| "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
Investigations & Criminal Enforcement 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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