Fraud:  Frequently Asked Questions...

There are 3 main types of fraud within the workers' compensation industry. Claimant Fraud:

This is the type of fraud that most people think of when they think of workers' compensation fraud. An employee either fakes or exaggerates an injury. Perhaps there really was an injury, but they indicate to the employer/doctor/insurance company that it was far more serious than it was so that they can stay off work or attempt to force a settlement with the insurance company. You see them walking in to the Dr.'s office on crutches and then on a jet ski later that day. OR Perhaps there really was an injury, but it occurred over the weekend and not while they were at work. These are both examples of fraud. Medical Provider Fraud: This occurs when medical providers deliberately over-treat a claimant or submit fraudulent bills to the insurance carrier. Premium Fraud: Employers who attempt to escape/reduce the cost of the legal purchasing of workers' compensation for their employees are committing fraud as well. They can do this by the following methods:

• Not purchasing workers' compensation, even though they know they are required by the State of Florida to do so.

• Under reporting payrolls to reduce cost.

• Knowingly misclassifying employees in the wrong class code to reduce cost.

• Paying workers cash "under the table".

• Trying to treat "employees" as "independent or sub" contractors.

While all types of fraud cost the system and ultimately all employers money, this is by far the largest financial impact to the fraud equation.

The first thing to do is to make sure you get a statement from the "injured" employee allowing them to describe, in their own words, what happened. If there is a disagreement with what the employee "claimed" occurred and what you believe, then identify it when either calling in the First Report of Injury or in writing when mailing it in. Be sure to include statements from any witnesses to the "accident".

If the disagreement is about the extent of the injury, then communicate with the insurance adjuster and explain the reasons for your disagreement.

You can report any type of suspected fraud to: State of Florida Department of Financial Services Bureau of Workers' Compensation Toll-Free FRAUD HOTLINE: 1-800-378-0445

or online at: WWW.MYFLORIDACFO.COM/FRAUD If you desire to remain anonymous in your report, you can do so.

The first thing you should always do when a claim occurs/is reported, is to determine if medical attention is required. With most claims, the need is obvious. In others, an employee may report an incident but may not require outside medical attention. After fulfilling the first and most important issue, then you move on to an accident investigation report.

Click here to download a report, if you do not have one:

By doing the proper accident investigation, which includes statements from the claimant and witnesses, you document what "actually happened" vs. what may be "claimed" to have happened. Provide these to the claims adjuster if outside medical is required.

If you suspect that your employee is being fraudulent in what is being claimed, then contact the claims adjuster. The adjuster can speak with their treating physician and assign surveillance, if necessary, to see if they are doing things they claim they are unable to do.

Do not take any actions on your own. While you may not agree with what is being claimed, It is important for you, the employer, to maintain a close employee/employer relationship. Let the claims adjuster deal with any issues which may questionable.

Part of the services that WCA provides is follow-up on every claim that our insured's have to make sure they are being guided through the claim process. This open communication between the various parties allows for a dramatically reduced claim costs, which results in lower workers' compensation premium costs.