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CONTROLLING THE COST OF DOING BUSINESS

There is a challenge that faces every business above and beyond the daily routine. It’s not an external market force—this challenge comes from within. Insurance fraud drains resources and can be the loss that keeps on costing.

When an individual attempts to make money through insurance transactions by deceiving others, it’s insurance fraud and it takes many forms. Annual costs on a national basis are estimated at more than $120 billion, but the effects can be felt very tangibly right here in Nevada.

Elite Investigations has experience, discretion and the leading investigative tactics and team in our market. We know what to look for and have methods that can reveal possible fraudulent behaviors that, over time, will have a dramatic effect on your bottom line.

FRAUD RED FLAGS

While in and of themselves the behaviors listed below do not constitute fraudulent behavior, they can be considered red flags, worthy of note and further examination.

A red flag is a warning or a sense that something isn’t right with a claim and should lead one to take a closer look. The lists below will help employers and claims professionals know what to look for when identifying possible fraudulent behaviors. Identification of any one of the following red flags does not mean that fraud exists, but these and others may be contributing factors.

Red flag indicators that may signal fraudulent activity include:

  • Number of days worked and amount of salary inconsistent with occupation;
  • Injured worker disputes average weekly wage due to additional income (i.e., per diem and/or 1099 income);
  • Cross-outs, white-outs and erasures on documents;
  • Injured worker files for benefits in a state other than principle location of the alleged industrial injury or occupational disease;
  • Injured worker-listed occupation is inconsistent with employer’s stated business;
  • Injured worker address is different than principle location of employer other than border states;
  • Injured worker cannot be reached because he or she is never home or is reportedly sleeping and cannot be disturbed;
  • Injured worker is seen with calluses on hands, grease under fingernails;
  • Injured worker moves out of state or country shortly after filing claim;
  • Accident/incident occurs immediately prior to strike, layoff, plant closing, job termination or job completion;
  • Injured worker is in line for early retirement;
  • Injured worker refuses (or delays multiple times) diagnostic procedures to confirm injury;
  • Conflicting descriptions of the accident/incident between employer’s report and initial medical evaluation;
  • Injury is not consistent with nature of business;
  • Date, time and place of accident is unknown;
  • Injured worker cannot recall specific details about the injury;
  • Report of injury not timely and immediate;
  • No witnesses to accident;
  • Tips from coworkers.