A Publication of WTVP

In my last column we discussed the bigger picture of workers’ compensation. Now we take a closer look at one of the players in workers’ compensation fraud, the employee. We will examine other players—including medical providers—in future articles.

INC. magazine reported poll results which indicate employers believe 19 percent of fraud is perpetrated by the employee. There are a several ways injured workers can commit workers’ compensation fraud. Let’s look at a few examples.

The first is the obvious—faking an injury. A few years ago, I worked as a therapist performing Functional Capacity Evaluations (FCE) in another community. On one occasion, an “injured” worker was scheduled to participate in an FCE. Having no means of transportation, the worker used the bus line to come to the clinic. On the first day of testing, this worker was observed getting off the bus and running a city block to the clinic. Once at the front doors of the clinic, the worker developed a drastic limp that continued throughout testing. After the day’s testing was complete, the worker left the clinic limping, only to lose the limp outside the front door and once again run to the bus stop. This performance was repeated the following day as well. While most people who say they are injured are indeed injured, a small percentage of these people do fake injuries.

The second type of fraud committed by the employee is what many term malingering, a legal—not medical—term. Malingering involves an actual injury with exaggerated symptoms or reported pain level in hopes of secondary financial and/or emotional gains (i.e. time off work, money in settlement, sympathy from others).

It is important to make the distinction between malingering and individual responses to an injury. People respond differently to similar injuries. Many variables go into the recovery process and one worker may take two weeks to fully recover from a back injury (working modified duty in the interim, of course), while another worker could take a couple of months to fully recover. Malingering versus individual differences is an issue that the well-seasoned occupational health practitioner should be able to differentiate.

There are some steps an employer can take to uncover fraudulent behaviors. The most important factor is ensuring that all injuries are investigated thoroughly and quickly. Get a detailed statement in writing from the worker as soon as possible. Interview not only the injured worker, but also those who witnessed the injury. Check logbooks and documentation to see if the worker was feasibly doing what they claimed. Check out potential faulty equipment, if stated as a cause. Have the worker evaluated by the provider of your choice as soon as possible (yes, you can do this legally). A thorough investigation early can save an employer the time, hassle and money involved in the cases of fraud. IBI