The High Cost of Fraud
Workers’ compensation fraud is prevalent and is costing employers and insurance carriers significant dollars each year.
There are many degrees of fraud. There are blatantly false claims, such as someone faking a fall or accident, to more subtle examples, such as complaining of false or lingering pain to get more time off of work.
All forms of fraud cost money. Recognizing fraudulent claims and controlling them can be difficult. Below are two of the many ways that workers’ compensation fraud can be controlled.
Get the Facts
The initial investigation is the first step, and one of the most important in preventing and controlling fraud. When an employee reports an injury, ensure that an accurate report is received.
Investigate every claim in detail. No matter how minor the injury, it is important to complete a thorough investigation.
How many times has that “minor” claim turned into a large exposure? An effective way to investigate is by interviewing the employee. Question the employee about how exactly the incident happened, who witnessed it and what could be done to avoid it in the future.
Specifically ask them to name all body parts that were injured. One form of fraud is an attempt to add non-related injuries to the claim by expanding reported injuries to different body parts as time goes on.
Ask them questions about their life. What are their hobbies, do they have other employment, and do they have a spouse and children?
These questions help document the accident and provide great information if there is a need to investigate the validity of the claim. Having their version of the accident in writing makes it less likely that the facts will change.
Nurse Case Management
Nurse case management is useful in many ways to help ensure proper treatment, mitigate costs and return the worker to full duty. It is also a way to help manage situations where there is suspected claims fraud.
The nurse can observe and establish a relationship with the claimant. The nurse should attend medical appointments with the injured worker and ensure the worker is being forthright with the doctor about their injury and job duties.
He/she should have a detailed job description so there is no question what restrictions the doctor should or shouldn’t place on the injured worker. The nurse can present information to the doctor about the worker’s hobbies and lifestyle.
If investigation reveals that an employee is performing activities that he/she states they cannot do, the nurse can present this to the doctor in the hope of getting a full duty release.
There are numerous ways to reduce or prevent claims fraud. Initial investigation and nurse case management are valuable tools.
While some fraudulent claims are prosecuted, most are not. The evidence of fraud can be used to limit exposure of the claim.
Use the information to bring the worker back to full duty as soon as possible. These tools can help shorten the length of a claim and save the company money.
Risk Management Is the Natural Owner of Compliance
With the adoption of Enterprise Risk Management (ERM), many organizations have already begun to include compliance risks as part of their organization’s risk management portfolio. However, even if the organization has not yet climbed aboard the ERM bandwagon, risk managers should be actively supporting, if not directing, their organization’s compliance efforts in several key areas, namely, interdepartmental risks.
After all, the compliance challenges in most organizations will not be those that land neatly in one department. Dining services managers will be on top of sanitation regulations; comptrollers will file their taxes.
No, the greatest compliance challenges are those that cross division and department lines.
Take a look at some of the compliance requirements that prove challenging to institutions of higher education.
• Title IX: Which prohibits discrimination on the basis of sex, covers not only equity in sports but also sexual assault and misconduct. Consequently, this impacts nearly every division of the institution.
• Americans with Disabilities Act (ADA): Its related laws and regulations impact academics, student life, facilities, IT, human resources, admissions, athletics and a multitude of other departments.
• Export Controls: A mishmash of laws that similarly effects any department involved with academics, research, technology, and travel.
• Records Retention Policy: Required under the tax form 990, covers every division and department and has additional privacy and security implications.
“…the compliance challenges in most organizations will not be those that land neatly in one department.”
Institutions traditionally find it difficult to manage compliance requirements such as these because there is no natural “owner” of the requirement. It is here that risk managers are ideally situated to help their institutions by gathering together individuals from the affected departments into a committee or task force.
Together, they can begin to create a shared management process for the institution. In the absence of hierarchical authority, committees and task forces can wield significant influence, especially if appointed by the president or board.
Furthermore, many compliance requirements are a natural fit within a risk management portfolio because they address insured risks. Compliance with anti-discrimination laws (like Title IX and ADA) is a perfect example, as acts of discrimination may be insured through educators’ or employers’ legal liability policies.
Other compliance matters may directly affect the essential identity of the institution. For instance, if an institution violates the regulations on political speech, it could lose its non-profit status and suffer reputational damages.
While it is impractical for a risk manager to be on top of every regulation that an institution is required to be in compliance with (they number in the hundreds) it is important that the risk manager be a leader in compliance matters that, when not addressed, can directly impact insurance and claims.
Offer to help organize a compliance effort. Make sure to (successfully) follow though.
You don’t have to be a subject expert to do this! Your results can showcase risk management services in the institution, reduce risk, and create a template for your next compliance project.
A Modern Claims Philosophy: Proactive and Integrated
According to some experts, “The best claim is the one that never happens.”
But is that even remotely realistic?
Experienced risk professionals know that in the real world, claims and losses are inevitable. After all, it’s called Risk Management, not Risk Avoidance.
And while no one likes losses, there are rich lessons to be gleaned from the claims management process. Through careful tracking and analysis of losses, risk professionals spot gaps in their risk control programs and identify new or emerging risks.
Aspen Insurance embraces this philosophy by viewing the data and expertise of their claims operation as a valuable asset. Unlike more traditional carriers, Aspen Insurance integrates their claims professionals into all of their client work – from the initial risk assessment and underwriting process through ongoing risk management consulting and loss control.
This proactive and integrated approach results in meaningful reductions to the frequency and severity of client losses. But when the inevitable does happen, Aspen Insurance claims professionals utilize their established understanding of client risks and operations to produce some truly amazing solutions.
“I worked at several of the most well known and respected insurance companies in my many years as a claims executive. But few of them utilize an approach that is as innovative as Aspen Insurance,” said Stephen Perrella, senior vice president, casualty claims, at Aspen Insurance.
“We do a lot of trending and data analysis to provide as much information as possible to our clients. Our analytics can help clients improve upon their own risk management procedures.”
– Stephen Perrella, Senior Vice President, Casualty Claims, Aspen Insurance
Utilizing claims expertise to improve underwriting
Acting as adviser and advocate, Aspen integrates the entire process under a coverage coordinator who ensures that the underwriters, claims and insureds agree on consistent, clear definitions and protocols. With claims professionals involved in the initial account review and the development of form language, Aspen’s underwriters have a full sense of risks so they can provide more specific and meaningful coverage, and identify risks and exclusions that the underwriter might not consider during a routine underwriting process.
“Most insurers don’t ever want to talk about claims and underwriting in the same sentence,” said Perrella. “That archaic view can potentially hurt the insurance company as well as their business partners.”
Aspen Insurance considered a company working on a large bridge refurbishment project on the West Coast as a potential insured, posing the array of generally anticipated construction-related risks. During underwriting, its claims managers discovered there was a large oil storage facility underneath the bridge. If a worker didn’t properly tether his or her tools, or a piece of steel fell onto a tank and fractured it, the consequences would be severe. Shutting down a widely used waterway channel for an oil cleanup would be devastating. The business interruption claims alone would be astronomical.
“We narrowed the opportunity for possible claims that the underwriter was unaware existed at the outset,” said Perrella.
Risk management improved
Claims professionals help Aspen Insurance’s clients with their risk management programs. When data analysis reveals high numbers of claims in a particular area, Aspen readily shares that information with the client. The Aspen team then works with the client to determine if there are better ways to handle certain processes.
“We do a lot of trending and data analysis to provide as much information as possible to our clients,” said Perrella. “Our analytics can help clients improve upon their own risk management procedures.”
For a large restaurant-and-entertainment group with locations in New York and Las Vegas, Aspen’s consultative approach has been critical. After meeting with risk managers and using analytics to study trends in the client’s portfolio, Aspen learned that the sheer size and volume of customers at each location led to disparate profiles of patron injuries.
Specifically, the organization had a high number of glass-related incidents across its multiple venues. So Aspen’s claims and underwriting professionals helped the organization implement new reporting protocols and risk-prevention strategies that led to a significant drop in glass-related claims over the following two years. Where one location would experience a disproportionate level of security assault or slip & fall claims, the possible genesis for those claims was discussed with the insured and corrective steps explored in response. Aspen’s proactive management of the account and working relationship with its principals led the organization to make changes that not only lowered the company’s exposures, but also kept patrons safer.
World-class claims management
Despite expert planning and careful prevention, losses and claims are inevitable. With Aspen’s claims department involved from the earliest stages of risk assessment, the department has developed world-class claims-processing capability.
“When a claim does arrive, everyone knows exactly how to operate,” said Perrella. “By understanding the perspectives of both the underwriters and the actuaries, our claims folks have grown to be better business people.
“We have dramatically reduced the potential for any problematic communication breakdown between our claims team, broker and the client,” said Perrella.
A fire ripped through an office building rendering it unusable by its seven tenants. An investigation revealed that an employee of the client intentionally set the fire. The client had not purchased business interruption insurance, and instead only had coverage for the physical damage to the building.
The Aspen claims team researched a way to assist the client in filing a third-party claim through secondary insurance that covered the business interruption portion of the loss. The attention, knowledge and creativity of the claims team saved the client from possible insurmountable losses.
Modernize your carrier relationship
Aspen Insurance’s claims philosophy is a great example of how this carrier’s innovative perspective is redefining the underwriter-client relationship. Learn more about how Aspen Insurance can benefit your risk management program at http://www.aspen.co/insurance/.
Stephen Perrella, Senior Vice President, Casualty, can be reached at Stephen.email@example.com.