Worker's Comp Fraud??

  1. 0
    All of you experienced EHS nurses.. We had an employee who was hurt on the job. He has been out on WC since the begining of the year. The insurance company that pays our claims videotaped him building a house, using a hammer with the broken hand. Also moving materials and running a saw. This has gone on for 6 months. The company contacted the doctor and he refuses to amend any of his reports regarding this guy's RTW status. He stated that there was no way to say the injury was taking longer because the guy was still using the hand. Am I crazy? What is the downside for this dco to review the tapes, talk to the patient and say WTH???
  2. 4 Comments so far...

  3. 0
    It's been my experience that in most instances similar to this these cases are resolved in mediation and a settlement is made. When we have employees suspected of fraud we have them observed and if they are observed doing anything outside of their restrictions their claims are mediated, settled and they are terminated due to their fraudulant actions. You should probably talk with your adjuster, case manager, and the attorney on retainer.
  4. 0
    In the state of NH these films could cause the employer to prevail in a Court Action. Yet in the state of nearby Vermont, these films would liikely have no effect, and that is the possible outcome in the State of Masachusetts.

    Different boards have different attitudes. Vermont seems to believe that the employee is virtually always right. *shrug*

    I suggest that you obtain through inter-library loan the book:

    Detecting Malingering and Deception; Forensic Distortion Analysis

    You will gain a lot of insight.
  5. 0
    At this point I would let the insurance company handle it. If they find he is a fraud through court then give that nurse the axe.
  6. 0
    How do you know how much analgesic he had used or what the after effects were of his working on his house? There is nothing unprofessional about taking a large amt. of analgesics to be able to control pain to fix your roof- the shingles may not be straight but you won't kill anyone but youself. I wouldn't want him to be my nurse while under the influence of higher doses of narcotics. For all you know he had to spend the evening in a drug induced stupor or packed in ice to recover from the use of his injured hand. I honestly don't feel most people want the hastle or stigma of a prolonged injury claim. Most people want to return to thier career as soon as they are recovered from thier injury and are safe in patient care. Any W.C. company that would waste thier time and money videotaping an injured worker in thier home activities is spending way too much of thier resources on denying claims/care. Thier focus isn't helping people to return to work but to cut the bottom line.


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