| Workers' Compensation Fraud Costs Millions! |
| Fraud costs the Texas workers' compensation system millions of dollars each year. Employers, employees, insurance carriers, and Texas consumers pay the cost of fraud in lost jobs and profit, lower wages and benefits, and higher costs for services and premiums.
In an effort to deter fraud, Business Staffing, Inc. has a policy of investigating all injuries and will prosecute those found committing workers' compensation fraud. These investigations can also lead to recovery of money gained through fraudulent schemes. |  |
Fraud occurs when a person knowingly or intentionally conceals, misrepresents, and makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit. The key to conviction is proving in court that the misrepresentation or concealment occurred knowingly or intentionally.
Benefit fraud is one of the most common types of workers' compensation fraud.
Benefit fraud is usually committed by an employee who works full time at an unreported job and draws benefits when he or she is supposed to be unable to work. Fraud is also committed when an employee fakes an injury; whether an attorney is involved or not.
Fraud indicators do not mean fraud has occurred, but they may require a closer review of the claim or application. Employee fraud indicators include but are not limited to:
- injuries that have no witness other than the employee
- injuries occurring late Friday or early Monday
- injuries not reported until a week or more after they occur
- injuries occurring before a strike or holiday, or in anticipation of lay off or termination
- injuries occurring where the employee would not usually work
- injuries not usually occurring in the particular job description, for example, a secretary injured when lifting a heavy object
- employee observed in activities inconsistent with the reported injury
- employee history of workers' compensation claims
- conflicting diagnosis from subsequent treating doctors
- evidence of employee working elsewhere while drawing benefits
Criminal. If an investigation establishes criminal fraud, the local district attorney may begin prosecution. Workers' compensation fraud involving amounts of $1,500 or more in benefits or premiums is a felony punishable by fines, orders for restitution, and imprisonment. If the amount is below $1,500, the action is a Class A misdemeanor punishable by fines, orders for restitution and imprisonment.
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