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Workers' Compensation Fraud Section

Common Types and Schemes

Benefit Fraud

  • An employee who is drawing benefits because he/she is supposed to be unable to work and is working full time at an unreported job
  • An employee fakes an injury in order to collect benefits
  • A health care provider assists the employee in a fraudulent scheme
  • A health care provider bills for services not provided

Premium Fraud

  • An employer misrepresents the amount of payroll or classification of employees in order to obtain a lower premium
  • An employer avoids a higher insurance risk modifier by transferring employees to a new business entity rated as a lower risk category

Workers' Comp Fraud Indicators

Fraud by Employees

  • Injury that has no witness other than the employee
  • Injury occurring late Friday or early Monday
  • Injury not reported until a week or more after it supposedly occurred
  • Injury occurring before a strike or holiday, or in anticipation of termination
  • Injury occurring in a location where the employee would not normally work
  • Injury that is inconsistent with normal job duties
  • Employee observed in activities inconsistent with the reported injury
  • Employee history of workers' comp claims
  • Conflicting diagnoses from subsequent treating providers
  • Evidence of employee working elsewhere while drawing benefits

Fraud by Employers

  • Classification codes inconsistent with duties normally associated with the employer's type of business (e.g. a construction company reporting mainly clerical classifications)
  • Payroll information on the insurance application inconsistent with payroll reported to the Texas Workforce Commission
  • Much larger premium paid for the previous year's policy
  • Unusually small payroll reported by a large employer or employee leasing company
  • Frequent additions and cancellations of coverage, especially if several business entities appear to be owned or controlled by the same person or group

Fraud by Health Care Providers

  • Bills or explanation of benefits for services from health care providers, insurers or attorneys that seem unnecessary or fictitious
  • "Boilerplate" medical reports, or reports that are merely copies of previously submitted reports
  • Treatment dates on holidays for non-emergency situations
  • Bills from a healthcare provider or attorney that represent an unreasonable amount of billable hours per day
  • Complaints from the employee that the attorney is rarely available although the attorney files fee affidavits for services
  • Attorney relationship with a health care provider that appears to be a partnership in handling workers' compensation claims

Ways to Report Suspected Fraud

For more information, contact:

Last updated: 01/13/2016

Contact Information and Other Helpful Links