Tips for spotting workers’ compensation fraud in the dental practice

Unfortunately, some employees try to make fraudulent workers’ compensation claims. There are signs dentists can watch for to see if an employee is trying to make a fraudulent claim.

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Dental practice employees can be susceptible to many types of workplace injuries and illnesses. For example, hygienists might experience musculoskeletal ailments from sitting or standing over patients for extended periods of time,1 or sharps injuries from being pierced by an explorer while looking for cavities in a patient’s mouth.2 While most injuries and illnesses are legitimate, employees may occasionally attempt to work the system by filing a fraudulent workers’ compensation claim.

Workers’ compensation insurance fraud is a serious crime that costs businesses $30 billion annually, puts a strain on business operations, and leads to higher insurance premiums.3

One common type of workers’ compensation insurance fraud is claim-related fraud. This typically occurs when an employee falsely claims a work-related injury or illness in an attempt to collect a workers’ compensation insurance benefit. An employee might commit this type of fraud by claiming an injury occurred at work when it actually happened outside of the workplace. Sometimes people exaggerate the severity of an injury or prolong an injury in order to receive a greater insurance benefit.4 For example, an employee may report that he has lower back strain from leaning over patients all day, when he actually threw out his back moving heavy boxes at home.

Fraud warning signs

While there is no exact science for identifying claim-related workers’ compensation fraud, there are several common indicators of which dental practice owners should be aware. Experience shows that the claim may be fraudulent if two or more of the following warning signs are present. Bear in mind that these are simply indicators. It is perfectly plausible that no witnesses saw the dental hygienist become injured while cleaning probes and scalpels on a Monday morning.

Monday morning reports—The alleged injury occurred first thing on Monday morning, or the injury occurred late Friday afternoon but was not reported until Monday.

Suspicious providers—An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.

Conflicting descriptions—The employee’s description of the accident conflicts with the medical history or first report of injury.

Treatment is refused—The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.

Claimant is hard to reach—The allegedly disabled claimant is hard to reach at home.

Employment change—The reported accident occurred immediately before or after a strike, job termination, layoff, end of a big project, or conclusion of seasonal work.

No witnesses—There are no witnesses to the accident and the employee’s own description does not logically support the cause of injury.

History of claims—The claimant has a history of making suspicious or litigated claims.

Late reporting—The employee delays reporting the claim without offering a reasonable explanation.

Numerous changes—The claimant has a history of frequently changing physicians, addresses, or employers.

If dental practice owners suspect an employee may be committing claim-related fraud, they should report it immediately to the appropriate law enforcement authorities or the workers’ compensation insurance carrier’s special fraud investigations unit. The appropriate party may investigate. If reporting claim-related fraud, a practice owner should be sure to gather as much information as possible, including documenting any possible misstatements and identifying witnesses.

Fraud prevention

There are proactive measures dental practice owners can take to prevent the potential for false claims. One is to establish a zero-tolerance policy for fraud. It is important to clearly communicate these expectations with employees through written antifraud policies. Most insurance carriers can provide materials, such as posters or payroll stuffers, to educate employees about the adverse impacts that fraud can have on a business. Just as clients visit dentists biannually for checkups, it is a best practice to review the zero-tolerance policy with staff once a year and whenever new team members join the practice.

Another step is to encourage employees to report suspicions of potential workers’ compensation fraud. As part of this, it is important to create an environment where employees don’t fear retaliation for doing so. Give employees ways to report suspicious or fraudulent activities safely and, potentially, anonymously, such as having an open-door policy or purchasing a suggestion box where employees can drop written tips.

By understanding the common warning signs of claim-related workers’ compensation insurance fraud, the steps to take if fraud occurs, and mitigation strategies, dental practice owners can help protect their practices, clients, and employees.

References

1. Ayatollahi J, Ayatollahi F, Ardekani AM, et al. Occupational hazards to dental staff. Dent Res J. 2012:9(1);2–7.
2. Robinson P. Sharps injuries in dental practice. Prim Dent Care. 1998:5(1);33–39.
3. Workers’ compensation and medical fraud prevention tips. NICB website. https://www.nicb.org/sites/files/2017-10/WorkersCompMedFraud.pdf.
4. Five ways businesses can prevent workers’ compensation claim-related fraud. Employers website. https://www.employers.com/resources/blog/2015/five-ways-businesses-can-prevent-workers-compensation-claimrelated-fraud. Published 2015.

 

Samuel V. King is vice president, fraud investigations, for EMPLOYERS, America’s small business insurance specialist. It offers workers’ compensation insurance and services through Employers Insurance Company of Nevada, Employers Compensation Insurance Company, Employers Preferred Insurance Company, and Employers Assurance Company. Not all insurers do business in all jurisdictions. EMPLOYERS and America’s small business insurance specialist are registered trademarks of Employers Insurance Company of Nevada.

 

The information provided is intended to provide a general overview. This information is not legal advice and should not be relied on as such. EMPLOYERS makes no warranties for the accuracy, adequacy, or completeness of the information provided, and will not be responsible for any actions taken based on the information contained herein. If you have legal questions or need legal advice, please consult an attorney.

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