Whether it is tax fraud, Medicare fraud, auto insurance fraud, or workers’ compensation fraud, it’s all the same thing. It is seeking financial gain through deception; it is lying for money. Anyone who touches a workers’ compensation claim has the opportunity to profit from lying. The fraudulent activity can be as simple as a patient exaggerating their symptoms to prolong disability duration or as complex as an organized crime ring involving doctors, lawyers, treatment facilities, claimants, and even insurance company kickbacks.
Doctors are trained to be patient advocates, but it is possible for doctors to take good care of patients while remaining vigilant for the fraud and abuse that takes place around us. There are three broad categories of clues the provider can use to detect claimant fraud: claimant circumstances, accident/injury circumstances, and physical examination.
Claimant Circumstances
One claimant circumstance that can serve as a red flag is the disgruntled employee. Employees often feel powerless before an employer with whom they have conflict, but one way a disgruntled employee can exert power is with a work injury. When taking a patient history, if the patient begins the interaction with a complaint about their supervisor, this alerts the provider that there may be motivation for symptom exaggeration or poor response to treatment. Another claimant circumstance is if the worker’s employment is about to end. This can be because seasonal work is coming to a close, imminent firing, lay-offs, or an employee’s department being relocated to another facility. In this circumstance, reporting a work injury with the opportunity for disability payments might appear preferable to simply losing one’s income. Other suspicious circumstances include an injured employee working a second job while on temporary total disability, a history of short-term employment, and subjective complaints that are not supported by objective findings.
Accident/Injury Circumstances
Circumstances surrounding the accident or injury can alert a provider to the possibility of fraudulent activity, for example, suspicious timing in reporting a claim such as late Friday afternoon when there are no witnesses or first thing Monday morning raising concern that the injury could have occurred over the weekend while off-duty. Reporting an injury just before impending disciplinary action can look attractive to a worker if the disciplinary action might appear retaliatory or if reporting a work injury provides an excuse for poor productivity. Details of the mechanism of injury can be suspicious if these details are vague, inconsistent, not corroborated by witnesses, or simply not credible.
The Physical Examination
Finally, the provider can get clues of fraud in the examining room. Overly exaggerated responses to minor stimuli, patterns of tenderness that do not follow normal anatomic boundaries, and non-physiologic physical complaints are examples. Other examples include inconsistent exam findings or the patient complaining of pain precipitated by a physical maneuver that the examiner knows should not cause pain with a legitimate injury.
Claimants are not the only participants in the workers’ compensation system to have an opportunity to commit fraud. The relationship between the provider and the employer presents incentives for fraudulent behavior as well. Andrew Fastow, CFO and main architect of a massive accounting scandal at the oil and gas trading company Enron in 2001 provided insights to business students about the insidiousness of fraud after he served his prison sentence. He told these students that in the beginning, he did not think of his behavior as fraudulent. He thought he was just doing his job as CFO to protect the interests of the company. He told the students he did not even recall when his activities slipped into outright fraud. Could well-meaning participants in the workers’ compensation system similarly slip into fraudulent behavior without intending to do so?
To answer this question, one must examine the relationship between the employer and the provider. The employer, like the Enron CFO, simply wants to do what it can to help the company ease the financial burden of workers’ compensation costs and enlists the assistance of the provider in doing so. The provider’s goal in this relationship is to earn loyalty from the employer. This provides incentives to trade favors from the provider in exchange for loyalty from the employer, favors such as keeping cases in the “first aid” category, having a bias in causation analysis favorable to the employer, or blurring the lines between preventive services versus medical treatment. Discussion between the employer and provider in order to inform the provider’s medical decisions is encouraged, but when informing the provider slips into colluding with the provider, the risk of fraudulent behavior presents itself. In other words, when an employer demands favors in exchange for loyalty, the provider acquiesces.
The workers’ compensation system can be exploited in numerous ways. By recognizing clues of fraudulent activity in others and by realizing our own vulnerabilities, we can all play an effective role in detecting and deterring workers’ compensation fraud and abuse.
