work comp fraud

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

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

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

An ACM senior adjuster received a head and neck injury worker’s compensation claim. The employee, who had only worked for the company for five days, reportedly passed out and fell at work. He claimed headaches, sleep problems and depression were a result of the fall. He denied priors, but the Insurance Services Office showed a… Read More

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

Yet another construction worker with a back and knee injury was not getting better as expected. He said he couldn’t walk, lift, climb, etc. Rest and treatment did not help. (This is statistically improbable.) Surveillance found the man driving 60 miles from his home to work at a construction site, an activity clearly inconsistent with… Read More