Definition of Fraud

Fraud occurs when a person knowingly or intentionally conceals, misrepresents, or makes a false statement to obtain workers’ compensation benefits or insure coverage, or otherwise profit from the deceit. Fraud ranges from a business under reporting worker hours to providers billing for services not performed, to an injured worker collecting undue time-loss compensations benefits.

Employer Fraud

  • Intentional failure to secure coverage for employees
    • An uninsured employer discourages an injured worker from filing a workers’ compensation claim
    • An employer falsely claims employees are independent contractors
  • Misrepresenting the amount of payroll to North Dakota Workforce Safety & Insurance (WSI)
  • An employer understates payroll in an effort to save on premium costs
  • Employers paying cash wages
    • An employer reports fewer workers than actually employed
  • Reporting wages under an incorrect rate classification to reduce premiums
    • An employer continually underbids other contractors, possibly saving money by reporting employees in lower-rated classes

Injured Worker Fraud

  • Filing a claim for an injury not sustained at work
    • The worker delays reporting the claim without reasonable explanation
    • The worker's description does not logically support the cause of injury
    • The accident occurred immediately before job termination, layoff, or end of seasonal work
  • Working while receiving wage-loss benefits and not reporting the income received
    • After the injury, the injured worker is never home
  • Misrepresenting their physical condition to WSI  and the medical provider
    • The injured worker refuses a diagnostic procedure to confirm the nature or extent of injury
    • The injured worker is seen engaging in activities outside the restrictions outlined by their medical provider

Medical Provider/Attorney Fraud

  • Inflated billing for services
    • Amount billed does not correspond to services rendered
  • Billing for services not performed
    • Charges submitted for payment without supporting documentation