Workers' Compensation Fraud Investigations

It is a felony in Colorado for someone to willfully make a false statement or representation material to a workers' compensation claim for the purpose of obtaining benefits, payments, compensation, or awards.

In order for the workers' compensation Fraud Investigation Unit to build a prosecutable case, we must be able to prove:

1. the statements or representations made are false,
2. claim decisions were made based on false statements or representations material to the claim, and
3. the statements or representations were made with the intent to defraud.

Recognizing Fraud

Possible "red flags" of fraudulent behavior may include:

• A "Monday morning" injury - The injury is reported early on the first work day of the week
• Injury is not witnessed
• Claimant is disgruntled or has been reprimanded
• There is material misrepresentation of facts
• Claimant malingers - Prolongs recovery and/or exaggerates symptoms
• Services billed seem inappropriate for type of injury

Additional Types of Fraud

Applicant/Claimant Fraud

• Knowingly making a false workers' comp claim
• Faked or exaggerated injuries
• Multiple claims/identities
• Injuries not sustained at work
• Unreported income/second jobs

Billing or Provider Fraud

• Inflated/over-billing
• Services not rendered

Attorney Fraud

• Soliciting or assisting in the filing of a false claim
• Direct claims to conspiring clinics

Adjuster Fraud

• Altering claim evidence to support a denial
• Accepting gratuities and/or bribes in exchange for implied promise of patient referral

Premium Fraud 

• Providing false information to obtain workers' compensation policy at rate lower than what is proper 

Employer Fraud

• Knowingly misrepresenting  the truth to avoid, deny, or obtain compensation on behalf of an employee
• Knowingly lies to discourage or prevent injured employees from pursuing claims
• Misclassification of employees and/or under-reporting wages