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
Stories
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
Surveillance prevents an auto theft claim
A senior investigator was doing what he enjoys – personally conducting surveillance on a workers’ compensation claim in Anaheim, California. Always aware of his surroundings, the investigator saw a car stop in the middle of the street. The passenger got out, and it was clear he was particularly interested in the truck behind the investigator…. Read More
Workers’ comp injuries actually from a previous accident
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
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