Benefit Claims – Warning Signs

September 11th, 2018 Comments off

Benefit claim fraud and abuse can deliver significant challenges to organizations. Enclosed you will find some helpful information to assist you in identifying questionable claims as well as best practices.

Problematic claims tend to revolve around the following:

  • Fake injuries
  • Exaggerated injuries
  • Old reoccurring injuries
  • Non-work-related injuries – claimed as a work injury

Why do individuals abuse benefit claims?

  • Additional time off
  • Do not like the current job they have
  • Individuals wants modified or light duty work
  • They have another job or interest

Warning Signs

  • The incident was not immediately reported, and there was no explanation regarding the delay
  • No witness to the incident
  • Employee did not seek medical attention
  • Employee refused treatment
  • Employee’s story is inconsistent
  • Diagnosed injury does not align with the incident
  • History of claims
  • Medical notes are vague and do not provide restrictions/limitations
  • Employee is hard to reach
  • Return to work meetings, and appointments are often missed
  • Restrictions seem excessive – based on the nature of the injury
  • Sudden change in medical providers
  • Employer is seeing similar claims from the same doctor
  • Employee is rumoured to have a side job or other interests outside of work
  • Accident occurs before a layoff, strike, long weekend or holiday
  • Accident occurs before termination or discipline
  • Employee can perform tasks outside their restrictions when not at the workplace
  • Employee engages third-party representation immediately

When a claim presents the above warning signs, the following should be considered:

  • Conduct a detailed internal investigation into the incident that includes the employee’s social media and online activity (before the employee ‘goes dark’)
    • Most people post all aspects of their lives online (Cost range $75-$375 per file)
  • Challenge validity of claim quickly – claims are often rubber stamped because the employer does not contest
  • Get restrictions immediately
  • Offer modified duties as soon as possible to get them back to work
  • Be prepared to manage the claim aggressively – the employee is banking you will give up
  • Work with other stakeholders
  • Engage surveillance when the employee is not participating in any return to work programs
    • ($1200 to $1500 per day)

Steps to consider after social media or surveillance investigation:

  • Meet with the employee
  • Ask them questions you know the answer to:
    • Can you drive?
    • Are you able to do yard work?
    • Are you still unable to stand for longer than 10 minutes?
  • If the employee is deceitful, it lends credibility to your case
  • You may elect to re-offer modified duties:
    • That match the activity observed
    • Goal is to have the employee provide written documentation that they cannot perform these duties
  • You may wish to engage a second round of surveillance
    • The feedback received did not align with observations
    • Found employee acting outside their restrictions
    • Show the employee the evidence
    • This often garners an immediate return to work

The test of reasonability should always be considered. During any proceedings, the employee will attempt to paint the employer in a negative light. You need to be able to demonstrate all the steps taken to have the employee return to the workplace. Ensure you do not appear heavy-handed in your approach.

Does Your Claimant go Dark on You?

August 29th, 2018 Comments off

By: Sophie Cranley, Risk Mitigation Specialist at AFIMAC Global

AFIMAC and our technology partners have undertaken industry research in an attempt to assist those managing claims to gain the most from our social media intelligence reports.

From our findings, at least 40% of subjects ‘go dark’ within a few days of the claim being reported!

The results have been validated by numerous lawyers who have confirmed that this is a tactic they deploy with their client to prevent anyone from utilizing open source social media intelligence that could be used by the industry to mitigate spiraling claims costs/associated fraud risks.

Clearly this is not an acceptable situation, however, with early intervention, there is an opportunity to change the landscape and reduce claims costs.

Remember the old adage – strike and strike fast!

Today nothing is this more critical than social media background reports. Structured background reports and financial records live on forever, but this is not the case with social media.  Not acting quick enough will deprive you of valuable intelligence in establishing your case.

Are you prepared to allow your claimant to ‘go dark’ on you?

To obtain a sample report or learn more, please email: scranley@afimaccan.com

 

Checklist for Cargo Theft Prevention

June 19th, 2018 Comments off

Key Statistical Indicators for the World’s Internet, Mobile and Social Media Users

May 17th, 2018 Comments off

Click to learn more about AFIMAC Social Media Investigations

Behind an Investigation

January 3rd, 2018 Comments off

When providing protection support, advanced planning is key to its success. Social media and open source intelligence is becoming increasingly important. We are conducting more investigative research on social media than ever before. Many times individuals post content that raises threat levels. Although they do not always act upon them, it is crucial to take them seriously to mitigate any possible risks.

Just like any security advance, you need to have a plan. Who is the person of interest? What information do you have about the individual? We use technology that allows us to complete an automated search of an individual’s social media content. Once this is complete, we can analyze and further investigate the data found and provide recommendations regarding any potential threat. This information is then shared, giving protection agents the necessary information.

The Security Guard

August 30th, 2017 Comments off

I have worked in the security industry for almost 30 years. Many times security guards get a bad rap when things go wrong but for the most part, you will find that they are some of the hardest working people.

I attended a concert the other night and saw a drunk individual taunt a guard. The guard remained composed, professional and utilized verbal de-escalation techniques. A lady serving drinks also witnessed this individual’s actions and walked over, grabbed him by the arm and asked him to stop. The man snapped to his senses and exited.

Great outcome. The situation was de-escalated without police or physical intervention. The right mindset, words and touch successfully steered this individual to pause and make a better choice.

The next time you see a guard, he or she is one of the people working hard every day to keep us safe.

Practice Makes Perfect

June 27th, 2017 Comments off

training_class

How many times have you sat through a boring training session and asked yourself, why am I here? Adding real life situations and hands-on training is a breath of fresh air.

I just completed my CPI Instructor course for Non-Violent Crisis Intervention and found that the hands-on and practical training very useful. You can only learn so much sitting in a classroom. It was also interesting how everyone offered different perspectives based on his or her work environment. There were people from various industries such as ER nurses to teachers that dealt with behavioural issues.

Next time you conduct a training exercise, get people up on their feet and subject them to real world situations. Not only will the class be engaging, but you will also end up with students that fully grasp what you are teaching.

Has the Whole World Gone Mad?

April 28th, 2017 Comments off

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Each week, we are contacted to provide protection agents for termination, workplace violence, corporate events as well as security details.

Over the past few years, we have noted a considerable change in people’s behaviours. No longer are people compliant or respectful of security personnel. It seems as if more and more individuals are looking to engage security and escalate the situation to the point of physical confrontation.

We recently faced a situation where a small group of protesters attended a client’s location. They were allowed to communicate their issues and then asked to leave by our security agents. The situation quickly escalated. All but one of the protesters complied. The lone remaining male protester refused to leave. Law enforcement was contacted, and the individual was contained in the lobby area. The situation attracted a crowd of onlookers videotaping the event.

The moment the police arrived the individual immediately became aggressive. The police did their best to de-escalate the situation and have the person exit the site, but he refused. The police then advised the protester that he would be arrested and handcuffed. Upon hearing this, he immediately assaulted one of the officers. Backup was called, and eight officers arrived. The man was arrested.

In my mind, this was a staged event. The individual went to the location with a plan and had no intention of complying.

Security and law enforcement can no longer assume people will comply. Individuals are becoming more aggressive than in the past.

The other disturbing element is the social media world we live in. The video captured in this case did not show all the attempts by security, protection agents and police to resolve the situation. Instead, the public saw two police officers aggressively arresting a man with eight additional officers present.

 

 

Christmas Blues – Workplace Violence

December 19th, 2016 Comments off

For many, the Christmas season is not filled with happiness. Remembering lost loved ones, and feelings of depression and loneliness can lead to behaviours that may be a cause for concern.

There is an increase in workplace violence during the months of December and January. Employers need to watch for signs that individuals may not be coping well.

Many firms also find themselves making year-end decisions related to employment levels. Downsizing is never a pleasant experience. During the Christmas season, it is important to pay particular attention if you are considering staff reductions. Individuals, who are already stressed, can feel a job loss is just one more thing they cannot handle.

You also need to take into consideration employees who no longer work for your company. Often the Christmas season will trigger individuals to act out. Many feel their job loss has resulted in their inability to provide gifts for loved ones. We have assisted numerous firms over the years where a terminated employee has acted out during the Christmas season, often targeting managers, supervisors, and co-workers.

Regardless of the season, you should pay attention to key dates that may be trigger points such as birthdays, date of hire or termination, and family members’ birthdays.

The office Christmas party can also be cause for concern. Bill 168 obligations are not just within your four office walls. Employers have a responsibility to ensure company events are treated in the same manner as in day-to-day operations. This recent article from HRM Canada may be of interest.

 
If you would like a complimentary copy of our Workplace Violence Guide, Click Here.

Online Bullying and Harassment

November 28th, 2016 Comments off

Today more than ever, online bullying and harassment continue to occur on social media. We have all heard of examples involving children being bullied. In some cases, these situations have been very high profile, receiving national media attention. Unfortunately, they do not just involve kids. Online bullying and harassment have become problematic for employers.  Most often online harassment is peer to peer. Customers and the public can also target your employees.

Recently an arbitrator ruled that the Toronto Transit Commission must investigate and do more to protect their employees from online threats. Police officers involved in the Standing Rock pipeline protest have become targets of online threats. It has been reported that their family members have also been targeted.

Investigating online threats can be challenging and time-consuming. LexisNexis recently reported that 75% of individuals polled indicated they had no formal training on how to conduct an online investigation. Most were self-taught.

The increase in online harassment and bullying is likely to continue. With that being said, you will need to develop a plan to investigate. Important considerations are as follows:

  • Who is making the threats?
  • What is their motivation and why?
  • What is the nature of the threat?
  • How often and aggressive are the threats?
  • What steps will I need to put in place to protect the individual being targeted?
  • What local laws exist to protect against online threats?

To complete an assessment, you will need to gather social media posts and complete a review. The collection of information can be the most challenging and time-consuming part of the process.

Today many techniques and tools exist that a qualified open source investigator can unearth. To learn more, please feel free to contact me jrovers@afimacglobal.com

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