August 2, 2023

Seven red flags and 10 prevention tips for fraud

healthcare fraud

At Texas Mutual, we have zero tolerance for fraud. We're dedicated to protecting our policyholders with the largest team of fraud investigators in the state. Our fraud experts are on your side. We want to empower you to report fraud by raising awareness and knowing what fraud can look like. Our investigators often receive tips from concerned policyholders and it's our job to investigate fraud. However, you might notice it on the job first and your role in reporting it is crucial to our ability to proceed when warranted.

Understand each type of fraud

There are three types of workers' compensation fraud you should know about:

  • Premium fraud is when an employer misrepresents his or her business operations and payroll to the workers' compensation company, often with the intention of paying a lower premium. Using this workers' compensation fraud scheme could give an employer an unfair advantage over competitors and negatively affect all involved in the workers' compensation system.
  • Claimant fraud is when an employee takes advantage of the system by falsifying incidents or the severity of injuries. One example is when an employee continues to work at another job while also receiving workers' compensation. This scheme is called double-dipping.
  • Medical provider fraud is when medical providers use unlicensed providers or overbill Texas Mutual for services.

Look at claims with a critical eye and keep these seven red flags in mind:

  1. Employee rumors or a tip from a credible source that the alleged injury is suspicious
  2. The suspicious injury occurs on a Monday or a Friday
  3. The worker is new or disgruntled
  4. There are no witnesses to the alleged injury
  5. The description of the incident is illogical or inconsistent
  6. It is difficult to contact the injured employee
  7. The injured employee seems upset when contacted

Be proactive with these 10 tips to prevent workers' compensation fraud:

  1. Use best practices for hiring: It's important to establish hiring practices that help you recruit quality, trustworthy candidates. Consider checking a candidate's references and conducting drug tests before hiring. Your employees' onboarding experience can also help set the tone for your workplace culture. Ensure your employees' success with training that informs them of workplace expectations.
  2. Lead with trust and respect: Establishing a positive relationship and maintaining rapport with employees has a direct effect on workplace morale. Employees are less likely to cheat employers they trust and respect. You can help facilitate this environment with an open-door policy, so that your employees feel comfortable sharing their concerns with you.
  3. Make safety a priority: Providing a safe work environment can help discourage employees from reporting fraudulent injuries. Employers are required to control hazards in their workplace and our safety department is here to help. You can find resources by logging in to your policyholder account at texasmutual.com and selecting the Safety tab.
  4. Set clear expectations: Be sure to reinforce the importance of workplace safety and your policy on dishonest behavior during new employee onboarding and regular training. Lead by example and clarify expectations with your employees, preferably in writing. Provide materials in English and Spanish that are expertly translated.
  5. Listen to your employees: Create an internal culture of transparency that allows employees to come forward with their concerns. Your employees may be the first ones to spot suspicious behavior in the workplace. With a foundation of trust and respect, they will be more likely to voice their concerns to you.
  6. Implement a return-to-work program: Formalize what injured employees can expect if a workplace injury occurs with a return-to-work program. Make sure you have a current record of your employees' daily job duties and encourage cross-training to help ensure that business operations can continue.
  7. Know what to expect with workers' compensation: Resources to better understand the workers' compensation process, including everyone's role in a claim, are available at texasmutual.com for employers and injured employees.
  8. Protect yourself against provider fraud by using our trusted network: Claimants who participate in our WorkWell, TX health care network return to work an average of eight days faster with 14% lower indemnity benefits than non-network participants.
  9. Know what to look for if you suspect fraud: Be familiar with the list of seven red flags and be prepared to report fraud when you suspect it. Find more information on the details that will be requested on our Fraud page.
  10. Let us do the investigation: We won't ask you to pursue the fraud investigation on your own. Our team of investigators will do their job so you can get back to managing your business. Fraud details, contacts and the reporters' identity will all remain confidential.

Fraud is not a victimless crime and its trickle-down effects can impact business owners throughout the state. Our expert fraud team investigates more than 1,500 potentially fraudulent cases each year to protect both our policyholders and legitimate claimants.

Fraud prevention is a partnership, and with your help, you can prevent fraud in your workplace and get us to work for you if you see anything suspicious. That commitment to investigating fraudulent claims underscores our role as a leader in workers' compensation.

How to report fraud

Email us at fraudstoppers@texasmutual.com or call (800) 488-4488.