Fighting Fraud

Republic Indemnity has a Zero Tolerance policy against fraud of any kind.

Fraud is generally defined as:

  • Making any knowingly false or fraudulent material statement or material misrepresentation to obtain or deny workers’ compensation benefits;
  • Presenting any knowingly false or fraudulent written or oral material statement in support of, or in opposition to, a claim for workers’ compensation benefits (“statement” includes notices, proof of injury, bill and payment for services, test results and medical/legal expense);
  • Knowingly assist, abet, conspire with or solicit a person in an unlawful act related to workers’ compensation benefits; and
  • Making a knowingly false or fraudulent statement regarding entitlement to benefits with the intent to discourage an injured worker from claiming benefits or pursuing a claim.

Fraud Red Flags

An employee’s actions or behavioral patterns can be suspicious and raise the possibility of workers’ compensation fraud.

These are frequently red flags:

  • Employee did not report the alleged incident to the employer, but sought own medical treatment. This is especially noteworthy after a strike, layoff, job termination, plant closure, immigration raid, or disciplinary action.
  • No other employee witnessed the incident, or witness accounts conflict with one another or differ from the claimant’s version.
  • Employee’s version of the alleged incident is not credible.
  • Questionable or unwitnessed incident occurred on the first day of work after a weekend.
  • Employees consistently use the same medical providers and/or attorneys to handle their claims.
  • Employee is unusually familiar with claim handling procedures and workers’ compensation rules, laws, and proceedings.
  • The first claim notice comes from the attorney or medical clinic.
  • Medical provider is located far from the employee’s residence or place of employment (may also be an indicator of medical fraud).

Fraud vs. Abuse

As the employer, you may be first to detect workers’ compensation fraud, so you must be able to recognize basic patterns indicating fraud and also be aware of the difference between fraud and abuse. For example, an injured employee may exaggerate the extent of his/her injuries to obtain additional time off. This is an instance of abuse rather than prosecutable fraud. Abuse is any practice that uses the workers’ compensation system in a way contrary to the intended purpose of the law.

Abuse becomes fraud when it is accompanied by provable misrepresentations. The standard of proof for fraud requires the intent to defraud to obtain workers’ compensation benefits. Determining fraud versus abuse can sometimes be a matter of perception. Excessive treatment by a doctor may only represent a difference of opinion; it may not constitute criminal fraud.

If you suspect an instance of fraud and would like to report it, please click here to complete the form.