Every state’s workers’ compensation program has policies and procedures structured into their claims review process that help to assure that only eligible applicants receive benefits. Detecting different types of fraud is an important part of managing programs and ensuring that there are sufficient resources to award benefits to every applicant who needs them.
Some claims falsify how an injury happened. For example, people may claim that an injury occurred in the workplace when it actually took place outside the scope of their employment. Accounts of an accident which seems improbable and don’t have evidentiary support could fit within this type of workers comp fraud.
Returning to Work
Program participants could take more time away from work than necessary. Examiners have to give close scrutiny to claims asserting that people cannot perform their job duties within the typical recovery period for a specific type of injury.
Because claimants do not pay directly for services, they may not review statements carefully. Healthcare providers could potentially defraud workers’ compensation for services that a claimant did not need or bill the program for services that a claimant did not actually receive.
Claims examiners exercise careful oversight of billable services. While it may not be possible to stop every instance of fraud, being vigilant for conspicuous signs of fraud can reduce their occurrence substantially.