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A Refresher on Workers' Compensation Claims-Related Fraud

Posted By Chris Prewit, Monday, February 26, 2018

By Samuel King, Vice President of Fraud Investigations, EMPLOYERS

In November 2017, Sam King, vice president of fraud investigations with EMPLOYERS (NYSE:EIG) presented a continuing education course to the Independent Insurance Agents of San Antonio on workers’ compensation insurance fraud. Following are key takeaways from the presentation and best practices for agents to help their clients start 2018 off strong and protect themselves from fraud.

What Are the Different Types of Fraud?

While most insurance claims are legitimate, studies indicate that 10 percent or more of all property/casualty insurance claims are fraudulent. In San Antonio, 1,624 workers’ compensation fraud cases were received by the Texas Department of Insurance in 2016. [1]

When it comes to workers’ compensation insurance, there are two different types of fraud that can directly impact businesses: “claim” related fraud and “policy” related fraud. Policy-related fraud occurs when either a policyholder or insurance agent misrepresents information about their business to obtain a workers’ compensation insurance policy or a policy at less than the appropriate cost. 

Claim-related fraud can be perpetrated by the claimant, a medical provider or vendor, or the policyholder during the workers’ compensation claim process. It frequently occurs when someone tries to gain a workers’ compensation insurance benefit by falsely stating that an injury or illness occurred at work, or by exaggerating an existing injury or illness.

While both types of fraud are serious crimes and can negatively impact the workers’ compensation system, more than one in 10 small-business owners are concerned an employee will commit claim-related fraud. [2]

Workers’ compensation claim-related fraud costs the workers’ compensation system billions of dollars every year and can lead to higher insurance costs for law-abiding businesses.

How Can Agents Help Policyholders?

By helping policyholders understand workers’ compensation claim-related fraud, including how to detect and prevent it, agents can provide a value-added service and ultimately strengthen their client relationships.

To educate policyholders, agents need to be aware of the warning signs of claim-related fraud, basic procedures for addressing it and the documentation required to report it to the proper authorities.

While there is no silver bullet when it comes to identifying claim-related workers’ compensation insurance fraud, there are patterns that can help spot fraud. Experience shows that when two or more of the following “red flags” are present in a workers’ compensation claim, there is a chance the claim may be fraudulent and the employer should notify the agent or carrier.

·        Monday morning (or start of shift) injury reports. The alleged injury occurs first thing on Monday morning, or the injury occurs late on Friday afternoon but is not reported until Monday.

·        Employment change. The reported accident occurs immediately before or after a strike, job termination, layoff, end of a big project, or the conclusion of seasonal work.

·        Suspicious providers. An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.

·        No witnesses. There are no witnesses to the accident and the employee’s own description does not logically support the cause of the injury.

·        Conflicting descriptions. The employee’s description of the accident conflicts with the medical history or injury report.

·        History of claims. The claimant has a history of suspicious or litigated claims.

·        Treatment is refused. The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.

·        Late reporting. The employee delays reporting the claim without a reasonable explanation.

·        Claimant is hard to reach. The claimant does not respond promptly to messages or claimant is hard to reach.

·        Changes. The claimant has a history of frequently changing physicians, addresses or jobs.

Suspicions of potential fraud should be reported immediately to the workers’ compensation insurance carrier or the Insurance Fraud Unit of the Texas Department of Insurance for further investigation. Policyholders should gather as much information as they can to support the claim, including identifying witnesses and misstatements. Additionally, they should get in touch with their workers’ compensation carrier’s claims department and special investigations unit or fraud investigation department so the carrier can begin investigating.

If the claim results in a criminal conviction, the insurance agent can help their client get the fraudulent claim, or the fraudulent portion of the claim, removed from the policyholder’s experience rating.

Workers’ compensation claim-related fraud can be a costly crime. By taking the time this year to remind policyholders of the “red flags” of workers’ compensation fraud and how to prevent it, agents can build a relationship with their clients and demonstrate the value they bring to the table.



[1] Texas Department of Insurance, Division of Workers’ Compensation Fraud Unit. Retrieved from: https://www.tdi.texas.gov/wc/smo/wcfraud.html

[2] EMPLOYERS, More than 1 in 10 Small Businesses are Concerned Their Employees Would Commit Workers’ Compensation Insurance Fraud, Study Finds. Retrieved from: https://blog.employers.com/EMPLOYERSBLOG/tabid/165/ArticleID/219/Default.aspx

 

Tags:  advice  best practices  fraud  Insurance  litigation  strategy 

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Business Risk Management in the Age of Increasing Workplace Violence

Posted By Chris Prewit, Monday, December 4, 2017

Article written by Robert Crosby, Executive Director of Independent Insurance Agents of San Antonio

It seems that every week we hear of another incident of violence in our society. Most recently, the shooting at the First Baptist Church in Sutherland Springs, Texas, reminded us that no place is safe from acts of violence. The frequency of these incidents seems to be increasing and the statistics are frightening and sobering.  

According to the Bureau of Labor Statistics, workplace violence is the second leading cause of death in the workplace. This can be one of the most frightening exposures for a company and just one incident can threaten the very survival of the company. The FBI reports that from 2000 and 2015 the number of annual active shooter incidents increased by 2000 percent. With these types of statistics, business owners must consider the ramifications of an incident in their place of business.  

According to CHUBB Insurance, there are several factors to consider when you are deciding whether or not to add workplace violence expense insurance coverage to your insurance portfolio. Expenses incurred in the aftermath of a workplace violence incident are often staggering and unforeseen. These expenses can include crisis management, independent security, employee counseling, public relations, and salaries for victim employees and for replacement employees, medical care, and rest & rehabilitation for employees.  

Additionally, loss of business income is a very real concern. Many business owners may believe that they have adequate insurance coverage with their General Liability insurance policy. However, Commercial General Liability may only respond if the business is considered legally liable for the incident. Business Interruption coverage will only respond if there is damage to your building. If you have to close your doors for a period of time while your staff recovers emotionally or physically, you may not be able to rely on Business Interruption coverage as a source of income replacement while your doors are shut. Workmen’s Compensation coverage very possibly will not cover a non-job-related injury in the workplace. The expenses to add temporary or new permanent employees is another non-covered expense.

Terrorism Coverage only covers events that generate at least $5 million in Property and Casualty losses and a terrorist attack certified by the U.S. Secretary of the Treasury, the Attorney General and the U.S. Secretary of Homeland Security. The September 11 attacks are the only incidents to date that meet those parameters. Most policies do not provide coverage event crisis response teams, victim counseling or funeral costs for employees, customers, visitors, and others.

Every business should consider assessing the risks that their specific type of business may have but there are certain businesses that have an increased risk of violence. Any company that deals with the public, exchanges money, delivers goods and services, works with unstable or violent persons, operates at night, or plans to reduce their workforce with layoffs or outsourcing of operations have an increased chance of a violent incident.  

There are policies in place through various carriers that provide for coverage in areas of third-party liability, crisis mental health specialists, independent forensic analysis's, funeral expenses, public relations, victim employees’ salaries and replacement employees’ salaries, informant rewards, risk assessment and response training and business interruption just to name a few.

A comprehensive risk assessment of your specific business is critical as coverages can vary widely.  Some policies have limitations depending on employee size, types of weapons and other incident specific particulars.

So where do you start? – take time to review your current coverages with your independent insurance agent and have your agent do a complete assessment of your company’s hiring and training practices, and workplace protection policies.

Recovery from any workplace violence incident is very difficult.  The better prepared a company is the more quickly the recovery process becomes and a return to normal operations is more successfully accomplished.

Tags:  advice  articles  best practices  business  Insurance  World Issues 

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7 Traits of True Insurance Leader

Posted By Chris Prewit, Tuesday, August 29, 2017
Article originally written by Brent Kelly

 

The idea of leadership is often misunderstood, especially in the insurance industry. In my 15 years of being an insurance agent, I rarely thought of myself as a leader. In my mind, I was just an agent. What a terrible mistake. That’s because I didn’t fully understand the true definition and role of leadership. I thought that “true” leadership was awarded, appointed or assigned. I thought that leadership only came with an impressive title or position. The reality is that none of those things are true. If you have ethical influence with those around you, then you are a leader. If you don’t’, no title or position will make up for your lack of influence. As the proverb says, “He who thinks he leads but has no followers is simply out taking a walk.” Leadership comes in various shapes and sizes. Every day you could be leading your family, your team, your prospects, your clients, your community, or your neighbor. Leadership is influence. If leadership is influence, what are the traits that can help you become a better leader regardless of whether you are a CEO, VP, agency principal, sales manager, producer, or service representative? The follow are seven traits of authentic insurance leader:

  1. Character- The first test of any true leader is how they lead themselves. Before you can lead and influence anyone else, you must first be able to lead yourself. Character itself is influence.

  2.  Relationships- In today’s fast and technological world, building authentic relationships is often overlooked. Strong relationships are foundational for any leader. Relationships are influence.

  3.  Knowledge- Knowledge won’t make you a leader, but without it you can’t lead effectively. An influential leader has vision, an understanding of facts, and keeps up to date on industry changes. Knowledge is influence.

  4.  Intuition-Intuitiveness is hard to define, but is vital for any leader. You must know more than just facts and data to lead. You must be able to trust your “feelings” and act when your get is telling you that there is low energy, poor timing, or lost momentum. Intuition is influence.

  5.  Experience- The more you experience, the more you can share. However, you can’t just experience each day; you must also spend time in reflection to turn that experience into insight. Evaluated experience allows you to add more value to those around you. Experience is influence.

  6.  Past Success-Every win you have in life and business builds credibility and influence. People want to know what you have done and what you have achieved. Small wins build into larger wins and give you momentum. Past success is influence.

  7.  Ability-Your followers want to know that you can help them. How can you make their lives better? Demonstrating your ability and willingness to serve others increase your influence. You may be helping an employee, solving a problem for your client, or adding premium growth with a partner company. Ability is influence.

Leadership is often misunderstood, but that does not reduce its impact. If you have influence, you are a leader. Apply and improve upon these seven traits of leadership to your life and business and increase your influence. The world and the insurance industry needs our leadership now more than ever.

Tags:  advice  best practices  careers  leadership 

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Exit Strategy: Succession Planning for your Small Business

Posted By Chris Prewit, Tuesday, August 1, 2017

Original article published by the Frost Brokerage Service

You have worked hard and overcomed obstacles to build the business you always dreamed was possible. With skill, ingenuity, even a little luck, you’ve succeeded in doing what few people achieve. While you’ve been concentrating on marketing issues, training and recruiting employees, and oh yes selling insurance, you probable may not have given much thought to the time when you will no longer be part of your business through retirement, becoming incapacitated or even dying or leaving for another reason. But business advisors say that neglecting to plan your own exit strategy would be a costly mistake. Why should you plan? Without succession planning, small business owners put their own future and the future of the business they have worked hard to build at risk. Lack of a comprehensive plan can have a negative impact on an owner’s future options, such as the business assets and value, employees and customers, tax obligations, even the businesses very existence. The stakes are so high that most of family and small businesses without a plan fail to make the transition because no one is willing or able to take on the ownership role. That is a sobering thought for small businesses owners who expect to hand over the business to a family member or trusted employee or who will need to sell their business at the best price to fund a future retirement or other enterprise. Perhaps it’s surprising, then, that only 50 percent of American small business owners have a transition plan, according to the Exit Planning Institute, and most of those with plans haven’t documented or communicated them to others. That is a critical omission and ideally, business owners should plan for their exit from the beginning, even if they don’t anticipate leaving for decades. There are three pillars of planning. Succession planning is not a cookie-cutter process with one model that fits everyone perfectly the professional advocate preparation based on “three key pillars”.  You must maximize the value of your business, prepare yourself personally and financially, and plan the act of your life.

Maximize the value of your business, what does that mean? Like many owners, you may want or need to sell your business someday. That can be complicated. Statistically, only 20 to 30 percent of small businesses on the market sell, and approximately 75 percent of owners who do sell profoundly regret the decision within 12 months. Business owners may have unrealistic assumptions about the value of their business. Believing that healthy sales and balance sheets automatically equate to a big return when the company is sold is not realistic. Potential buyers may not agree, especially if they can’t see concrete evidence of value. If selling your agency is part of your plan, ensure that your company is in the strongest possible position, financially and operationally. You will want to minimize areas of risk for your agency, such as preparing others to step into leadership roles, ensuring that essential employees want to stay when you leave, and diversifying your customer base and carriers.

Prepare yourself personally and financially with professional help. Planning a successful exit is a complex and sometimes delicate undertaking that can require the skills and specialized knowledge of multiple professionals. As much as 90 per cent of a typical business owner’s net worth is tied up in the agency and that can complicate the planning process. That’s why an owner should form a team of knowledgeable professionals to help the owner navigate all the issues. The professional recommends the services of a certified exit planning advisor, an attorney, tax advisor, CPA, banker and wealth advisor to review the owner’s personal assets, help explore all available options and ensure the owner’s wishes are accommodated.

Plan the third act of your life.

Building a business means decades of your life’s passion, identity and personal self-worth are linked to your agency. Although leaving that behind can bring changes in family relationships, personal wealth and free time, new realities may not be all you expected. Many agency owners incorrectly assume that they will retire happily to a life of golf, extensive travel and time with the grandchildren. Life’s third act often requires more for lasting fulfillment. Life coaches can help the retired owner determine the owner’s passions and match them with opportunities, such as serving on corporate or nonprofit boards, starting family foundations or even entering into other business ventures. This is your life enjoy it, you deserve it!!!

Tags:  advice  business  careers  retirement  strategy  succession planning 

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Career Path

Posted By Chris Prewit, Wednesday, July 5, 2017

Few of us take the time to actually plan our careers. Too often, a career is something that just seems to happen to us. We take a job, and five years later we discover that we have a “career”. The career planning process is relevant and valuable whether you are in the first year of your first job, or 20 years into your career. A good career path can help you make your career happen instead of just settling for what shows up

Current thinking on career management emphasizes five possible career directions. Understanding these strategies can help you in your career planning process since some certain types of movement are available in some jobs and not others.

  • Upward movement-the traditional conception of career growth. Typically an option for larger companies with multiple layers of management.
  • Downward movement-sometimes a positive career move when you have been promoted or hired into the wrong role and you have a mismatch of values or competencies for a position.
  • Lateral movement-movement from one job type to another.
  • Moving on-sometimes career goals can best be realized by moving on to a position in another organization.
  • Enrich the current job-involves developing yourself and expanding the duties in your present job. This is a traditional path in smaller P & C agencies.

The following is a simple four step process to keep your career path on track.

  1. Setting my values compass is the first step. A good compass will help you find True North when there is no visibility. Likewise, having clearly articulated values that tie to your key life roles and goals allow you to identify what’s truly important and to orchestrate your activities into big accomplishments over the long run, such as completing the education and work experience required to obtain a more challenging and higher paying position.

  2. After you have established your value compass direction, then you set out to map a five year career path. Competencies are the underlying characteristics of a five year career path. Knowing what you are competent of doing will give you direction. Some examples of competencies are easily identifiable such as skills and knowledge. Less obvious examples of competencies include items like behavioral traits/preference, motives, social roles. They can be found in position descriptions, through personality and trait testing like the “Omnia Profile”

  3. Providing provisions for the journey. It’s time to really dig in and be with honest yourself. Which competencies have you mastered and which you need to develop in order to start you journey and to successfully navigate your five year plan.

  4. Staying the course, the following are development methods to keep your career compass pointed true North.

Here are a few recommendations on where to start:

  • Designations, for example CIC, CRM and CPCU.
  • Classroom and insurance company training classes
  • Online training
  • Coaching/Mentoring
  • Cross-Training
  • Challenging Assignments
  • Volunteer Projects
  • Reading

Best wishes and good luck on your career journey!

Tags:  advice  best practices  business  Career planning  careers  industry 

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