Workers' Compensation Fraud Investigations

It is a felony in Colorado for someone to willfully make a false statement or representation relevant 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 signs of fraudulent behavior may include:

• The injury is reported early on the first work day of the week
• The injury is not witnessed
• The claimant is disgruntled or has been reprimanded
• There is material misrepresentation of facts
• Claimant malingers by prolonging recovery and/or exaggerating symptoms
• Medical services billed seem inappropriate for the type of injury

Additional Types of Fraud

Applicant/Claimant fraud is characterized by:

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

Billing or medical provider fraud is characterized by:

• Inflated/over-billing
• Medical services not rendered

Attorney fraud is characterized by:

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

Adjuster fraud is characterized by:

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

Premium fraud is characterized by:

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

Employer fraud is characterized by:

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

Workers' Compensation Resources