PHILADELPHIA -- February 26, 2004 - When workers compensation insurance fraud occurs, everyone pays the price, including legitimately injured employees. According to the National Insurance Crime Bureau (NICB), workers compensation claimant fraud and medical fraud combine to contribute significantly to an annual estimated $30 billion insurance fraud problem. In addition, questionable workers compensation claims continue to be reported at a rapid pace. The Special Investigation Unit (SIU) of ESIS, Inc., the risk management services company of ACE USA, recently released a top ten list detailing tips and methods for reducing the risk of workers compensation fraud.
"The workers compensation system is designed to provide a disability benefit and medical care to assist the employee back to work. Job one is ensuring that legitimate claims receive the attention they deserve. Fraudulent workers compensation claims drain time and resources that are meant to assist workers who have been injured on the job," said Al Marrazzo, SIU Manager, ESIS, Inc.
Though insurance fraud is a staggering problem, there are steps employers can take to lessen the risk of suspect or bogus workers compensation claims. According to Robert Persico, Senior Vice President, Claims, ESIS, Inc., spreading the word that carriers will vigorously investigate suspect claims and refer employees who bring fraudulent claimants to appropriate law enforcement agencies for prosecution can be a significant deterrent.
"The NICB has found that anti-fraud laws specific to workers compensation insurance have lessened the number and size of claims, while decreasing the systems costs per worker. In addition, proactive tactics on the part of employers have been proven to further reduce the risk of fraudulent workers compensation claims," said Mr. Persico.
ESIS's TOP TEN TIPS FOR FIGHTING WORKERS COMPENSATION FRAUD
Build Safety and Fraud Awareness in the Workplace and Beyond
1. Employee awareness campaigns challenge misperceptions. Workers compensation fraud is not a victimless crime, and perpetrators are prosecuted to the fullest extent of the law. Make employee awareness a part of your corporate culture. Use posters, employee newsletters, and other notices to ensure that employees know that workers compensation fraud is a serious crime and they can anonymously report suspected workers compensation fraud. Provide workers with your updated workers compensation fraud reporting notice at least once a year.
2. Conduct thorough background checks. Reduce the risk of workers compensation fraud by thoroughly screening prospective employees. Has this person previously filed a fraudulent workers compensation claim, or been convicted of other types of fraud? Devoting the resources to thorough background checks on the front end lessens the risk of fraudulent claims.
3. Install video equipment in the workplace. A visual record can help support legitimate workers compensation claims while weeding out bogus injuries. Additionally, the installation of cameras and video surveillance equipment has been proven to deter fraud and other crimes in the workplace across the board.
4. Implement a rapid and timely workplace injury response plan. Who is in charge when an injury occurs? Your response plan should include the following: immediately recommending a medical facility for treatment; securing the description of accident and injury; reporting the occurrence immediately to your administrator; preserving any workplace evidence; securing the names of any witnesses; and, if possible, taking statements from the injured worker and witnesses and securing a photograph of the area. It is important to create and clearly communicate to all employees the accident reporting procedures prior to accidents actually happening. This will ensure that timely and proper procedures are followed when an accident occurs.
5. Implement a comprehensive workplace safety program. Make workplace safety a priority by conducting regular safety awareness seminars. Use posters, flyers and newsletters to stress safety procedures, and reward workers for achieving safety milestones. A truly safe workplace makes it that much harder to persuade someone that a fraudulent workers compensation claim is a legitimate one.
6. Know how your organization's claims are handled. Are claim representatives and adjusters properly trained to detect fraud indicators "red flags," which suggest a claim may not be legitimate? Do they receive ongoing fraud awareness training? Your organization benefits when they do, since such training can reduce the incidence of fraud.
7. Know the role of your insurer's Special Investigation Unit (SIU). Suspect claims are referred to your insurer's SIU representatives for potential fraud investigation. These specialists are trained to investigate signs that a claim may be fraudulent, and after thoroughly doing so, will share their investigation with the proper law enforcement agencies. What resources does your insurer and its SIU call upon to flag and investigate suspect claims? Have fraudulent cases been successfully prosecuted? The professional resources of a well-trained claims professional staff and the SIU that supports it are key to reducing the risk of workers' compensation fraud.
8. Pay attention to worker scuttlebutt. Following a workplace injury, and throughout the claims process, rumors often circulate among employees. Sometimes rumors are grounded in fact. Paying attention to worker scuttlebutt can help in investigating a claim's validity.
9. Know the contents of your insurer's fraud fighting toolbox. Does your Third Party Administrator maintain professional memberships in organizations that provide ongoing education and training as well as access to indexes and databases that can help pinpoint fraud? A well-equipped fraud-fighting toolbox can decrease your odds of becoming the victim of fraudulent claims.
10. Utilize the resources of your insurer. If your insurer is committed to fighting workers compensation fraud, they'll be able to demonstrate that commitment. Talk to their SIU about developing your own in-house program aimed at decreasing fraudulent claims. Customer awareness education is just one of the resources your insurer can bring to the table.
According to Jim Henwood, SIU Manager, ESIS, Inc. preventing fraudulent workers compensation claims is a win/win for employers and employees.
"Our job is to conduct an impartial investigation into every suspect claim, so those filing fraudulent claims are identified and referred to law enforcement agencies for prosecution. The workers compensation system is only designed for employees who have suffered legitimate workplace injuries," said Mr. Henwood.
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ESIS, Inc. (ESIS), is one of the industry's oldest and largest risk management services companies. ESIS is among the insurance services companies of ACE USA. ACE USA is a U.S-based operating division of the ACE Group of Companies, headed by ACE Limited (NYSE: ACE).