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
|AOE/COE||Arising Out Of Employment/In the Course Of Employment|
|AWW||Average Weekly Wage|
|BWC||Bureau of Workers’ Compensation|
|DOL/DOI/DOA||Date of Loss/Date of Injury/Date of Accident|
|EMR/MOD RATE||Experience Modification Rate/Experience rate used in determining WC premiums|
|EOR||Employer of Record|
|FROI||First Report of Injury|
|IME||Independent Medical Exam|
|MCO||Managed Care Organization|
|MDOS||Modified Duty Onsite|
|Med Only||Medical Claim Only, No Lost Work Time|
|MEDCO 14||Ohio’s specific Physician’s Report of Workability|
|MMI||Maximum Medical Improvement|
|NCM||Nurse Case Manager|
|POR||Physician of Record|
|PTD||Permanent Total Disability|
|RTW||Return To Work|
|SIU||Special Investigations Unit|
|STD||Short Term Disability|
|TPA||Third Party Administrator|
|TTD||Temporary Total Disability|
|Voc/Voc Rehab||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.
Have you ever been asked what you do for a living? When people ask me, I tell them I’m a private investigator (PI).
Kind of interesting, right? You don’t get the opportunity to meet private investigators every day, let alone talk to them about what they do.
Inevitably, the next question asked is:
“Who hires you?”
Aside from “educational” shows about private investigators (like Cheaters), I’m surprised at the lack of information available. One look at web search results and it seems all we PIs do are infidelity or domestic cases. Case in point:
There are a lot of false assumptions about the identity of both private investigators and our clients. We all don’t look like this guy:
In truth, private investigators offer a mix of services that are useful to a wide array of customers.
Here are 7 types of people that commonly use our services:
Human Resource (HR) Professionals
As an HR pro, you strive to bring in quality employees to fill open positions in your company. But how can you be sure new employees will be a great fit?
I’m glad you asked.
By hiring a private investigator to conduct a background check.
Running a background check before you hire an employee (a pre-employment screening) helps to develop and evaluate a candidate’s profile.
A good screening will help you answer several questions, such as:
- Does the candidate have a criminal record? Avoiding workplace violence is crucial and is one of the first items a pre-employment screen uncovers. According to the Bureau of Labor Statistics, of the 4,679 fatal workplace injuries that occurred in the United States in 2014, 403 (9%) were workplace homicides. (You’ll also want to make sure your investigator is compliant with pre-employment regulations and laws – see Ban the Box for more info.)
- Do their resumes check out? PIs screen candidates to make sure all the details of a resume are true. Lying on a resume is illegal in some states, not to mention it’s ethically wrong and can lead to serious harm to a company’s reputation if it becomes public.
- Did they attend the college(s) they claim they did? The number one lie on resumes comes in the form of “education padding,” where applicants embellish or fudge their education information. PIs can track down college records, years attended, and degrees that a candidate received.
- Are their past employment records accurate? PIs specialize in tracking down past employers. Many times, PIs can uncover false employment claims or omission of previous employment on a resume.
- Do they have good credit? PIs can run credit reports to find credit ratings that leave much to be desired. Again, it’s important to find a PI who understands and complies with the consumer reporting laws. (See Using Consumer Reports: What Employers Need to Know and Fair Credit Reporting Act for more info.)
- Is he/she a sex offender? Sexual harassment costs companies bundles of money. In 2011, over $52 million was doled out to victims of sexual harassment in the workplace. That number doesn’t even count the number of women (and men) who don’t report the act altogether, which could be as high as 1 in 3. PIs can access nationwide data on sexual offenders so you can avoid this problem altogether.
Preventing workplace injuries is an integral part of the job description for occupational, environmental, and industrial safety professionals.
The ability to administer the workers’ compensation program is lumped into many of those job descriptions. On top of that, it’s beneficial to a safety manager to be informed about how to save the company money. One way to do this is by eliminating fraudulent claims.
How do you work towards eliminating fraud?
You guessed it: hire a private investigator.
Private investigators can conduct surveillance on fraudulent workers’ compensation claimants. Obtaining compromising video, along with a detailed report of a fraudulent claimant’s activities, can magically make claims go away. Safety professionals that partner with a competent and well-versed surveillance expert can help deliver this result.
Insurance Claims Adjusters
Unfortunately, insurance fraud is a booming business in today’s world. Automobile accidents, arson, and healthcare fraud total approximately $40 – $80 billion annually,  costing the average U.S. family anywhere from $400-$700 per year.
To defeat insurance fraud, insurance companies hire private investigators. PIs can perform automobile accident reconstructions, interview claimants and witnesses, and gather law enforcement records to determine who is at fault and who might be cheating the system.
The end result equals money saved and risk avoided.
Lawyers are another type of private investigator client.
Private investigators can help lawyers dig into opposing parties’ backgrounds, interview potential witnesses, and aid in the litigation process.
Also, private investigators serve subpoenas and specialize in tracking down witnesses and plaintiffs who may not want to be found. Hiring a PI to do the legwork is a cost that’s worth the investment.
Caregiver or Homemaker
What if you need a babysitter to watch your child, but the next-door neighbor isn’t available?
Conducting a background check on a nanny, babysitter, or caregiver gives you peace of mind.
You’ll want to know if the person looking after your son or daughter is responsible enough to babysit your child. Private investigators can locate past and current criminal records, sexual offenses, and verify your babysitter’s identity.
Business owners want to make sure their business interests are protected. They also want to determine if they’re getting into business with the right partners.
Hiring a private investigator to conduct a business background check on a client’s business partner, a.k.a a due diligence search helps to evaluate the quality of a business partnership.
You’ll want to know what kind of credit both the candidate and the business have, a list of their business assets, the business representative, any negative media associated with the business, and any other past issues.
Businesses also use private investigators to conduct security and integrity audits.
For example, a PI can do anything from investigating the security of a building or inspecting the quality of service at a restaurant. Private investigators can follow salespeople to learn if they’re regularly attending their sales meetings, stake out bars and clubs to make sure the staff isn’t stealing from the register, and attempt to (legally) “break into” data storage companies to test their safeguards.
Landlord (Property Owner)
Renting your property to bad tenants is a problem. Hiring an investigator helps mitigate the risk of renting to untrustworthy renters.
That’s your property that you’re allowing someone else to live in, so you have a vested interest in making sure it’s not torn to pieces once the lease expires. Vetting your tenants upfront can help to ensure you collect your rent check every month and alleviate property damage concerns.
Private investigators can help by conducting a background check on your potential tenant to find criminal records, prior evictions, civil suits, and bad credit. Searches like this will paint a picture of your potential tenant on the front end. From there, you can make the decision to rent to them or hold off and wait for a better candidate to come along.
What Other Ways Can Private Investigators Serve You?
Leave a message in the comments below.
 “What you should know about workplace violence – CNN.com.” 2014. 12 Jan. 2016 <http://www.cnn.com/2014/09/27/us/workplace-violence-questions-answers/>
 “Sexual harassment charge statistics – EEOC.” 2009. 13 Jan. 2016 <http://www.eeoc.gov/eeoc/statistics/enforcement/sexual_harassment.cfm>
 “1 In 3 Women Has Been Sexually Harassed At Work …” 2015. 13 Jan. 2016 <http://www.huffingtonpost.com/2015/02/19/1-in-3-women-sexually-harassed-work-cosmopolitan_n_6713814.html>
 “FBI — Insurance Fraud.” 2015. 13 Jan. 2016 <https://www.fbi.gov/stats-services/publications/insurance-fraud>
“You wouldn’t mind if I… you know… videotaped us working out, would you?” I said to Lifter Guy, a man I suspected of fraud. “Just to look at my form and stuff?”
“No problem. You gonna put it on YouTube or something?” Lifter Guy responded.
“Yeah,” I smirked, “something like that.”
Little did Lifter Guy know that I was a Private Investigator (P.I.) working undercover to videotape him powerlifting while defrauding the workers’ compensation system.
If you want to beat surveillance, let’s assume a few things first.
Let’s say you get hurt at your job and go on workers’ compensation (WC). And let’s also say that after you’re off work for a few days you start to enjoy not having to get up and go to work every morning. You get paid about two-thirds of your weekly paycheck for sitting on your behind. Occasionally, your employer makes you go to medical checkups and visits, but that’s it.
You like your new life.
What you don’t know is that your employer has hired a surveillance investigator to find out exactly what you are doing with this newfound free time.
There are tons of red flags that signal to an employer that a workers’ compensation claimant is fraudulent. To find out if an employee is abusing the system, employers hire private investigators to conduct surveillance to follow up on those suspicions.
We stake out your house, dig through your public records, and scour your social media posts for clues. We want to catch you, but you don’t want to get caught. You’ve become accustomed to your lifestyle.
Here’s how to get away with a workers’ compensation fraud and not get caught by a PI like me.