Building Your Team to Battle Workers’ Comp Fraud

The most overlooked part of workers’ compensation claims handling is assembling the best team possible and getting that team to communicate openly. When in complete concert, the members of that team have a much greater efficiency than the sum of their individual parts. This session at the 2020 CLM Workers’ Compensation and Retail, Restaurant and Hospitality Conference focused on how to assemble the best team possible and, in turn, how that team can work collaboratively to combat workers’ compensation claims fraud.

Speakers included:

• Steve Carman, Director of Workers’ Compensation, Celadon Trucking
• Jennifer Meyer, Partner, Kopka, Pinkus, Dolin

Building the Team

Information flow is key in claims handling. It indicates the best course of action. You must have a roadmap. There are specific techniques and procedures to apply when you begin working on a claim. These must be set early, but evolve as needed.

• Great communication skills – Good communication is a message, but great claims communication is dialogue. The more rapid, real-time exchange of information between the company, adjuster and defense attorney, the better.
• Industry AND team member experience – There is no better substitute for team experience or working together on past claims. Choose your teammates wisely and develop efficient strategies for that team.
• Honesty and transparency – To achieve the best outcome, it is vital that all team members know the strengths and weaknesses of every claim as soon as they are revealed. This allows time to address or prepare.
• Ability to discuss and analyze – To have honest and open communication between team members, egos must be left at the door. The interaction must be about the facts and finding a path to the correct claims resolution. Uncover the desire to investigate specific techniques/procedures used prior to referral and those used after referral. In addition, determine if there is a desire to litigate or settle – whatever is most prudent. All considerations rely on constant evaluation based on the facts and economics of the claim.

As the Claim Progresses

Everyone on the team needs to know what is happening as it happens. This keeps everyone on the team up-to-date and eliminates backpedaling.

• Continue that great communication – Dialogue is key to understanding and should continue to address changing scenarios. This can include regular conference calls and emails. In this situation, the adjuster has the ability to speak plainly. All team member should be open to doing what is best at any time.
• Be flexible – The team must have the ability to change gears easily when red flags indicate problems or fraud. This is much easier to achieve when dialogue is consistently occurring, so the claim strategy can quickly change and constantly adjust to fit needs. Great claims strategy may change many times over the course of a claim.
• Instill trust – It is essential to impart trust in the team you assembled. Some of this comes from the talent/skill set of the other team members and some of it comes from the rapport built from working claims together. When both are combined, the effectiveness of your team rises dramatically.

Fraud Indicators

There are several strategies you can use to uncover facts and detect fraud.

• Odds of possibility – Consider “what are the odds” of certain things happening. This helps uncover red flags to formulate questions to get the facts.
• Details more than three deep – When fabricating or lying, most people can handle three follow up questions, but struggle when you ask more. Try going at least five questions deep in the interview process.
• Mixed time sequence – Explaining what happened in order is typically easy. But asking what happened out of sequence makes it hard for a claimant to keep their story straight, if the claim is fraudulent.
• Word limiting use – I “think” I was doing this versus I “was” doing this. Require definitive statements, which offer little wiggle room.
• Word velocity – In the beginning of the interview, use casual conversation to understand the individual’s natural speed of speech, so that when it is time to press for details, you can see if the speed increases or decreases.