Exaggeration? Protracted Treatment? Is Your Employee Really Injured?

Exaggeration?  Protracted Treatment?  Is Your Employee Really Injured?

Workers’ Compensation is fraught with a myriad of complicated situations that may cause an employer to think there is fraud occurring.  Not all such situations actually rise to the level of fraud.   Insurance Fraud occurs when someone knowingly lies with the intent to obtain a benefit or advantage to which they are not otherwise entitled.   While you might expect claimant fraud to be the most common fraud in the system, provider fraud is actually more common.  Examples of provider fraud include things such as billing with incorrect codes resulting in higher fees or billing for services not rendered.  If you believe that one of your employees or a provider is engaging in fraudulent activity, please contact your Claims Examiner to further discuss the situation.   Sometimes we have information in our file that you may not be aware of that explains the situation.

An example might be when you have an injured worker unable to work because of a temporary restriction from reaching overhead with the right arm.  You then happen to notice the employee at the repeatedly reaching the top shelf at a grocery store.  Or, perhaps your employee with an elbow injury is unable to work because they cannot lift in excess of 15 pounds, and find out that the injured worker was a finalist in the local marathon.  Neither of these situations necessarily translate to fraud.  The injured worker may have reached to the top shelf with the un-injured arm, and the runner had no weight bearing restrictions – unless the physician provided a restriction from the activity in question, fraud may not be indicated.

If you believe that one of your employees or a provider is engaging in fraudulent activity, please contact your Claims Examiner to further discuss the situation.   Sometimes we have information in our file that you may not be aware of that explains the situation.  An example might be when you have an injured worker unable to work because of a temporary restriction from reaching overhead with the right arm.  You then happen to notice the employee at the repeatedly reaching the top shelf at a grocery store.  Or, perhaps your employee with an elbow injury is unable to work because they cannot lift in excess of 15 pounds, and find out that the injured worker was a finalist in the local marathon.  Neither of these situations necessarily translate to fraud.  The injured worker may have reached to the top shelf with the un-injured arm, and the runner had no weight bearing restrictions – unless the physician provided a restriction from the activity in question, fraud may not be indicated.

Neither of these situations necessarily translate to fraud.  The injured worker may have reached to the top shelf with the un-injured arm, and the runner had no weight bearing restrictions – unless the physician provided a restriction from the activity in question, fraud may not be indicated.

Below are a few links to important information regarding insurance fraud that you may find interesting.

 

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