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
workers' compensation fraud
Fraudulent durable medical equipment helped us break up a work comp ring
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
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
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