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Workers Comp Fraud Retraction by Adjuster – WTF?

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Workers Comp Fraud Retraction – Where’s The Fraud?

Last week, I wrote an article on how most workers comp adjuster work had improved quite a bit over the pandemic.  My heart sank when I saw an article (thanks WorkCompCentral) this week where a workers comp adjuster fraud accusation and referral to the authorities was withdrawn due to lack of evidence.  The workers comp fraud retraction seemed very unusual.

pic of woman looking at workers comp fraud retraction with magnifying glass
(c) Wiki Public Use License

I avoid writing on Workers Comp fraud as a huge number of press outlets always ring the bell when any type of fraud whether by an employer, injured employee, medical provider, or carrier/TPA personnel. The Workers Comp “blogosphere” buzzed this week on the Workers Comp adjuster fraud retraction.

Almost 2,000 articles appear on this website, I have only written five (now six) articles on fraud.

One of the old workers comp statistics quoted often is that 3% of claims start with an element of fraud.  After one year of providing benefits,  the number rises tenfold to 30%.

I will not name any of the parties involved other than to say the injured employee was an up-and-coming actor.  If you wish to read further, please check out this article.

One passage from the Variety that caught my eye was this quote from the county District attorney on the workers comp fraud retraction –

“After the charges were filed, the Workers Compensation Insurance claims adjuster retroactively changed his conclusion regarding her ability to work,” a D.A. spokesperson said in a statement.

There is always more to the story – so here is the original article where charges were filed.

My Experience With Workers Comp Fraud Prosecutions

My experience over the years when working on or consulting on claims adjusting nationwide is pursuing fraud on workers compensation claims resulted in an “0-for-30.”  Many claim dollars and time were spent pursuing fraud with zero convictions.  The charges were usually dropped as in this matter.

The Bottom Line

Should this actor have been pursued for workers comp fraud?  Many developments happen over the life of a file.  I cannot say the adjuster was wrong in referring the file to the authorities.  Having to retract a “final decision”  does not look good in print.

Without reviewing the claim file, one cannot lay the blame on any party.  I do encourage reading both of the Variety articles linked to in this article and drawing your own conclusions.

Related: Third Party Administrator Adjusts Workers Comp Claims For Self-Insureds

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications

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