work comp fraud

The “injured” worker claimed a cumulative trauma work injury to his shoulder and leg, doing construction work. Lots of subjective complaints, without objective findings. He was missing physical therapy appointments. He had an attorney, so a face-to-face discussion about his recovery was not an option. The employer suspected he was working elsewhere. Time for surveillance…. Read More

An electrician was injured at work. He needed surgery and could not work. Accidents happen – that’s why employers have workers’ compensation insurance…or not. The employer tried to provide benefits directly. The claimant hired an attorney. The case came to our sister company, American Claims Management (ACM) late, preventing their claims and medical staff from… Read More

One of our adjusters received a claim from a part-time hospital respiratory therapist of injuries to the shoulders from lifting patients. The claimant was paid lost wages for two years. The PQME gave the claimant a 10-pound lifting limit. In his deposition, the claimant testified that he could not, and had not, lifted more than… Read More

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