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Workers’ Compensation Fraud Trends

Posted by Dalene Bartholomew on October 25, 2017 at 9:50 AM

Despite best efforts, workers’ compensation (WC) fraud is very difficult to eradicate. Unfortunately, both employers and workers sometime try to take advantage of the system. Nevertheless, there are now more sufficient means to combat these fraudulent activities, resulting in a recent change for the better.

The involvement of the Fraud Assessment Commission, task forces and other agencies (FBI, etc.) have signaled a new dawn in the battle against WC fraud. For instance, the Fraud Assessment Commission doles out grant funding to district attorneys that is specifically designated to combat WC fraud. Those district attorneys now hold an increased sense of accountability to pursue WC fraud claims.

One trend that will surely prove beneficial is the increased specialization of law enforcement agencies. Workers’ comp fraud is a very specific branch of activities and the agencies working on these cases constantly improve. The surge of cooperation among agencies also effectively erases the boundaries between different counties, which casts a wider net of coverage with regards to pursuing WC fraud.

Provider and Claimant Fraud

Fraud is constantly evolving. As soon as the industry gets its grip on one type of scheme, another one is underway. There has been success in imposing serious sanctions on fraudulent providers, however, this does not prevent dishonest providers from trying their hand. An influx of grant money, as alluded to previously, as well as an increase in law enforcement training appear to be a couple of solutions in the war against WC fraud.

While provider fraud is often investigated by law enforcement agencies, claimant fraud is handled by Special Investigation Units (SIUs). With a highly successful 90% conviction rate, SIUs have also seen improvement in other areas over the years, including significantly cutting down the time between the presentation of the case and the conviction. The future of the fight against claimant fraud lies in the alteration of the sentencing structure. What’s needed is less cases going to costly trials and more community work.

Public agencies are in a great position to combine the efforts of law enforcement and SIUs. When choosing what SIU to partner up with, the following qualifications should be considered:

  • System integration
  • The ability for early detection
  • Action plan for dealing with early reports and preventable frauds
  • Regular communication across the industry
  • Anti-fraud expert training
  • Maintain relations with law enforcement agencies

Early involvement and communication across the industry is the key to successful prevention of fraudulent behavior. Public agencies want the SIU to be involved as early as possible so that they have the time to build sufficient evidence. If prevention fails, the next best option is timely reaction.