The Phoenix Arizona News describes an extreme case of Workers Compensation fraud – woman competes in Ironman while on Workers Compensation. As an experienced case manager, I see workers compensation fraud often – although it is not usually as extreme as collecting Workers Compensation cheques while competing in an Ironman event.

How does fraud happen and what can you do about it?

The problem starts when employers and Case Managers accept a Doctor’s Note from a family or general physician. The family physician often gets only one side of the story and claims are approved by “word of one doctor”.

Be in control. Proactively manage your disability claims.

As the employer, you will ultimately be paying for this fraud so you need to proactively manage claims and not rely on the worker’s compensation board. Claims Management relies on a complete diagnosis that takes into account the physical demands of the job as well as the physical and mental limits of the employee. Often an employee will advise their doctor that their job demands exceed their limitations, and the doctor will diagnose from there. Employers are not privy to the medical background that went into the diagnosis and thus, cannot know how complete the assessment was. This is when a company needs an Occupational Health Physician.

What role does a Company Doctor play?

My recommendation is that the employer should have their own “company doctor” or occupational health physician to review the physical demands of the job and compare that to the capabilities of the employee. If the employee is completely unfit for duty, the Physician would be able to recommend a rehabilitation program. If the employee is somewhat fit for duty, they could potentially go back to work immediately, with modified work duties. The Occupational Health Physician would then reassess the employee to mark any changes or improvements until the time that the employee could return safely to work. Case Managers require the Occupational Health perspective in order to effectively manage claim expenses for the employer and to ensure the employer is in control.

5 Ways to Avoid Fraudulent Claims

  1. Be involved in Case Management. Ensure Case Managers obtain all of the medical information used to make the diagnosis and do not rely on the interpretation of the information from treating providers. The employee should not drive the diagnosis.
  2. Separate medical from non-medical information in order to determine the cause of an absence.
  3. Work with Case Managers who will validate the initial medical report by using Doctor-to-Doctor Conferencing and Time-Loss Reviews, which are medical assessments performed by an Occupational Health Physician.
  4. Confirm that the diagnosis takes into account the actual requirements of the employee’s job, and note the potential for modified work duties.
  5. Require that Case Managers have ongoing contact with the employee to note their responses to their rehabilitative treatment and reassess their functional abilities over time.
For more information about Claims Management, Workers Compensation disputes and how to prevent avoidable absences, contact us.

Strategic Absence Management Inc., a division of Workplace Medical

Penny Buckner is the Director of Strategic Absence Management Inc. She is also a Registered Nurse with over 15 years of experience in the Group Disability arena in both Canada and the United States. Penny’s experience includes managing Short and Long Term Disability claims at Canada Life and Sun Life, developing and implementing an Early Intervention product used at several national insurers as well as providing case management and auditing services for OTIP (Ontario Teachers Insurance Plan).  Currently, Penny leads our disability management program and our team of nurse case managers.