The total number of workers’ comp claims has been decreasing, but the percentage deemed “questionable” has been rising, according to the National Insurance Crime Bureau (NICB). In 2011, 3,349,925 workers’ comp 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.
Through analysis of workers’ comp questionable claims (QC) referrals submitted from January 1, 2011 through June 30, 2013, NICB discovered that number of workers’ comp QCs submitted increased from 3,474 in 2011, to 4,460 in 2012, and with 2,325 in the first half of 2013 the number of workers’ comp QCs is on course to increase again in 2013.
California generates the most claims that insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud with a total of 2,270 QCs, according to NICB. It was followed by Illinois with 689 and New York with 688. North Dakota and Wyoming had the fewest, with two and three respectively. Washington experienced the greatest increase in QC up 300 percent, and District of Columbia experienced the greatest decrease, down 38 percent.
Los Angeles, Chicago and New York were the cities with the most workers’ comp QCs.
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” — suffering a legitimate injury, but continuing to feign symptoms thus collecting benefits long after he or she has fully recovered — with 1,380.
August 2011 was the month with the largest number of workers’ comp QC losses (322). February, April and May had an increase in the number of workers’ comp QCs from 2011 to 2012. And, the distribution of workers’ comp 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.
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