Once we receive the scope of assignment and pertinent information regarding the claim, we launch a full background investigation. The background investigation is useful in determining the overall activities and patterns of behavior in order to schedule surveillance around the times most likely to yield the best results. We also confirm the claimant’s residence, monitor social media activities, check civil/criminal records, and search for various type of professional or recreational licenses.

When actual surveillance begins we provide clients with twice-daily, real-time updates so that decisions on how to proceed are done collectively with the employer’s best interest in mind. After the surveillance is completed, small snippets of video are available within X (need to confirm what Brian is comfortable committing to) hours and we begin completing the full report and processing the video for distribution to the client.

How to Submit Information

Type of information we would like to have prior to surveillance:

  • Claimant’s personal information (Name, DOB, SSN, LKA, etc.)
  • Address to which time loss checks are sent (if applicable)
  • Photo
  • Time of work shift
  • List of restrictions/APF
  • Claim Number
  • Any upcoming appointments
  • Why initiating investigation now?
  • Any prior investigations?
  • Acceptable Level of Risk
  • Scope of the assignment

What we need during the investigation:

  • Someone to be available & responsive during the investigation
  • Alternate point or method of contact (just in case)

Possible Outcomes of Investigations:

  • Create a culture of accountability by reducing or eliminating the habitual misuse of disability benefits
  • Willful misrepresentation
  • Return employees back to work sooner on questionable or red-flagged claims by investigating claims early in the process
  • Reduce frivolous expenses by minimizing unwarranted surgeries, counseling, and retraining costs by confirming the legitimacy of the claims.
  • Stop unjustified pensions

Reasonable Expectations

We are frequently asked about our surveillance success rate. Our response is always the same: it depends on how you define success.

To us, a successful case is one where we positively identify the claimant and record their activities for the mutually agreed upon amount of time without incident. This does not mean that the claimant will be active or that their action during the allotted surveillance duration will significantly impact the adjudication of the claim.

However, there is no company better equipped and more prepared to assess the likelihood of surveillance success given the specific nature of your claim. McDonald & Associates will help you use all collected post-investigation information to maximize the return on your investigative dollars.

Red Flags List

  • Suspicious injury
  • Request for time off declined
  • Upcoming layoffs
  • Anonymous tip
  • Malingering
  • Lack of objective evidence
  • Denied or involuntary transfer
  • Negative performance review
  • Early legal representation
  • Resists light-duty
  • Excessive use of prescription medication
  • Difficult to reach during normal business hours
  • No witness or witness is a known acquaintance
  • Approaching retirement or social security age
  • Non-compliance or refusal of treatment
  • Doctor shopping
  • Children under the age of six
  • Injury coincides with known hobbies
  • History of absenteeism or filing claims
  • Monday morning claim

L&I Fraud Check List

The following documentation is required for the department to make a determination regarding willful misrepresentation or fraud. If any of these elements are missing, it may significantly delay the decision-making process.

Upon review of the these elements, the Pension Adjudicator will make a decision as to whether or not fraud can be proven with an overpayment and 50% penalty. They may determine to issue an overpayment instead.

Before submission to the department, please mark all documents related to fraud or willful representation “DO NOT FILM”. The documents should not be placed in the file as investigation information isn’t released to the claimant or their attorney while the investigation is still pending.

An investigation report including:

  • Summary
  • Date of Discovery
  • Copies of time-loss checks (front and back)
  • Statement from witnesses or employers (name, addresses and phone numbers of all witnesses)
  • Interview with claimant (or documentation of attempt to interview)
  • Specific dates fraud occurred
  • Amount of money involved

– If you are contending medical or prescription fraud, include documentation regarding the specific medical/prescriptions and dates involved.

– If you are contending vocational services received are included in the fraud, include documentation regarding the specific vocational services and dates involved.

– If you have video of the worker, please send a description of what the video contains. The department doesn’t require original or copies of videotapes. However, please retain the video. If the order goes to hearing the videos will be needed at that time.

A draft order describing exactly what you are contending will help in making a determination regarding fraud, though it is not required.

FAQ’s

Q. I would like more information but do not want the claimant to think that I question the claim. If I ask for a statement, won’t the claimant become apprehensive?

A. Not usually. Sometimes there is some apprehension when the claimant is first contacted, though this can easily be overcome by the attitude of the investigator prior to the interview. A confrontational setting is not conducive to obtaining a good statement and will be avoided. At first contact, the investigator begins to build rapport with the claimant and is frequently viewed by the claimant as an advocate by the conclusion of the statement.

Q. What kind of information can I expect from a background/activity check?

A. A background check can reveal a claimant’s criminal history, business licenses or self-employment, prior injuries/motor vehicle accidents, any previous claims, activities or hobbies, and bankruptcies or other financial troubles. The objective and tangible nature of these findings can be extremely valuable in the claims management process. A drive-by of the claimant’s residence can also be helpful is deciding whether surveillance would be appropriate.

Q. When should I get a statement on a claim?

A. There are a variety of reasons to obtain a statement early in the claim process. For example, on a back claim, or a strain or sprain where the time loss exceeds roughly 40 days, you should consider scheduling a statement. You may find a statement useful on a back claim even if it appears to be resolved. Often times, the statement proves useful at a later date if an individual files a reopening application or a new claim for another injury. Statements can also provide a good foundation on which to base decisions on future investigative action.

Q. I have a claim that certainly seems to be valid. There were several witnesses, and the claimant had to be taken to the hospital emergency room in an ambulance. Why would I need a statement on this type of claim?

A. A claimant statement can be useful for many reasons other than when someone questions the claim. It can provide you with information related to a pre-existing impairment of the same body part from a previous injury (even one that was not listed on the claim form), or it can alert you to possible problems that have surfaced since the time of the initial injury. The information can be submitted for an independent medical examination, and may also be used to communicate with the attending physician when you suspect that the course of treatment may not be the best for the claimant.

Q. I would like more information but do not want the claimant to think that I question the claim. If I ask for a statement, won’t the claimant become apprehensive?

A. Not usually. Sometimes there is some apprehension when the claimant is first contacted, though this can easily be overcome by the attitude of the investigator prior to the interview. A confrontational setting is not very conducive to obtaining a good statement and will be avoided. At first contact, the investigator begins to build rapport with the claimant and is frequently viewed by the claimant as an advocate for them by the conclusion of the statement.

Q. How can a claimant statement be used to help an independent medical examination?

A. There are several factors that are covered in the claimant statement that should be considered by the IME panel. There will be a clear description of the mechanical process involved at the time of the injury, the symptoms that were present initially, and those, if any, that have continued. In the event of an in-person statement, a detailed account of the current symptoms and physical conditions of the claimant during the time of the interview will also be included in the report. This includes how the claimant moves, sits, bends, and walks. Their demeanor may also be considered, when appropriate. This information can be used and evaluated by the IME panel to aid in their conclusions.

Q. I have a claimant with a minor injury that keeps recurring. I don’t understand how an injury of this type can be attributed to the circumstances that were reported, but the employer feels that the claim should be accepted because the claimant is honest and hasn’t lost any time as a result of the injury. What could a statement do for me on this type of injury?

A. This is a tough judgment call. We are aware of many claims in the past, however, that were initially misdiagnosed by the physician simply because they did not have enough information when they saw the injured worker. We have been able to develop this information during the interview.

An example of this injury type would be tendonitis or carpal tunnel syndrome of the wrist without supporting EMGs. Cervical injuries can frequently cause symptoms affecting the shoulder, arm, elbow, wrist, and/or hand, and are commonly misdiagnosed as tendonitis or overuse syndrome. If an IME panel is made aware of a cervical injury and asked to consider that information, it may result in a diagnosis that is more accurate and allows for proper treatment of the claimant.

Another type of misdiagnosis would be a previous foot or hip injury that had caused the injured worker to walk in a manner that would place undue stress on the knee. While the knee injury may be very real, the cause may be related to a prior injury that would be the responsibility of another party.

Q. One of my claimants denies any previous injury of this type when asked and also on the accident report form. How would a statement help in this instance? Wouldn’t the claimant simply continue to lie to you?

A. If your claimant is lying, then you should probably expect that he or she would continue to lie during the statement. However, there are several points you might want to consider in this situation. For instance, the claimant might not be lying; rather, he or she may not believe that the previous injury is in any way related to the current injury. A statement can help develop this information. On the other hand, if your claimant is obviously being untruthful and continues to lie during the statement, different types of investigation, such as a background check and/or medical record retrieval, can be used to develop further information to either verify or refute the claimant’s reports.