| "Evidence
proving intentional material false statements is a 'must' to
enable us to build prosecutable cases and gain recoveries of losses."
Workers'
Compensation Fraud
The Colorado
Workers' Compensation Act,
§8-43-402
C.R.S., provides that if a person willfully makes a false statement or
representation material to a Workers' Compensation claim for the purpose
of obtaining benefits, payments, compensation, or awards such person
commits a class 5 felony, punishable as provided in
§18-1-105
C.R.S.
To be convicted of Workers'
Compensation fraud in Colorado, it must be proved that material false
statements or representations were made.
In order for
the Workers' Compensation Fraud Investigation Unit to build a prosecutable case, we
must be able to prove:
- the
statements or representations made are false
- claim
decisions were made based on false statements or representations
material to the claim
- the
statements or representations were made with intent
to defraud
Types of Fraud
Applicant/Claimant
Fraud . . .
- Knowingly
making a false Workers' Comp claim
- Faked or
exaggerated injuries
- Multiple
claims/identities
- Injuries
not sustained at work
- Unreported
income/second jobs
Billing
or Provider Fraud . . .
- Inflated/over-billing
- Services
not rendered
Attorney
Fraud . . .
- Soliciting
or assisting in the filing of a false claim
- Direct
claims to conspiring clinics
Adjuster
Fraud . . .
- Altering
claim evidence to support a denial
- Accepting
gratuities and/or bribes in exchange for implied promise of patient
referrals
Premium
Fraud . . .
-
Providing
false information to obtain Workers' Comp policy at less than the
proper rate
Employer
Fraud . . .
-
Knowing
misrepresentation of the truth to avoid, deny, or obtain compensation
on behalf of employees
-
Knowingly
lies to discourage or prevent injured employees from pursuing claims
-
Misclassification
of employees and/or under-reporting wages
How
do I recognize Workers' Comp fraud?
- A
"Monday morning" injury
-
The
injury is reported early on the first work day of the week.
- Injury is
not witnessed
- Claimant
is disgruntled or has been reprimanded
- There is
material misrepresentation of facts
- Claimant
malingers
-
Prolongs
recovery and/or exaggerates symptoms.
- Services
billed seem inappropriate for type of injury
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