Top 20 Workers’ Compensation Fraud Red Flags

  1. An upset, dissatisfied or disgruntled employee. If a claimant has a motive, they may have fabricated the claim. Motives can include denied vacation time, demotion, lay off, or termination.
  2. A claim made immediately before lays off, business closure, completion or termination of a task or position.
  3. An injured worker in line for early retirement files a claim.
  4. The injured employee is difficult to contact. Calls to the home are not answered, or the claimant is reported sleeping or unable to be disturbed. These employees could be working at another job while simultaneously collecting benefits. This is termed “double-dipping,” a fraud in most states.
  5. A new employee. Statistics indicate the newer an employee, the greater chance of a fraudulent claim. This is a common tactic of an organized crime operation.
  6. No witnesses to the alleged incident, which is even more of a red flag when responsibilities do not require working independently.
  7. Varied or shifting accounts of an accident.
  8. A worker who is unable to remember the date, time, or specific location of the accident or injury.
  9. An alleged accident on a Monday or Friday, especially when in conjunction with other red flags.
  10. Claims paperwork with cross-outs, erasure marks or extensive use of White-Out.
  11. A claim filed in a state other than where the alleged injury or occupational disease occurred.
  12. Additionally, claimants who file for benefits shortly before relocating out of state.
  13. An injured worker with obvious signs of hard work: callused hands, grease under fingernails, etc. This can also extend to evidence of continuing activities that would be impossible given the stated injury.
  14. A claimant who is starting a business or interested in self-employment.
  15. A refusal of medical or diagnostic procedures to confirm an injury.
  16. An occupation listed on the claim that is inconsistent with the business, or an injury that is inconsistent with the nature of that business.
  17. Unseen injuries or injures that are impossible to prove through diagnostic or medical evidence, or moving or changing symptoms.
  18. Diagnostic tests with conflicting results.
  19. Failure to report an injury in a timely manner.
  20. Tips concerning fraud from co-workers, family, or other individuals.