Medical Treatment Red Flags Triggering Case Management Intervention

  • The employee gives completely different versions of the accident to the employer, the adjuster and the doctor.
  • The injured employee is not at home during the normal workday.
  • The employee is always sleeping when the adjuster calls or cannot be disturbed.
  • The employee’s spouse is not working and is drawing workers’ comp indemnity benefits, Social Security disability payments, welfare or unemployment insurance, and the employee wants the same lifestyle.
  • The employee asks about a settlement early in the claim process.
  • The employee fails to report other work income while drawing indemnity benefits.
  • The employee took excessive time off just before the injury.
  • The Social Security number used by the employee belongs to someone else.
  • The employee applies for Social Security benefits before the injury occurs.
  • Income from workers’ comp, disability or other sources exceeds the employees prior after-tax income.
  • The employee protests about returning to work and never seems to improve.
  • All the injuries are subjective – pain without trauma, soft-tissue, emotional.
  • The employee changes doctors frequently (“doctor shopping”) or changes doctors when released to return to work.
  • The employee has excessive treatment for soft-tissue injuries.
  • The medical treatment reported by the employee is different from the medical care stated in the medical reports.
  • The nature of the medical treatment changes from one body part to another after the employee has been treating for a while.
  • The employee misses medical appointments.
  • The employee fails to show up for an independent medical examination.
  • The employee refuses or delays diagnostic testing.
  • There are whiteouts, corrections or erasures on medical forms submitted by the employee.
  • Pain is exaggerated.
  • Invalid or inconsistent effort is reported on the functional capacity evaluation.
  • The injury relates to a preexisting medical condition or health problem.
  • The length of recovery is excessive for the nature of the injury.
  • The medical reports reflect “muscular,” “tanned” or other adjectives that reflect that the employee is in good health.
  • The employee is unable to work because of the injury but is seen painting her house, mowing the lawn, carrying heavy objects, etc.
  • The employee has a high-risk hobby or does other activities involving considerable physical exertion.
  • Surveillance reflects physical activity greater than what is reflected in the medical reports.
  • The employee is unusually pushy to settle the workers’ comp claim.
  • The employee has extensive medical knowledge but no training in the medical field, or uses extensive insurance terminology but has no work experience in the insurance field.
  • The employee is a part of a group of employees using the same doctor and the same attorney for their workers’ comp injuries. 

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