WC Fraud - Reality

There are many discussions, seminars and vendors nationwide that warn in a threatening way of the 'devastating' costs of workers' compensation fraud. To be sure, there are some egregious situations which lead to millions of dollars leaving the system to undeserving workers, vendors, medical clinics, and even physicians. In our experience, supervising and administering claims in 35 states for as many years, the percentage of claims where actual, true fraud is attempted is less than 1% in workers' compensation. For the WC adjuster / examiner / supervisor / case manager, always being mindful that some involved in the process may try to push the limits of the law or facts is a positive thing when kept in perspective of all of the other issues for which they are responsible. But when this shifts to a mindset of 'everyone is cheating the system', as has been witnessed in far too many instances, the basic tenets of the workers' compensation system are violated. If this happens for a claims adjuster or firm, or the focus on fraud takes priority over providing excellent, timely, well-communicated service, wage loss benefit payments and facilitated 'best in class' medical care to the injured worker making a claim, and all other stakeholders, overall effectiveness for the customers, insureds and injured workers that they are intended to serve drops, or is eliminated. And these other 99% deserve the best that we can give them.

However, when a stakeholder in the system cheats, lies and / or violates the law to take money from the system, depriving others of critical benefits and service, the full weight of the law should be put upon them. As in this case: