SURVEILLANCE FRAUD

EFFECTIVE SURVEILLANCE REDUCES THE PAID COSTS ON CLAIMS

Experience has shown us that some injured workers will prolong their return to work by malingering or exaggerating their disabilities. Surveillance investigations should be initiated when you have good reason to believe the worker is misrepresenting his / her disability, and when visual evidence can be utilized or be a benefit in closing or managing the claim. In those instances, conducting covert surveillance and gathering video evidence of the injured worker’s disability and activity level is necessary to manage the claim effectively and avoid paying undeserved benefits.

Surveillance video may also be beneficial – or necessary in some cases for establishing evidence that supports a fraud investigation and resulting in criminal prosecution. The goal in the fraud investigation is to determine whether fraudulent activity has occurred and to identify the course of action that should be pursued. That may lead to a recovery method that would include collection of monies owed, or civil / criminal prosecution.

There are three main categories of fraud investigations: worker, employer and provider. You may recognize the indicators when dealing with the injured worker, but there are other red flags that may alert you to the need for further investigation of other types of possible fraud.

Criminal prosecution differs from the WCB Hearing arena, in that we must establish Proof Beyond a Reasonable Doubt rather than a preponderance of evidence (which may suffice at the Hearings level). There must be an opportunity for fraudulent activity.

  • You must establish monetary or other loss
  • Crime-the action must be a criminal offense
  • Intent (motive) – you must establish that the individual knew of or intended to commit the crime

CHARACTERISTICS OF SURVEILLANCE “HIGH HIT” RATIO CASES: LIKELY TO OBTAIN RESULTS

  • Geographic limitations prevent line of sight surveillance
  • Worker is back to work (either full or part time)
  • If worker is obese, they are less likely to be active
  • Worker has pre-existing medical problems which indicate a low level of activity
  • Prior surveillance investigator was spotted, and worker is suspicious
  • Unknown physical address, worker uses PO Box for mail
  • Prior investigations indicate lack of activity
  • No prior investigation completed (Statement / Activity Check)
  • Injury is not readily visible (stress, psych, headaches, sensitivity to loud sounds )
  • Worker has more than one last name
  • Worker lives in a remote area or small town where unknown vehicles stand out
  • Worker’s restrictions are such that most surveillance would be unusable (no lifting over 50 ponds, no walking over 2 miles)

CHARACTERISTICS OF SURVEILLANCE “LOW HIT” RATIO CASES: LESS LIKELY TO OBTAIN RESULTS

 

  • Geographic limitations prevent line of sight surveillance
  • Worker is back to work (either full or part time)
  • If worker is obese, they are less likely to be active
  • Worker has pre-existing medical problems which indicate a low level of activity
  • Prior surveillance investigator was spotted, and worker is suspicious
  • Unknown physical address, worker uses PO Box for mail
  • Prior investigations indicate lack of activity
  • No prior investigation completed (Statement / Activity Check)
  • Injury is not readily visible (stress, psych, headaches, sensitivity to loud sounds )
  • Worker has more than one last name
  • Worker lives in a remote area or small town where unknown vehicles stand out
  • Worker’s restrictions are such that most surveillance would be unusable (no lifting over 50 ponds, no walking over 2 miles)

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