Richard Easton, M.D., M.P.H.

The idea of teamwork pervades health care these days, and it applies in a distinct way to workers' comp, where the physician may be expected to identify fraudulent claims. Fortunately, they're often easy to spot.

Richard Easton, M.D., M.P.H.

Physicians who want to participate in workers' compensation programs should recognize that employers are not just buying their expertise in treating illness and injury, though they will surely insist on that expertise.

The companies that pay high premiums for workers' comp insurance want physicians to do their utmost to get their employees back on the job quickly. Increasingly, they will want them to root out fraudulent claims. And the physician is in a very good position to alert the employer to the possibility of fraud.

Workers' comp rates are going up faster than the Consumer Price Index's medical component. In 1995, costs were over $70 billion, and by 1998, it has been estimated, the figure will exceed $95 billion. And since the medical costs of workers' comp are more than 45 percent of the total cost of this program, medical management directly affects indemnity and litigation costs.

Furthermore, various researchers have determined that between 5 and 15 percent of workers' comp claims are fraudulent — no injury ever occurred — or constitute an abuse of the system in that while an injury did occur, the worker tried to prolong the "free ride."

Detecting fraud can have a directly beneficial effect for the physician, in that it stops the delivery of medical care that is not warranted. Of course, the workers' comp managed care plan benefits as well, as do the employer and, if there is one, the carrier of the indemnity risk. Society benefits too and — who knows? — the worker himself might learn a valuable lesson.

Here is a pragmatic, step-by-step process that takes little effort and almost no cost.

The 5-step fraud detection process

1. Copy the claim profile chart below to use with all medical disability complaints. Do not distribute to the employers whose patients you are treating.

2. Current claims:

Action: From cases you are seeing, select those about which you have a "gut" feeling that there is "something questionable" going on.

Objective: Use the profile chart to evaluate cases quickly and choose one course of action.

Course 1: Consider it legitimate and continue to treat.

Course 2: Refer suspected claim for investigation.

Primary result: You continue to see claimants with valid injuries, but refer those of questionable etiology to the employer's human relations or risk management department for investigation.

Secondary result: The grapevine will circulate the word that the occupational medicine physician can "spot a fraudulent claim a mile away" and may inhibit future fraud attempts.

3. Future claims:

Action: Have the office place a profile form in each new patient chart to remind physicians to look for "red flags."

Objective: To sensitize you, your colleagues and staff to indicators of fraud and abuse by workers' compensation patients.

Primary result: Increased sensitivity to the possibility of fraud may lead to very early detection of potentially very expensive claims, which can help you protect your risk pool monies against very heavy and totally unnecessary losses, such as charges for MRIs, CAT scans and consultations with orthopedists or neurosurgeons.

4. Retrospective claims

Action: Have your staff pull prior claims and review them using the profile chart.

Objective: To detect flaws in the current evaluation process by examining claims that have run up unnecessary medical expense.


Detection of patients with multiple questionable claims.

Detection of companies from which repeated claims of questionable nature have emerged.

Detection of fraudulent disability claims for which settlements are currently costing clients, with whom you are contracted, ongoing expenses and stopping the payments.

5. Consult with workers' comp fraud specialists

Action: Identify medical and legal professionals who deal with workers' comp fraud routinely.

Objective: Obtain support and advice.

Result: The workers' comp health plan's legal counsel can advise on actions permissible in your state. A workers' comp medical specialist can advise on two crucial items needed to prove fraud: Medical causality (could the alleged incident really have led to the claimed injury and is the injury a reasonable result of the claimed incident?), and objective evidence of true disability (e.g., evidence that the claimant shows no evidence of impairment when he believes he is not being watched).

One thing to avoid is confronting the patient you suspect of fraud or abuse. That is not your job, and there is no reason to place yourself in a position of incurring resentment and/or even retribution from a "fingered" employee who may even see his attempt to manipulate the system as justified by unsatisfactory aspects of his past relationship with his employer.

Claim Profile

For each item in the first column, circle an entry in the second or third column. If column 1 contains two or more circled items, consider referring the case to the employer for investigation. If column 1 contains only one circled item, and you still suspect fraud, consider monitoring the profile as the case develops and refer for review on a PRN basis.
Items to consider Item circled indicates problem Item circled does not indicate fraud
Incident was witnessed by manager or supervisor No Yes
Details of injury are... Vague and contradictory Clear and concise
Employee is disgruntled Yes No
Incident occurred at regular work site No Yes
Worker had deviated from normal duties Yes No
Disciplined by management at least once Yes No
Worker insecure about job: (Impending strike, layoff or other downsizing? Seasonal worker? Nearing retirement?) Yes No
Work performance had been... Fair to poor Average or above
Allegation of blunt trauma Nothing to see, but employee complains of pain Visible injury


The author is medical director of the FraudWatch division of Health Information Services Inc. in Virginia Beach, Va.

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