Workers' Comp Red Flag Checklist
While most Workers' Comp claims are legitimate, fraudulent claims occur and drive up costs unnecessarily. Red flags are indicators that the claim requires further investigation to assess legitimacy. The applicability of one or even several of these flags does not necessarily mean the claim is fraudulent, but it warrants further examination:
- Unexplainable delay in reporting
- No witnesses to the alleged injury-producing incident
- Insufficient detail was provided surrounding the injury-producing incident
- Alleged injury seems inconceivable considering the work which the claimant performs
- Injury is not visible (e.g., soft tissue injury)
- Degree of injury is not likely to result from alleged injury-producing incident
- Allegations or rumors of fraud and/or the claimant has been observed working elsewhere
- Incident was reported on a Monday morning (or after one or more days off work)
- Claimant has recently purchased disability insurance
- Claimant is a new employee
- Claimant has no health insurance coverage
- Claimant has used all available sick days and vacation days
- Claimant is known to have personal financial problems
- Claimant is physically active outside
- Claimant has submitted Worker’s Compensation claims in the past
- Inconsistencies revealed from the claimant’s initial description of the injury-producing incident
- Claimant is unusually familiar with the Workers’ Compensation system
- Claimant is uncooperative and/or objects to administrative controls intended to address Workers’ Compensation fraud
- Claimant does not provide a street address for a residence
- Employer is frequently unable to contact the claimant while off work due to an alleged injury
- Claimant obtained legal representation soon after the alleged incident and/or has obtained legal counsel with a questionable reputation
- Claimant has indemnity checks mailed to his/her residence
- Subsequent medical evaluations apparently contradict the initial evaluation
- Employee has missed scheduled physician visits or rehabilitation appointments
- Treatment being provided seems more extensive than the injury warrants
- Claimant has changed medical providers more than once after the initial treatment
- Claimant has been referred to a medical provider close in proximity to the referring medical provider