Workers' comp fraud is a felony and not a victimless crime. Fraud increases business costs, consumer prices and inhibits job growth.
Help NYSIF fight fraud workers' comp and disability benefits insurance fraud. If you have information regarding any type of fraud against NYSIF, you can anonymously report fraud online or call 1-877-WCNYSIF (926-9743).
Here are common types of workers’ comp fraud:
Claims Fraud Red Flags
- Employment History
- - New hire has history of injury claims; injury is reported following disciplinary action, demotion, being passed over for promotion, or notified of a layoff. Claimant has an extensive history of failure to hold a job.
- Personal History
- - Worker has financial difficulties, domestic problems, engages in high-risk leisure activities, or has recently purchased personal disability insurance. Worker took unexplained leave or excessive time off before the injury.
- Circumstances of Accident
- - Accident occurs early Monday, on return from vacation, was not immediately reported, or is not witnessed. Worker’s accident description or injury is inconsistent with witness accounts or normal job duties. Injury coincides with a strike, layoff, plant closure, job termination, completion of seasonal, temporary work, probationary period, or notice of downsizing or relocation. Injury relates to a pre-existing injury or health problem.
- Claimant Behavior
- - Claimant is difficult to contact,uses the addresses of friends or family, uses post office boxes, has no permanent address, or changes addresses frequently. Family members know nothing about the claim, or are evasive in discussing it.
Provider Fraud Red Flags
- Inconsistent Treatment
- - Treatment is inconsistent with injuries originally reported by the claimant, or claimant’s description of medical treatment is significantly different from the medical report. Claimant reports very brief visit, when medical report and billing reflect a lengthy visit. Claimant cannot describe diagnostic tests or treatment included in provider billing. Diagnostic tests are performed by a vendor not in proximity to the doctor’s office or the claimant’s home. Claimant reports receiving medical treatment from non-medical personnel.
- Excessive Treatment
- - Excessive treatment of soft tissue injury. Multiple referrals to specialists in cases usually handled by one doctor. Claimant receives frequent treatment from a medical facility far from home.Doctor ordered unnecessary diagnostic testing.
Policy Fraud Red Flags
- Application Fraud
- - Applicant misrepresents having had prior insurance with NYSIF to avoid paying past due premium. Applicant misrepresents the nature of business, number of employees and/or payroll.
- Premium Fraud
- - Policyholder misrepresents amount of payroll, number of employees and/or nature of employment.
- Broker Fraud
- - Broker misrepresents client's nature of business with or without the knowledge of policyholder.
- Certificate Fraud
- - Business presents forged certificate of workers' compensation insurance to obtain mostly subcontracting jobs while workers remain uninsured, leaving the certificate holder liable. See "Verify Coverage of All Subcontractors".