When Investigation Solutions started 13 years ago, we opened an investigation into Prime Orthopedics, noting what seemed to be unreasonably high charges for durable medical equipment (DME), billed on California workers’ compensation claims. DME must be prescribed by the attending physician. The actual equipment must be certified, and it must be billed with the appropriate… Read More
Here’s what happens when an “off-the-books” employee is injured
An Arrowhead General Insurance Agency premium auditor was working on a workers’ compensation policy audit for a construction company. The employer reported having only one employee. Their policy application showed a denial of the use of subcontractors. However, the premium auditor identified two claims filed during the policy year. The employer explained that they had… Read More
Worker claims injury after he quit
ACM’s claims examiner was assigned a two-month late report: a post-termination work injury claim. The attorney reported that the claimant fell from scaffolding, two stories off the ground, suffering major injuries. The insured said the claimant did not work on the claimed date of loss, nor did any of their staff, as they are closed… Read More
Insureds’ statements reveal fraudulent smoke and ash claims by PA firm
An adjuster was handling a smoke and ash claim in California, which was reported a year after the claimed wildfire. The inspection found ash in the home, with a cleaning estimate at $5,533.00. The claim was paid. The claim was made by a public adjusting (PA) firm, which stated the cost to clean the home… Read More
Claimant tried to get new appliances – for free
The insured purchased a homeowners policy in early December 2021 for her newly constructed home. She called the next month to say that someone broke into her home in early January, taking her stove, refrigerator, washer/dryer and a tankless water heater. She said she had not moved in yet. Her cousin noticed the front door… Read More
Bogus workers’ comp claim blocked
An adjuster was assigned a late report specific arm injury claim by a new employee, who was believed to also be self-employed. She referred the claim to Investigation Solutions. We found social media posts of the claimant’s martial arts. Others showed construction work done just before and after his date of injury. The claimant had… Read More