As the holiday season approaches, knowing the potential risks of increased workplace activity is important. Industries like retail and hospitality are especially vulnerable, with longer working hours and higher customer traffic. Unfortunately, this surge in activity could bring an increase in fraudulent workers’ compensation claims.

Not only can these claims lead to financial losses for employers and insurance companies, but they can also harm the overall workplace atmosphere. The Coalition Against Insurance Fraud has released a staggering statistic – workers’ compensation claims fraud leads to $25 billion in losses annually. It is crucial to consider the amount of money lost due to false claims, mainly when it could be utilized to enhance workplace safety and help injured employees get back on their feet. Companies and employees must be vigilant against fraud and work towards a more honest and fair claims process.

So, what causes increased injuries during the holiday season, and how can you identify and prevent these fraudulent claims?

Holiday Season Injuries

1. Increased Workplace Stress: The holiday season can bring added stress to employees, with concerns about gift buying, family gatherings, and work-life balance. Stress can lead to distracted employees and potentially more accidents.
2.  Seasonal Factors: In some industries, weather-related factors like snow and ice can increase the risk of slips, trips, and falls during the winter months.
3.  Increased Workload: Some industries, such as retail, experience an upsurge in demand during the holidays. This can lead to increased work hours and potentially more fatigue-related accidents.

Signs of potential fraud by employees include:

1. Inconsistencies between the number of days worked and the salary earned for their occupation.
2. Document alterations, such as cross-outs, white-outs, and erasures.
3. Claiming benefits in a different state than where the alleged industrial injury or occupational disease occurred.
4. Employee listing an occupation that does not align with the employer’s stated business.
5. Employee address not matching the main location of employers, excluding border states.
6. Difficulty contacting the employee due to them never being home or being unbothered when asleep.
7. Physical signs such as calluses on hands and grease under fingernails.
8. Employees relocating out of state or country shortly after filing a claim.
9. Employees nearing early retirement age.
10. Filing a claim just as seasonal work is about to end.

Identifying Fraudulent Situations

Look for inconsistencies in the accident report.

The first step in identifying a fraudulent workers’ compensation claim is carefully reviewing the accident report. Look for any inconsistencies or discrepancies in the report, such as conflicting statements or missing details. Fraudulent employees may also exaggerate the extent of their injuries or claim to have been injured on the job when the injury occurred outside of work.

Investigate the employee’s social media accounts.

Social media can be a helpful tool in identifying fraudulent workers’ compensation claims. Investigate the employee’s social media accounts to see if they have posted anything that contradicts their claim. For example, if the employee claims to be bedridden with a back injury but posts pictures of themselves skiing or playing sports, this could indicate that they are not as injured as they claim.

Look for a history of prior claims.

Some fraudulent employees may have a history of filing multiple claims over a short period of time. This could be a red flag that the employee is not being truthful about their injuries or that they are purposely injuring themselves to file a claim. Review the employee’s claims history to see any patterns or inconsistencies.

Conduct surveillance

If there is suspicion that an employee is dishonest about their injuries, conducting surveillance can effectively gather evidence. This may involve hiring a private investigator to monitor the employee’s activities or reviewing security camera footage. Surveillance can provide valuable evidence to support or dispute a claim.

The holiday season can be busy and stressful for employers and workers in many industries. Unfortunately, it can also increase the risk of workplace injuries and fraudulent workers’ compensation claims. By following the tips and strategies outlined in this article, you can better identify and prevent fraudulent claims during the holiday season and throughout the year. Remember to stay vigilant and proactive, and always investigate claims thoroughly to protect your business from financial losses.

Bah, Humbug Bias

Of final note, while it’s crucial to be vigilant against fraudulent workers’ compensation claims, it’s equally important to recognize that not all cases are deceptive. It’s essential to approach each claim with an open mind and avoid predispositions that may lead to bias. Genuine workplace injuries do occur, and employees rightfully deserve support and compensation for their injuries.

As we navigate the challenges of the holiday season and beyond, let us not forget that a balanced and fair evaluation of workers’ compensation claims is crucial. By ditching biases and focusing on the facts, we can better protect both employers and employees, ensuring better claim outcomes for all.

Sources:

U.S. Department of Justice:  https://www.justice.gov/opa/pr/false-claims-act-settlements-and-judgments-exceed-2-billion-fiscal-year-2022
NAIC Insurance Fraud: https://content.naic.org/cipr-topics/insurance-fraudUtah Insurance Department (.gov): https://insurance.utah.gov/wp-content/uploads/WorkersCompFraudAmerica.pdf