|
|
|
|
"Experience is a good school, but the fees are
high." -Heinrich Heine
Suspected fraud claims are a serious allegation and must be handled with the utmost caution. The claim should not be discussed with anyone who is not directly involved in the investigation or handling of the claim. When investigating the claim, the belief that the claim may be suspicious in nature should not be discussed or mentioned to any of the potential involved parties, including the claimant, the medical provider, or the claimant’s attorney. Mention of this belief to the injured worker’s employer should only be done in a very circumspect manner (i.e. only with senior risk management). The investigation should not lead any of the witnesses inappropriately. It must be objective in nature in order to properly clarify the suspicious issues. Once the investigation has been completed, and it is believed that fraud does exist, the claim must again be reviewed with the Account Manager and the Branch Manager. If necessary, legal counsel may be consulted at this point. If it is believed that the employer is not involved in any way, the client should be advised of the concerns and suspicions. Prior to reporting the claim to state agencies, ClaimQuest senior management must be informed, and concur that this course of action is to be taken. The claim will be reported to the Fraud Division of the State of California Department of Insurance, and the appropriate District Attorney office where the suspected fraud has occurred. To assist in detecting potential fraud in Workers’ Compensation, fraud detectors have been developed. Colloquially, these indicators are known as "Red Flags". While not all indicators establish fraud, they must be completely investigated and dealt with accordingly. New claims are reviewed for potential fraud from several different sources: employee, employer, medical provider, general provider, and attorney. Any individual who has a potential monetary interest in the claim, may be a contributor in a fraudulent case. The key to properly identifying and handling suspicious claims is constant communication with the employer. Valuable information can be obtained which can clarify a suspicion. |
|
Copyright © 2002 ClaimQuestSite Design by Scott Mead Communications
|
One of the largest concerns a Risk Manager carries is the control
of fraud. If ClaimQuest suspects a claim to be questionable in nature, the
Claims Representative must review the claim with the Account Manager and reach an
agreement on the best approach for investigating and clarifying the suspected issues.