With the approval of IPIU Senior Management in London and the United States, I would like to create a forum containing actual questionnaires and investigative tools that would assist the IPIU member investigator in assignments they may receive relative to insurance and fraud claims investigation.

An example of would be a Workers Compensation checklist of fraud indicators. Secondly, a questionnaire and tool most widely used among insurance adjusters and SIU insurance investigators is the Fraud Abuse Indicator Checklist and a list of guidelines for handling suspected fraud/abuse claims on property and casualty assignments.

Checklist
Workers Compensation Fraud Indicators

Note to adjuster and investigator: Any single indicator or group of indicators does not establish fraudulent activity. Their presence indicates the need for further investigation including running a CLUE report. Required am and pm activity checks/drive by's by SIU are suggested prior to assigning to SIU for surveillance.

1. Employee planning or in process of plant shutdown
2. Employer cutting back hours or laying off people
3. Employer terminated employee
4. Employer notified employee of poor performance, tardiness
5. Disgruntled injured worker, soon to retire
6. Injured worker is a seasonal worker
7. Injured worker took unexplained, or excessive time off prior to claimed injury.
8. Injured worker is a new employee
9. Injured worker experiencing financial difficulty
10. Injured worker shows history of reporting an injury that is "subjective in nature" meaning, a soft tissue injury. no visible sign.
11. Injured worker did not report the injury immediately
12. No witnesses to injury
13. The injury is reported first thing Monday morning or late Friday
14. Injury occurred in an area not approved for work, or does not usually work in.
15. Injured worker is never home when called by adjuster or investigator. Comments made by spouse or roommate indicates that worker is employed elsewhere, or the spouse or roommate always says, call back in one hour.

The 6 Key Indicators of Workers Compensation Fraud

Note: If you have two or more indicators present, submit to SIU immediately.

1. No witnesses
2. Claim history found in CLUE
3. Conflicting statement(s)
4. Medical TX and RX appointment no show
5. Release to work by treating. No restrictions. No followup
6. Attorney letter is submitted immediately. Lost time demand.