Worker Advocacy and Preventing Workers’ Comp Fraud Aren’t Incompatible. Here’s How They Can Work Together

In a RIMS Live 2021 session, two leaders explained how they investigate workers' comp claims with integrity and pounce when finding fraud.
By: | May 23, 2021

Clad in a blue singlet, a professional wrestler jumped from the top rope and made a thunderous dropkick to his opponent’s chest. In a flash, he pinned his opponent and was declared victorious.

Not bad for someone receiving workers’ compensation benefits for back and wrist injuries.

Kevin Lederer, senior key account manager at Command Investigations, shared video of the match during a session of the RIMS Live 2021 conference.

In that instance, Lederer was investigating an injury claim made by a theme park worker. He learned that the claimant moonlighted as a professional wrestler. So on fight night, he took video and got clear-cut evidence of workers’ compensation fraud.

Later in the presentation, Lederer showed side-by-side videos.

One showed a worker explaining his mobility limitations due to arm and shoulder pain. The other showed him playing running back on an amateur tackle football team — getting tackled, blocking and even throwing a pass with his supposedly injured arm. Yet again, Lederer found fraud.

Lederer isn’t out to get anybody. He’s just doing his job.

“Finding a claimant and showing video documentation of their injuries being legitimate is just as important and impactful as getting someone jumping off the ropes at a wrestling match,” Lederer said.

His co-presenter, Steve Figliuolo, principal program lead at Chick-fil-A, agreed. He argued that employers should be advocates for injured workers while investigating claims. In fact, Figliuolo shared Chick-fil-A’s motto on the subject: “Pay the claims we owe and defend the claims we do not.”

“We believe the best claim is the claim that never exists,” said Figliuolo. “We like to dive in and focus on the root cause of an injury.”

Investigating with integrity means encouraging managers to stay supportive of an injured worker during the process. Chick-fil-A also stresses transparency throughout the process from managers, claims processors and others working the claim.

“That really leads to trust and has them feeling cared for throughout their claim,” Figliuolo said.

Chick-fil-A leaders instruct employees at the store level to report all worker injuries no matter the circumstance. They should trust the insurance company to determine compensability.

“It should never be the job of a frontline manager to say ‘I’m sorry we don’t think this is work related, so we’re not going to report your claim to the insurance company.’ This is why licensed claims professionals exist,” Figliuolo said.

A Picture Is Worth 1,000 Words 

What happens when injury stories don’t add up? Investigators like Lederer get involved.

He starts his investigations by getting a detailed report on the injury and specific mobility restrictions. Then he scours the web and social media for information by working with cyber investigators and proprietary software.

If the person is part of a cycling group but out of work with a leg injury, he just might find them taking a rigorous bike ride. If they are a pro wrestler, he might just find them jumping off the top rope.

What happens when a person’s social media profiles are set to private? Lederer looks for alternative ways in, like examining the accounts of spouses or friends that may be public.

In one instance, Lederer found critical information about a supposedly injured woman through her husband’s public profile. Despite doctor’s orders that she not bend at the waist, he learned that the couple was going to participate in a mud obstacle course. His video evidence eventually saved the employer $80,000, he said.

“A picture is worth 1,000 words,” Figliuolo said.

What if the claimant argues that they were just having a good day when the investigator caught them violating their injury restrictions? It’s a common argument that’s best combated with ongoing video surveillance. Perhaps investigators can get a week’s worth of video showing behavior that consistently violates injury restrictions.

“If you can develop patterns of five days or a week, that goes a lot further in many jurisdictions,” said Figliuolo.

Lederer agreed. “Spend a little bit of money to save money,” he said. “It will pay off in the long run without a doubt.”  &

Jared Shelly is a journalist based in Philadelphia. He can be reached at [email protected]

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