| Summer 2010


Help Us Protect Your Premium Dollars

By David Wylie • senior editor

Tommy Jones is 6’3" with broad shoulders, gray hair and a booming voice. He’s the kind of guy who rarely goes unnoticed.

So Jones, a former cop who joined Texas Mutual’s fraud investigation team 14 years ago, was in a tough spot the night he planned to stake out a claimant.

Jones suspected the man was collecting workers’ comp benefits and earning an income playing the drums in a heavy metal band.

This kind of scam, called double-dipping, is illegal. Unfortunately for Jones, suspicion without evidence isn’t enough to prove fraud.

"I needed to get the guy on camera in the act, but there was no way I could walk into that concert alone," said Jones. "Those people were half my age. I definitely would have raised some eyebrows."

Enter Jones’ co-worker, Lora Reeves. Reeves is an adjuster who administers benefits to injured workers. When Jones asked her to help him with the stakeout, she had her doubts.

Fraud steals $7.2 billion a year from the workers’ compensation system and honest employers. You don’t have to be a private eye to combat fraud. You can start by simply learning what it is.

"I knew my job description included ‘other duties as assigned,’ but I never dreamed I’d find myself on an undercover stakeout," joked Reeves. "I was a nervous wreck, but Tommy was cool and collected."

Jones put a video camera in Reeves’ purse, and the two went to the bar where the claimant was playing. It wasn’t long before they had the evidence they needed.

"The guy was even nice enough to take off his shirt so we could see his rib brace," said Jones. "Then, he took the brace off and kept playing."

Jones is one of 24 members of the Texas Mutual special investigations division (SID). In 2009, he and his co-workers saved, identified or recovered $16 million through our zero tolerance for fraud program.

They do a pretty good job of protecting your premium dollars on their own, but they can always use your help.

Don’t worry; they won’t ask you to put on a disguise and slink around dark alleys with a video camera. You can start by simply learning what fraud is.

Fraud is lying for financial gain. Claimant fraud happens when workers fake or exaggerate injuries, collect benefits for injuries that were not work-related, or collect benefits after returning to work.

Some activities that injured workers engage in are easy to mistake for fraud. For example, workers may take longer than expected to recover. If there is not a valid medical reason for the delayed recovery, the worker may be malingering. Malingering does not necessarily equal fraud.

Employers can follow their injured employees’ work status by contacting their workers’ compensation specialist for a copy of DWC Form-73, Texas Workers’ Compensation Work Status Report.

As soon as the injured employee returns to work in any capacity, the employer should notify the adjuster assigned to the claim. The adjuster will reduce the employee’s benefit payments or discontinue the benefits accordingly.

Some investigations hinge on evidence or testimony provided by the claimant’s co-workers. Hector Ruiz of Ruiz Protective Services Inc. has gotten his employees’ buy-in by putting fraud in terms they can relate to.

"We make them fully aware of the cost of our insurance program and how it impacts everyone in the company," said Ruiz. "And then we make them fully aware of what fraud costs us as a company and them as employees."

Employers and their employees can reduce the bill by learning the red flags for fraud and reporting suspicious activity immediately. If you recognize two or more of the red flags below in a Texas Mutual claim, call our Fraud StoppersSM program at (800) 488-4488, or email fraudstoppers@texasmutual.com.

If you provide a tip that leads to an arrest or an indictment, you may be eligible for a reward of up to $1,000:

  • Tip from a credible source
  • New or disgruntled worker
  • No witness to alleged injury
  • Inconsistent or illogical description of incident
  • Injured worker difficult to contact
  • Injured worker acts upset when contacted
  • Suspicious injury that happens on Monday or Friday

Your role does not end when you report your suspicions. If we open an investigation, we need you to notify us if new evidence surfaces or the claimant’s work status changes. We might also ask you to attend hearings and allow employees to testify.

You can visit the Fighting Fraud section at texasmutual.com to read about our fraud-fighting success, get a sample zero tolerance for fraud policy, and download a free Fraud StoppersSM poster to display around your workplace.

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