What Constitutes Fraud?

Fraud is a deliberately deceitful activity intended to result in financial or personal gain. It’s not just the worker that can commit fraud. The provider or even an employer can be found to have committed fraud.

Three components are typically needed to create the conditions that are conducive to fraud:

1. Financial pressures – these can affect anyone
2. Rationalization – they deserve it, the insurer can afford it, or it not hurting anyone
3. Opportunity – “faceless” system with infrequent personal interaction, complex system with little accountability

Workers Compensation fraud can present itself in a variety of ways.

1. Worker Unreported Income – earned income, passive income, or concurrent unemployment benefits are just a few ways this could occur
2. Worker Malingering – when the worker exaggerates the injury to prolong benefits and delay return to work
3. Worker False Claims – when the injury was not work related or no injury occurred
4. Worker Forgery – this includes prescription receipts or expense reimbursements
5. Employer – false claims, failure to report claims, misrepresentation of payroll or class codes
6. Provider – billing for services not rendered, double billing, upcoding, unbundling, and false claims