No business wants their WC claim count and dollar amounts to rise, but they especially don’t want suspected fraudulent claims to go through their WC. Workers’ comp is an insurance program designed to protect and care for employees hurt on the job. So, the burden of proof for fraud always rests with the employer.
The good news is that the solution is in the employers’ hands. The most effective ways to avoid workers’ comp fraud is to 1) implement pre-employment screening; 2) inform new hires about the company’s personal integrity expectations both inside and outside the workplace; 3) establish “medical baselines” to make sure the person hired can do the job they are hired to do; and 4) keep drugs out of the workplace – both legal drugs used illegally and those drugs classified as illegal. These steps are necessary to attempt to “prove fraud” because it is so difficult to do so.
For any prosecution of fraud to go forward, the employer must prove intent, which is almost impossible legally. Denials are possible but require documented conflicting statements by the injured employee, written records, investigative reports of witnesses and supervisors, surveillance video(s), questionable medical findings, or co-workers/family reports revealing an employee’s motive or intent. Even with all this diligence, fraud prosecutions are extremely rare.back