In the past two weeks, we have published articles by Richard Hawk and Doug Carr addressing the issue of workers' compensation fraud. We asked you for your views on the question. Here are your responses.

The Perspective of a Former Claims Investigator

I spent many years in the Workers' Comp arena, having worked at a State Fund as a Claims Examiner, Claims Investigator, and a Risk Management Consultant. I agree whole heartedly with Doug Carr when he points out that positive employee relations are a key factor in preventing fraudulent claims. A significant percentage of the claims I was sent to investigate involved an antagonistic employer/employee relationship. Doug is also correct that hearsay isn't grounds to declare a claim fraudulent, even when it is accompanied by questions such as "if he was in so much pain on Friday, why didn't we hear about it until Tuesday?"

Where I disagree with Doug is with his recommendation not to "intervene" in the disposition of a claim "unless and until you have solid evidence." Granted, an employer never really has the legal ability to control the surety's ultimate decision, but I always encourage employers to notify their claims adjuster when they have concerns. (It helps to have established a good working relationship with your surety!) This gives the adjuster a "heads up" to more closely monitor and direct claim activity, which in turn can reveal additional discrepancies. At the very least, circumstantial evidence can add up to the quicker resolution of questionable claims. But don't expect miracles. Most Workers' Comp law is specifically written to be "construed liberally in favor of the employee." Remembering that will help keep your blood pressure within tolerable limits.

Marsha McKinney
ARM Health & Safety Specialist Idaho Department of Health & Welfare

Measures to Take

This is some of what we do to prevent injuries and injury fraud:

• Extensive safety training program
• Daily safety observations of people performing their tasks with coaching and discipline when needed
• Provide equipment to handle materials that weigh over 35 pounds
• Educate our employees on the cost and effect of workers compensation (creates peer pressure, also employees will report each other when they know an injury is being faked)

Our YTD OSHA Incident Rate is 2.45.

Michael Coleman

Communicate Up Front. . .

My experience with preventing "fake injuries" among our employees is to be very "up front" with this situation. Hoping these types of "injuries" won't happen if we don't bring the subject up with our employees, simply doesn't work.

We train people during orientation and again throughout the year that no-one likes to be injured and that our goal is "zero injuries." But, if one is injured they are to report it immediately. We emphatically state that the primary reason for prompt reporting is to conduct a prompt investigation so that we can prevent its recurrence. Also, we manage a very effective Behavioral Safety Observation Program, where leadership and hourly employees document observations of employees performing their normal job duties. The entire culture revolves around performing tasks safely. As a result of leading this Safety Culture, we have experienced a 67% reduction in injuries and subsequent Workers' Compensation costs this first year at the new company I am presently working with. I can also honestly say that this proactive approach of activities and communication, UP FRONT, has always been just as successful in my prior experiences, spanning the past 25 years.

. . . And at the Back End

We have one employee that recently filed a worker comp. claim that eye witness reports revealed was not true. This same employee has a questionable past with previous claims as well. Once we had the evidence to substantiate our suspicion, our President sat down one on one with the employee and had a heart to heart about this and previous claims, indicating that not only could he be fired for fraudulent claims, but he could be taken to court as well. Since that time, the problems with questionable claims from this employee have gone away. Thus, I think a simple heart to heart may help sometimes to simply let the employee know that the company is aware of their games, and that it will not be tolerated.

Josh DeBroux
Environmental, Health & Safety Director
Systems Control, Inc.

Have a Doctor in the House

I've found that having a company physician well versed in fraudulent claims is one major answer. The doctor we use can "smell" a fake when he conducts the initial interview with the claimant. This comes only with many years of experience but finding the right physician to me is critical.

Victor M. Woody
The Mundy Company
200 Kelly Lane
Moncks Corner, SC

Talk to the Doctors

If you manage your injury cases very closely and have constant communication with the physicians then your fraud cases are Identified early and have a great probability of being denied. A lot of companies will take an employee that is injured to a emergency room setting and receive restricted or off duty and medications for the employee and not see another physician and waiting till the restrictions are completed, then allowing the employee to return to work. This is where a follow up with a physician that understands the comp law would be beneficial in managing the injury and determining fraud cases.

Lee Cantu
Safety Officer

Smoking Out Fakers Isn't Worth the Hassle

Even when we have an obvious faker our insurance company tells us just to pay them because it's cheaper than taking them to court and proving they're faking. The system seems to be our biggest problem.

Melanie Hunter
Safety Specialist
(Company name withheld)

Smoking Out Fakers Is Worth the Hassle

I am coming to believe that the greatest deterrent to fraudulent claims would be rigorous investigation of them. If every claim were investigated, then there would be no basis for allegations of discrimination, and illegitimate claims would be refused - and hopefully, turned over to law enforcement for potential prosecution. I find far too many of my clients' workers' comp carriers just roll over on many questionable claims, averring that it's cheaper to pay some bogus ones than to investigate.

C. Alec MacLean
EH & S Specialist
Du-All Safety
Fremont, CA

Be Proactive

Disc's or JSA's should include a section for each employee to sign prior to beginning work. It should also include a section to sign off on at the completion of the work day where employees verify that they did not incur any accident, injury or near miss that was not reported to supervision that day. Also, ensure that employees have numbers to reach HSE personnel during non-work hours for alleged pain that begins after employees have left the jobsite. This allows HSE to be involved in any ER or medical services rendered the employee.

Connie Savoie
HSE Manager

Let the "Buyer Beware"

Make it known that fraud is taken seriously and that people are watching. That is why I have implemented as part of our company safety plan that reporting fraud is required (to our workers' compensation carrier's hotline or to a manager) and that the calls will remain confidential. Signs are also posted within the facilities about reporting fraud, which conveys the message, "buyer beware."

The other measure we have in place to control/mitigate fraud is that our employees are required to undergo back training and become certified. If someone sustains a back injury, they may be subject to disciplinary action if they are in violation of their back training certification. Although this may not help in instances of unwitnessed accidents or accidents that may be staged where they suggest sustaining an injury from proper lifting practice, it still does act as a deterrent and mitigates your overall number of soft tissue back injuries. Employees may think twice about staging a back injury in fear of being written up for a safety violation.

As part of our accident investigation report, the injured worker is asked if they had any prior sustained injuries and this is documented on the report. Our insurance carrier is provided with this information, who then files a CIB report to determine if the worker is being truthful about their prior condition. This measure may not have a significant impact on the frequency of fraudulent claims, but certainly has a major impact on what is paid out on the claim, if anything at all.

George A. Zaroogian
Risk Management Analyst
Arrow Electronics, Inc.
Melville, NY

It's a Culture Thing

Data I've seen on several studies in this area all put the incidence of false reporting at under 2% (with the normal median being in the under 1% range). So, it's important to not lose sight of the fact that 99% or more of your injuries are real and need real solutions. That said , the most significant way to stop false reporting is to work very hard at having a supportive and inclusive workplace culture. If people like where they work, are treated well by management and supervision, and they see that safety is a very important core value in their organization, they will be far less likely to try to scam the company. Another important action is a strong and ongoing effort to involve all employees in the safety process. If they have a sense of ownership in the effort, they won't mess that up with false reporting (and they won't let peers do it either).

Lawrence H. "Chip" Dawson
Dawson Associates
Rochester Business Alliance Coordinating Consultant for HSE
Fairport, NY

Debriefing

One effective method I've found to reduce fraudulent claims is to have the injured worker describe in writing exactly how the accident/incident occurred. We do this as part of a "Workplace Injury Information" packet that employees are required to fill out as soon as they report a workplace injury/illness, even if it is a chronic injury such as Work Related Musculoskeletal Disorders. We have found in a number of cases, the way in which they document how the injury occurred that they may implicate at home activities that are really at the root cause of the injury. In the case of acute injuries they may indicate that they have disregarded a plant safety rule and, even though we are responsible under Workers' Comp. laws to pay for medical and any time off required, we can place the employee on disciplinary action in order to help change unsafe behaviors and let employees know that we are serious about our workplace safety policies and procedures.

If you decide to post this, please list me as anonymous.

Signing Off

One practice that is used in the industry I work in is to have a sign off, usually on the worker's Field Level Risk Assessments (FLRAs) that they fill out daily, that states, "I am unhurt or uninjured," at the end of shift. Or they can circle yes or no to "Did you sustain a workplace injury?" on the sign in sheet at the end of shift meeting. It is also made very clear in orientations that it is a requirement to report any workplace injury IMMEDIATELY, no matter how insignificant it may seem. This way, if workers do sustain injuries, they can be dealt with right away, not prolonged where conditions can often become worse and drag on.

Nicole Orr CSO
Project Safety Manager
Stantec Consulting Ltd.

A Twist

The biggest problem regarding fraud would be when the employee goes home, and "discovers" an injury after leaving the work area. Unless the incident was witnessed by others, this situation would be difficult to prove or disprove as the case may be. Where musculature injuries are being claimed, casual observation of the employee may be required - this won't be the case for everyone: Someone who very seldom or has never processed an injury claim would be less likely to fake a injury than one who has made seemingly regular claims.

R.G. Hills
Master Corporal
Canadian Defence Liaison Staff
Washington Fin Mgmt Svcs Comm

Deter with Discipline

Policies that accompany accident investigation must be in place to deter and assure incident legitimacy. At our facility, we conduct a drug and alcohol test on every employee who reports an incident, no matter the type; near miss, recordable, or lost time. This has helped in minimizing fraudulent claims.

Also, disciplinary action is taken in the form of written reprimand if the injury was caused by a flagrant act of carelessness or if it is found to be the employee's own fault. You may think that a reprimand won't do much but if your policy states that three reprimands grants you termination then they will hesitate to get one.

Perhaps you are under the impression that these policies may deter employees from reporting incidents. On the contrary, effective education on the importance of accident reporting and its rewards, such as eliminating the hazards and employee recognition programs accompany these policies in order to avoid sending the wrong message.

Ely (the safety guy) Dorado
Safety Manager

Build a Case

Workers who are faking injuries don't want to come to work. They usually don't show up, or they come in late, and don't call, or leave early. It's very important to document all of these instances to build your case for the Compensation board, to show them that the worker is not participating in your program.

Corey Jones
EllisDon Corporation

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