supervision data such as whether they were under direct supervision or not at all,
- causal factors such as the contributing workplace conditions,
- corrective actions are taken whether immediate, interim, or long-term.
The “How” of Your Investigation
The “how” refers to the tools with which you investigate the accident. Having a ready to go kit will help you complete a timely investigation. This kit needs to include:
- investigation and interview forms,
- barricade markers/tape,
- padlocks or warning tags,
- camera or video recorder,
- voice recorder,
- measuring tape,
- sample containers.
Having this kit ready to go lets you begin interviewing people immediately after the event occurs. You’ll produce better results by building rapport with injured employees and witnesses. Reassure each person interviewed that you want to fact-find. They need to know it is not about determining fault.
Your full investigation will also include a background investigation that reviews the employment and injury records of each injured employee, as well as, any other party whose actions may have contributed to the accident. Pay close attention to reports of any injuries or damage to equipment, machines, buildings, or property.
Interview each individual separately. Have each person recount their recollection of the account uninterrupted. Record their response and take notes.
After their recount, ask any clarifying questions needed. Repeat the factual information they said to clarify inconsistencies. One of the key questions you will ask is “What do you think could have prevented this?”
Remember that you need to uncover the causal factors to prevent them from ever happening again. Ask “why?” of those you interview.
Six Steps to Better Investigations
Succinctly, you can sum up a properly administered investigation in six steps. These are:
- Handle the immediate risk by obtaining immediate medical help for the injured employee(s). Cordon off the incident area to preserve evidence and deny access. Report the accident/incident to OSHA.
- Collect evidence as soon as possible after the injured have been removed for medical attention.
- Conduct the investigation interviews as soon as possible. You can interview witnesses while the injured receive medical attention. This immediacy provides the most accurate details.
- Analyze your findings. Your analysis develops the corrective actions that will stop it from happening again.
- Write your findings report. This summarizes the incident and describes the corrective actions applied to prevent its reoccurrence.
- Apply corrective actions. Implement new procedures to ensure the prevention of future accidents. This might include machine replacement or repairs or signage.
Determining Deeper Causality
Once combined and analyzed, the accident photos, videos, interviews, and physical evidence should lead you to the deeper causality of the accident. Pay close attention to potentially contributing environmental conditions such as weather, light, and noise. Also, examine extenuating factors and externalities.
The accident investigation becomes an opportunity for you to discover an improvement for your company’s business processes. The focus should be on identifying flaws in the process that lead to the incident. It should unearth the reason that procedures were not followed or what prevented them from happening.
Your final report should discuss the contributing, direct, and indirect causes of the accident. Reference data that support each cause.
While your ultimate goal is the prevention of future accidents, a secondary goal is preparation for possible litigation. This is a likely outcome if the accident resulted in severe injuries or fatalities.
The lessons learned from each accident can help prevent larger ones in the future. It’s also important to investigate so that employees and regulators see that your company consistently pursues its commitment to a safe workplace.
Key Questions to Ask
During the interviews, you need to focus on questions that will help you answer larger, deeper issues. Your interview focus should apply queries that help you eventually address the following questions.
- Was a hazardous condition or defective tool a contributing factor?
- Did the worker’s location or equipment location contribute to the accident?
- Did the established job procedure or process contribute to the accident?
- Did the employee’s ability to perform the job contribute to the accident?
- Did any mandates such as speed incentives or production quotas encourage deviation from job procedures that contributed to the accident?
- Was lack of personal protective equipment or emergency equipment a contributing factor?
- Did management or a manager’s decision contribute to the accident?
The answers you derive from evidentiary analysis help you determine the appropriate prevention methods to pursue. This could mean a need for new procedures or the need for new equipment. This may also indicate the need for employee education and training or for improved education and training. Another potential result is the need for additional safety gear or to develop or improve protection from natural hazards or phenomena. Finally, it could also point to the need for or improvement of systems to account for possible physical, physiological, or psychological limitations of employees.
Your investigation of any workplace accident should include a background investigation, site investigation, interviews, analysis, and a final report. The aftereffect of the investigation should be amended or new procedures and processes. During your investigation, remember that placing blame is not the reason for your investigation – creating a safer workplace that in the future prevents its re-occurrence is.
While your company could tackle the workers’ compensation process alone, we believe you better serve your company and its employees with a safer workplace by including our private investigation firm in the total process. We help you take your investigation beyond finding the party at fault and to developing preventative measures that keep the accident from repeating itself. Commit to a safer workplace by developing a standardized workplace accident investigation procedure and process. The work you do today results in a safer, stronger workplace tomorrow for all of your employees.
Companies of all sizes should have return-to-work (RTW) programs in place. When an injured employee makes a seamless transition back to full duty, everybody wins.
Ideally, RTW programs (sometimes called modified duty, light-duty, and transitional duty) are launched with extensive training in how to avoid injury in the first place. The best time to implement a program is before someone strains a back, takes a hard fall, or inhales toxic fumes.
Still, it’s never too late to put safety first.
The Goal OF RTW PROGRAMS
Workers who were hurt or made ill on the job need time to get up to speed. Good programs help employees ease back into full productivity without reinjury.
During recovery, light-duty jobs are modified to accommodate physical limitations.
It’s true that RTW programs require planning, collaboration, and training. They take time to develop. But, their success is a product of trial and error.
However, companies that design effective programs are never sorry that they did. Boosting productivity, morale and the bottom line always pays off.
Benefits for Employers
The biggest perk for employers is a reduction in Workers’ Compensation costs. According to the Bureau of Labor Statistics, payments to injured or sickened workers approached a whopping $40 billion in 2015.
Injured employees who return to work even part-time collect fewer benefits.
Also, Workers’ Compensation premiums are often the largest expense after payroll. Keeping accidents and injuries to a minimum keeps premiums in line.
Effective RTW programs also limit fraudulent and abusive claims. If your boss were genuinely interested in your recovery and accommodated you with light-duty, wouldn’t you be less inclined to scam him?
Along the same lines, private investigation is rarely called for when employees get back to work quickly.
Even a little productivity is better than none, and retaining good workers saves a fortune in hiring and training costs.
For all these reasons, RTW programs make good business sense.
Benefits for Employees
Continuing to earn income — even if wages are temporarily reduced for light-duty — keeps food on the table. There are also physical and psychological benefits.
Private investigation usually exposes injured workers who attempt to cheat the system, but it sometimes reveals just how isolating and depressing a serious injury can be.
Experts agree that returning to work, even on a limited basis, speeds recovery. Purpose, socialization, and a sense of one’s own value have a positive impact on health.
Making RTW Programs Effective
The hardest part is getting started, but employers who drag their feet could soon find themselves out of business.
It’s a collective effort. If you’re in safety, risk management, Workers’ Compensation or law, business owners and executives could use your help.
Here are some factors that distinguish truly effective programs:
Safety is ingrained in the workplace culture
What does that look like?
The best programs are a valued part of the company culture just like teamwork or work-life balance.
Time and financial resources are invested in safety. Training is thorough and unrushed. Safety is the first item on the agenda of every meeting.
Safety is a condition of employment, and there are consequences for violating rules. Workers are comfortable pointing out unsafe conditions or behavior.
Licenses and certifications are current. There are high standards for documenting injuries.
Not surprisingly, injury rates are low or nonexistent.
Everyone is on board
Management is 100% committed, and workers at all levels know that their superiors embrace safety as a core value.
It takes a natural leader with an engaging personality to make that happen.
Hazards are identified and addressed
New companies identify jobs, equipment, or workspaces with high potential for injury. Older companies review their history to pinpoint the most common injuries and find out how they occurred.
The RTW team brainstorms about ways to protect workers in those positions. Certain jobs may be modified. Safer equipment might be installed. Training may be reevaluated.
This is a great time to ask at-risk employees for suggestions.
Thorough job descriptions are published
Existing job descriptions include duties, physical requirements, and functional requirements such as standing or heavy lifting.
Planners have even thought of ways to convert existing jobs to transitional duty.
For instance, a kitchen steward with a back injury shouldn’t lift 50-pound bags of rice, but there are plenty of onions to chop and potatoes to peel. There may even be bigger fish to fry.
Jobs have also been cobbled together for alternate duty. Ideas include oiling machinery, taking inventory, labeling shelves, answering phones, ordering supplies, making copies, and monitoring security video.
These transitional jobs may be rough sketches, so to speak, but they’re down on paper as possibilities anyway. That shows employees that management will do its best to accommodate them.
RTW-minded managers also consider injured workers for vacant positions.
There’s a designated liaison
A compassionate, organized person who likes working with people acts as a liaison between injured workers, managers, and doctors. Someone who hopes to partner with a doctor is ideal. Third-party administrators (TPAs) can be that solution – there to keep in close contact with all parties and keep the program moving forward.
RTW policies are published and distributed
Company policy clearly defines expectations for both managers and workers. Everyone has a copy.
Workers know how and when to notify the company of injury. Contact numbers are provided.
Employees are familiar with the Family and Medical Leave Act (FMLA) and the Americans with Disabilities Act (ADA). Where workers’ compensation is concerned, they understand both their rights and their accountability.
Effective RTW programs are fair to everyone.
Evaluation metrics are in place
RTW coordinators track results – bigwigs in corner offices dig that stuff.
Executives or small-business owners comply with municipal, state and federal laws
Compliance is a lot more complicated than most suits or entrepreneurs know. The importance of working with an attorney can’t be overstated.
The High Cost of Complacency
The cost of keeping workers safe and active is a drop in the bucket compared to the cost of settlements, high turnover rates and lost productivity.
Employers simply can’t afford to be complacent.
Having been a private investigator in the Workers’ Compensation (WC) industry for almost 15 years, IMHO, I come across quite a bit of industry jargon – an alphabet soup of acronyms only trumped by the federal government.
If you’re new to the
|Arising Out Of Employment/In the Course Of Employment
|Average Weekly Wage
|Bureau of Workers’ Compensation
|Date of Loss/Date of Injury/Date of Accident
|Experience Modification Rate/Experience rate used in determining WC premiums
|Employer of Record
|First Report of Injury
|Independent Medical Exam
|Managed Care Organization
|Modified Duty Onsite
|Medical Claim Only, No Lost Work Time
|Ohio’s specific Physician’s Report of Workability
|Maximum Medical Improvement
|Nurse Case Manager
|Physician of Record
|Permanent Total Disability
|Return To Work
|Special Investigations Unit
|Short Term Disability
|Third Party Administrator
|Temporary Total Disability
|Vocation Rehabilitation (training to do another job)
A new workers’ compensation claim hits your inbox, littered with red flags. But your spidey- sense kicks in. Why?
Well, several warning signs pop up; the claimant was injured on a Friday before a holiday weekend, they’ve already booked appointments with a chiropractor, and nobody witnessed the injury.
You ask yourself, “Is it fraud?!?”
Though not every claim you see is fraudulent, this one appears to be. But, what now?
You know that proving fraud could save your client tons of money in insurance premiums.
What if you had a comprehensive list of red flags to check against your suspicions? A list that was compiled by a fraud investigator with the help of claims professionals like you?…
..well, we did it.
We asked a dozen claims adjusters, examiners, insurance professionals, attorneys, and others for their workers’ compensation claim advice and compiled the results into a comprehensive list.
Here is the list of red flags (67 total) they provided:
The Timeliness of the Injury Report
- The injury occurred immediately before a holiday or a long weekend (many “injuries” occur on Fridays). – The most common red flag is the injury without a timely report of injury – Lisa Fike, Staff Attorney
- The claimant was injured after a holiday or a long weekend (this repeatedly occurs if the claimant is ineligible for holiday or paid-time-off).
- The claim was filed prior to a planned vacation allowing the claimant to collect disability during their trips.
- The claimant reports the accident days, weeks, months, or years after it occurred.
- The claim is filed after the claimant becomes aware of their imminent termination.
- The claimant is injured shortly after initial hiring (this is especially true after the initial probationary period for full-time hires).
- The claimant recently purchased personal disability insurance (a.k.a. gap coverage).
- The claimant hires an attorney immediately after filing a claim.
- The claimant instantly asks for a settlement.– Amy Rodallega, Claims Representative, Nationwide Insurance
- There were no witnesses to the accident.
- The accident occurred on the employer’s premises but out of view of security cameras.
- The claimant was helping another employee despite being asked not to do so (not their department or job duties) by management.
- The claimant’s version of the accident is inconsistent – there are multiple variations of the story.
- The claimant experiences a psychological injury, which is hard to substantiate.
- The claimant experiences a back injury, which is hard to substantiate.
- The claimant engages in physical activities inconsistent with the limitations they claim to have due to their injury.
- The claimant has a pre-existing injury.
- A hospital canvass determines that the claimant has been treated elsewhere for the same condition and/or an Insurance Service Office (ISO) check reveals that the claimant had prior injuries to the same body part. – Lori Terry, Claims Examiner, Careworks Consultants Inc.
- The claimant has a history of subjective injuries, psychological, mental pain, undisclosed pain, or general pain.
- The claimant seeks to open or start a new claim based on a flow-through injury (an injury developing in a body part not originally alleged) or from the result of an old injury. – Jean McEntarfer, Human Resources Manager, Teleperformance USA
- The claimant is never available to answer calls.
- The claimant has limited availability for exams and/or appointments.
- The claimant has a preference for receiving emails from claim representatives rather than phone calls.
- The claimant’s voicemail box is always full.
- The claimant screens or avoids calls.
- The claimant frequently changes appointments or does not show for appointments to avoid field case manager or nurse case manager. – Debbie Lantman, Manager – Workers’ Compensation, Formica Corporation
Circumstances Around the Job
- The claimant files a claim for job security – the claimant knows the employer will not terminate the claimant while on disability.
- The claimant performs seasonal work that will end soon.
- The claimant is approaching retirement and files a claim.
- The claimant has absenteeism problems.– “They ‘earn and burn’ their time by attempting to get off work when they’re out of PTO or off-days.” – Brenda Scalf, Client Services Manager, Sheakley
- The claimant has frequently used the Family Medical Leave Act (FMLA).
- The injury occurred as a result of the claimant’s side job.
- The claimant has a personal vendetta against management or fellow employees.
- The claim occurred just prior to or after a strike.
- The claimant shows up in pictures or in person with indications of having worked another job:
- they have calluses on their hands, or
- grease under their fingers.
- The physician of record (POR) does not mention checking the state pharmacy website for the claimant’s narcotic prescriptions.
- In states where it’s permissible to do so, the claimant refuses to seek medical treatment or physical therapy.
- Multiple workers’ compensation claimants seek out the same physician. -“It’s suspicious when employees of the same organization magically go to the same doctor when they are injured.” – Kelly Flynn Reimer, Claims Manager
- The claimant refuses to go to vocational rehabilitation.
- The claimant refuses to go to an independent medical exam (IME).
- The subject explores “doctor shopping,” where they seek out physicians who substantiate their injury claims. –“I would say that anyone who gets released from the physician, or is told they can’t have any more narcotics/meds, who then immediately starts ‘doctor shopping’ is a big red flag.” – Jill Thomas, Director of Claims, V&A Risk Services, LLC
- The claimant seeks narcotics and once their prescription runs out, they shop for another doctor who will fill that prescription.
- After a doctor’s appointment, the claimant cannot describe the types of medical services that were performed on him or her.
- The claimant has a doctor that is a great distance from their residence for no reason at all.
- The claimant tells the doctor what kind of treatment they need.
- The claimant tells the doctor their employer has no light-duty work.
- The claimant immediately seeks treatment with a doctor or chiropractor that is known to automatically take patients off work. “Some doctors are on the suspicious provider list if claimants go to them for initial treatment. Suspicions increase when employees of the same organization frequent the same physicians” – Anonymous Claims Professional
- The claimant sells their prescriptions to others or seeks out various medical providers to obtain multiple prescriptions.
- The injured worker immediately schedules a meeting with a chiropractor. -“Even if I’m not familiar with that chiropractor, that’s always a red flag to me because it means the injured worker (IW) is familiar with chiropractors” – Jackie Spring, Self-Insured Manager, Alternative Risk Management
- Social media pictures and profile information indicate that the claimant is active and moving normally against their restrictions. – Lisa Ball, SIU, Allstate Insurance
- The claimant has a history of filing Worker’s Compensation claims in the past.– “I have seen people do this because most employers will not get rid of someone that has filed a workers’ comp claim.” – Debra Goetz, Spooner Inc.
- Employees that are friends or associates with the claimant observe the claimant conducting activities that are in contradiction to their limitations.
- The injury occurred during a side sporting activity.
- The claimant is a nomad; they live in multiple places, and/or drive around from job to job.
- The claimant uses a PO Box as their mailing address, rather than an actual address, and/or refuses to provide a physical address.
- The claimant lives in an economically depressed area.
- The claimant has a history of bad credit, monetary problems, or is always in debt.
- Several of the claimant’s relatives and friends have similar Worker’s Compensation claims. This is what some investigators call ‘fraud school,’ where fraud/abuse methods are passed from relative to relative.
- When taking a claimant’s statement, the claimant feels inclined to provide information on their personal character. For example, “I’m a good person, and I am not looking to scam the system or get something I don’t deserve.’ I can tell you that 9 times out of 10 when someone makes a comment like that to me they end up trying to scam the system!” – Adriane R. Thompson, SCLA, Senior Resolution Manager, Gallagher Bassett
- Claims representatives suspect the claimant’s character or personality traits determine the claimant is engaged in workers’ compensation fraud or abuse (The claimant’s demeanor is very calm or savvy).
Other Red Flags
- The claimant does not have medical insurance.
- The claimant opts out of employer-provided health insurance and soon after files a workers’ compensation claim.
- The claimant has a high-deductible insurance meaning they’ll pay a lot in out of pocket expenses.
- The employee will file a claim before going out for a non-industrial health reason (i.e. major surgery) & their PTO time won’t cover the entire period of time they’re off.
- Employees who plan to visit their out-of-the-country/town family members for extended periods of time will file a temporary total disability (TTD) claim, allowing them to collect a Workers’ Compensation check if their doctor writes them off on a Physician’s Report of Work Ability. “For example, someone from a foreign country who is planning to visit their family for 1-2 months will file a claim the week just before they leave thinking they will be paid TTD the entire time they are gone.” – Holly Miller, The Ohio Manufacturer’s Association
- The claimant has shown an overall pattern of behavior that indicates fraud.
- The claimant had a recent auto accident or has had multiple auto accidents where they were injured.
When that next claim with red flags hits your inbox, do your clients a favor – check it against the list above. If it saves them money, they’ll be happy you did.
Did we leave out any red flags? Let us know in the comments below or email Gravitas Investigations at email@example.com with your suggestion.
If you’d like to discuss a plan to combat fraud, Call Us Now to speak directly with an investigator.