Questionable Workers’ Compensation Claims Increase: NICB

September 24, 2013

While the total number of workers’ compensation (WC) claims has decreased, the percentage deemed “questionable” is rising, according to the National Insurance Crime Bureau’s analysis of WC questionable claims (QC) referrals submitted from January 1, 2011 through June 30, 2013.

QCs are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud. A single claim may contain up to seven referral reasons.

California ranked first generating a total of 2,270 WC QCs, followed by Illinois with 689. New York was third with 688.

In 2011, 3,349,925 WC claims were found in the Insurance Services Office (ISO) ClaimSearch database. That number decreased to 3,244,679 in 2012 and is on track to decrease again in 2013 based on the 1,498,725 claims received in the first half of 2013.

In 2011, 3,474 WC QCs were referred to NICB. That number increased to 4,460 in 2012 — a 28 percent rise. WC QCs accounted for 3.5 percent of the 100,201 QCs submitted in 2011 and increased to 3.8 percent of the 116,171 QCs in 2012. Through the first half of 2013, 2,325 WC CQs have been referred to NICB (3.7 percent of 62,352 total QCs), compared with 1,681 through the first half of 2011 and 2,174 through the first half of 2013.

The distribution of WC QCs follows a standard Monday-Friday work week with the QCs almost evenly divided during the week with steep drop-offs in the numbers for Saturday and Sunday.

There are several referral reasons from which NICB member companies can select to further describe a QC. The top three referral reasons were the same in each year. First was “claimant fraud” with 6,107. Second was “prior injury/not related to work” with 2,319 and third was “malingering” with 1,380.

An injury not related to work is typically a person who suffers an injury during a recreational or day off activity, but fails to report it until at work thus claiming the injury happened on the job. A malingerer is someone who has suffered a legitimate injury, but continues to feign symptoms thus collecting benefits long after he or she has fully recovered.

The full report is available here.

Source: National Insurance Crime Bureau

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