Monday, June 24, 2019


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Industry News
Department Of Insurance Grants Funding To Fight Workers’ Compensation Insurance Fraud
Insurance Commissioner Dave Jones announced that 32 million dollars in grants will be distributed to District Attorneys in California by the Department of Insurance in order to support their efforts in investigating and prosecuting workers’ compensation insurance fraud.
“Without question, workers’ compensation insurance fraud is a problem that brings a significant cost with it in California,” Commissioner Jones said.  “During any time, especially during these challenging economical times, these types of fraud places a significant added burden on the system.  We have an obligation to provide protection to injured workers who require both care and compensation so they are able to get back to work as quickly as possible, while also ruling out fraud perpetrated by those seeking to gain the system.”
Each year, the Fraud Assessment Commission determines the grant funding based upon assessment placed on California employers.  CDI leads the workers’ compensation grant review panel that reviews and makes grant funding recommendations based on multiple criteria including previous year’s performance based on applications submitted by counties.  Subsequently, the panel then sends the recommendation to the insurance commissioner who accepts or amends the panel’s recommendations.  Upon completion, the commissioner’s recommendation is submitted to the Fraud Assessment Commission for advice and consent. 
The following is a graph that shows the amount of grant funding received by each County District Attorney’s Office that has applied for the grant for the upcoming 2012 thru 2013 calendar year.  In addition, we have also added the prior grant funding for each of those counties so as to identify those agencies receiving an increase and/or decrease in grant funding. 
Top 20 Red Flag Indicators
  1. Injured worker is disgruntled, seeming to retire, or facing imminent firing or layoff.
  2. Accident occurs late Friday afternoon or shortly after the employee reports to work on Monday.
  3. Accident is not witnessed.
  4. Fellow workers hear rumors circulating that the accident was not legitimate.
  5. Accident occurs in an area where injured employee would not normally be.
  6. After injury, injured worker is never home or spouse/relative answers phone saying injured worker just stepped out or is in the shower, etc.
  7. Injured worker changes physician when release for work has been issued.
  8. Injured worker has a history of reporting subjective injuries.
  9. Several employees from same employer have similar injuries and use same doctors and/or attorneys.
  10. First notice of claim comes from attorney or medical clinic.
  11. First notification of injury or claim made after employee is terminated or laid off.
  12. Employee cancels or fails to keep appointment or refuses a diagnostic procedure to confirm an injury.
  13. Attorney is known for handling suspicious claims.
  14. Physician is known for handling suspect claims.
  15. Boiler plate medical reports are identical to other reports from same doctor
  16. Diagnosis inconsistent with medical treatment.
  17. Injuries are all subjective (i.e. pain, headaches, nausea, inability to sleep) and there are no credible objective findings.
  18. Surveillance or tip indicates the totally disabled worker is currently employed elsewhere.
  19. Claimant overly familiar with the workers’ compensation system & terminology.
  20. Background investigation reveals evidence of self-employment, prior claims, motor vehicle accident and/or domestic violence issues.
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