Starting A Claim

Accident Investigation & Fraud

Red Flags

Even after getting through the hiring process, a new employee might have some dishonest motives. The biggest motive is free money. Sometimes these workers even take another job or have a side business while making false claims that they are too injured to work. They would be receiving lost wages from their workers comp policy while also earning money from their other job.

Another draw to fraud is time off. If a worker is dishonest, they can collect insurance money and claim they are unable to work while pursuing other activities.

Common Cases of Fraudulent Claims

  • Hurt Off the Job
  • Fake Injuries
  • Old Injury
  • Malingering
  • Inflated Injuries

What Can Employers Do to Combat Workman’s Comp Fraud?

It’s important to have a safety program in place to prevent accidents from happening in the first place. However, if an accident does occur, it’s important to have a post injury management regime in place. Having a provider that is aware of the red flags can help as well.

Accident Investigation

Accident investigation is about finding the root cause of the event in order to prevent it from happening again. The investigation isn’t about disproving the employee involved or placing blame on them, it’s simply a safety measure. It’s important for managers and employees to work together to solve the issue and bring different perspectives to the situation

How to Conduct an Accident Investigation

  1. Get a concise explanation of how the injury occurred.
  2. Immediately refer the injured employee for medical treatment.
  3. Identify where the accident occurred.
  4. If there were witnesses, get their names, contact information and their account of the incident.
  5. Save all of the information and make sure reports were filled out completely.

Claims Process

24/7 Nurse Care Line

If an injury occurs, the employee involved must tell their supervisor immediately. As soon as the injury is reported, the injured worker and their supervisor should call the 24/7 nurse line. Of course, if it is an emergency, call 911. Explain the injury to the nurse and they will recommend what to do next. The injured worker can always call back with any questions or concerns.

Reporting/First Report Online (FROL)/OSHA 300

Reporting your workplace injuries through First Report Online (FROL) or through your insurance carrier’s online filing system is a vital way to help you manage your employee injuries. Reporting on time can ensure your claim is processed in a timely manner, and save on the overall cost of claims.  Delays in reporting work-related injuries can cause costs to increase up to 51%.

First Report Online makes filing a claim faster and easier. The system will automatically:

  • Auto fill all physician and clinic location details
  • Auto fill carrier and company department information
  • Allow you to run trend reports
  • Saves time
  • Send the First Report of Injury to:
    • Carrier
    • Company Management
  • Generate all OSHA reports including:
    • OSHA 300
    • OSHA Summary

For best results, have your HR manager complete FROL reporting. Employees may not understand the questions being asked or could alter the answers regarding how the injury occurred or how much they are being paid.

 

Drug Testing

Employees who test positive for drugs after sustaining a work-related injury may be denied workers compensation. Employers should have a solid drug test system in place.

Return to Work

As the employee’s health and strength improve, job tasks are gradually increased until the employee is back to work and functioning at full capacity.

Facts About Return to Work and Injured Workers

  • 60% of workers who miss 14 days of work are in financial trouble.
  • A patient’s emotional distress usually increases as days away from work increase. This is greatly reduced when a worker enters a productive role.
  • 80-90% of workers injured on the job would rather be working in some capacity than recovering at home.
  • Returning an injured worker to the work place reduces associated recovery costs including medical expense, rehab expense, therapy, and surgical expense.
  • 80% of all litigated claims result in higher settlements.
  • Early return to work programs have proven effective in reducing attorney involvement, quicker recovery, and reduced related costs while providing an excellent employee benefit.

The Goals of Return to Work

  •  Address the physical, emotional, attitudinal, and environmental factors to accelerate the employee’s return.
  • Give the employee a different task if they are unable to perform their usual job.
  • Investigate the incident to insure the event does not repeat itself.
  • Decrease the number of lost work days.
  • Help motivate employees to return to work.

How the Employer Benefits

  • Decrease workers compensation insurance costs.
  • Encourage good will and improve corporate image.
  • Allow active participation of management in the employee’s recovery.
  • Moderate costs of temporary or additional workers.
  • Reduce potential for litigation.
  • Keep an experienced work force.
  • Minimize productivity slow down.
  • Expand employee/management relations.
  • Promote employee morale/security.
  • Improve work ethic.
  • Decrease chances for repeaters and malingerers.
  • Decrease potential of re-injury.
  • Tie workers, supervision, and management together.

How the Employee Benefits

  • Provides sense of safety and stability.
  • Strengthen management commitment to employee welfare.
  • Reinforce a confident self-image to injured worker.
  • Provide helpful support to injured worker to recover quickly.
  • Inspire normal working relationships with other employees.
  • Reinforce the “going to work daily” habit.
  • Allow injured worker to directly contribute to success of employer.

Med Clinic Relationships

Physician Education

The financial and emotional impact of workplace injuries on employees, and the resulting financial impact for employers isn’t usually something considered by most doctors. This can result in needless time off given to employees, especially for minor injuries, and increased premiums for employers. Physician education bridges the gap and ensures employees receive the best possible care for their injuries.

Physician education can completely change how a medical facility looks at work comp claims. One example involves the HR department of a large hospital system. They were having a hard time getting employees back to work because some of their own physicians were automatically giving 2 weeks off for any injury. The department had a brief training on the subject and it was discovered that the time off issue wasn’t something the doctors really thought about. The entire attitude regarding workplace injuries has changed.

Local providers changing their attitudes, can positively impact employers throughout the area.

Who Does What?

Employee Role & Responsibilities:

  • Immediately report the accident
  • Give your supervisor updates
  • Go to all scheduled medical appointments
  • After each doctor visit, bring the report of workability to the supervisor
  • If any issues arise, report them to the supervisor
  • At work and home, stay within restrictions

Accidents should be reported immediately for a few reasons. The injured employee needs to receive immediate medical attention and the incident should be reviewed to change any unsafe activities.

Communication between the injured employee and the supervisor is very important. Supervisors should do everything they can to make sure the employee doesn’t push themselves too far and the employee should make sure to attend every medical appointment. Employees should let their supervisors know if their job becomes too strenuous.

Supervisor Role & Responsibilities:

  • Conduct a thorough investigation
  • Help the injured employee Return to Work
  • Communicate with the injured worker
  • Follow up with HR
  • Make sure the injured employee doesn’t work beyond their limitations
  • Document everything that occurs
  • Follow medical instructions

HR Department Role & Responsibilities

  • Immediately report the claim
  • Provide payroll information and job information to the claims adjuster
  • Assist with Return to Work
  • Document everything and keep the files
  • Stay up to date with the injured employee, the supervisor and claims adjuster