Determining when workers’ compensation ends and how to get employees back to work safely can be a long process. Here’s how to make the transition go smoothly and avoid workers’ comp fraud.
Workers’ compensation benefits continue for as long as an employee is unable to work after a workplace injury. But how do you know when that time ends? What needs to happen to get your employee back to work safely? And what do you do if you suspect fraud?
Discover how to address common employer concerns.
When a doctor clears the employee for work
The process for ending workers’ comp benefits typically requires a physician’s clearance indicating that the employee is fit to return to work. Until this clearance is obtained, the employee can’t return to work and must remain on workers’ compensation.
Once the employee is cleared to work, you’ll need to communicate the details of their role. Ideally, the employee will resume their work duties without restrictions. However, some employees may need to return part time and gradually increase their hours. Others require job accommodations, such as a modified workstation or job duties that meet them where they’re at in their healing process. Each situation is unique and will require flexibility on your part.
A return-to-work program can smooth the transition
Having a formal return-to-work (RTW) program helps employees and supervisors understand the process. An effective RTW program:
- Streamlines communication among all stakeholders involved in the process
- Establishes procedures for requesting job duty accommodation
- Formalizes training for supervisors and managers on handling RTW situations
- Creates additional job opportunities for employees returning from workers’ compensation leave
How an RTW advocate can help you and your employees
RTW advocates, or coordinators, play a key role in supporting your employees’ transitions back to work. These individuals can be employees of your company or external vendors. Your workers’ compensation insurance provider may even offer these services to you as part of your contract.
RTW advocates collaborate with you, your employees and medical providers to design a tailored RTW plan. Responsibilities may include:
- Developing a rehabilitation plan in partnership with occupational health providers
- Verifying pain management strategies with the employee’s physician
- Clarifying work duties and responsibilities with supervisors
- Coordinating with all parties to ensure proper clearance is obtained for the employee’s return
With an RTW advocate, you don’t have to be the sole intermediary. You can rely on the RTW advocate’s expertise and guidance to ensure a smooth process for everyone involved. Additionally, employees have a single point of contact for their questions and concerns.
Light-duty work programs
Light-duty work programs are valuable tools for helping employees reintegrate into the workplace following an injury. These programs allow employees to continue contributing and maintain their skills, even if they are not yet able to perform all the tasks of their regular position. Types of programs include:
- Light duty: Employees are excused from certain tasks but work their regular schedule. For example, an employee who cannot lift heavy items may handle inventory or operate a cash register instead.
- Limited duty: Employees work reduced hours but perform their usual job responsibilities. For example, an employee might work half-days instead of full days.
- Modified duty: Employees receive new tasks to replace those they cannot perform, working their regular schedule. For instance, a bus driver who is unable to drive may help with dispatch duties.
Keep in mind that these programs are not only for employees who have work-related disabilities. These programs must be made available to all employees considered to have disabilities under the Americans with Disabilities Act (ADA).
Other reasons for ending workers’ comp benefits
Other circumstances can also result in workers’ compensation benefits being terminated, voluntarily or otherwise. These include:
- The employee failing to complete the required paperwork
- The employee not following prescribed medical orders
- The employee refusing to participate in or submit to a required medical exam
- The employee giving written consent to stop receiving benefits
- The employee accepting a legal settlement to conclude the claim
- A judge suspending or terminating workers’ compensation benefits
Workers’ compensation benefits may also be terminated if the employee, the employer, the employee’s supervisor, the employee’s lawyer or the employee’s health care provider commits fraud.
Watch out for workers’ comp fraud
Unfortunately, not everyone is honest. Injuries can be faked, and accidents can be staged. Workers’ compensation fraud costs everyone, from employers to insurance carriers. It also puts an undue burden on injured workers with legitimate claims.
Warning signs of fraud
Here’s what to look for if you suspect a false claim:
- There are no witnesses to the incident.
- The injury was sustained late Friday afternoon or early Monday morning.
- The injury was not reported in a timely manner.
- The employee has a history of workers’ compensation claims.
- The employee refuses certain tests.
- The employee refuses modified duty assignments to return to work.
If you suspect a false claim
If you suspect fraudulent activity, consult your insurance agent, attorney or benefits adviser before taking any action against employees. This will shield you from legal mistakes. Many insurance companies offer anonymous hotlines for reporting workers’ compensation fraud, which include special investigation units for handling tips. You can also report it to your state Department of Labor’s fraud unit.
If a claim appears suspicious, it will require an investigation into the circumstances leading up to the incident and the subsequent steps taken afterward. Investigators may:
- Review statements from the employee and witnesses to look for inconsistencies
- Reinterview all witnesses to the accident and resulting injury
- Document strange circumstances at the location, such as questionable spills or debris
- Review any odd aspects of the situation, such as there being no witnesses to the incident or the employee performing work duties outside of normal operational protocols
- Determine if the employee was already exhibiting signs of injury before the reported injury (Individuals have been known to fake workplace injuries to pay for injuries sustained during their free time.)
- Consider surveilling the employee during their time away from work (Individuals may fake injuries in the presence of others.)
- Consult with an independent third party to investigate the claim
- Investigate all supervisors, health care providers and attorneys involved in the claim (Professionals have been known to help employees in workers’ compensation scams.)
AI for detecting workers’ comp fraud
Artificial intelligence (AI) technologies are increasingly being used to combat workers’ compensation fraud. AI systems can analyze large volumes of claims data to identify unusual patterns or anomalies that may indicate fraudulent activity. For example, they can flag claims with suspicious similarities, repeated behaviors or inconsistencies in reported injuries and treatment timelines.
AI-powered tools can also monitor social media and public records for evidence that contradicts reported injuries. They might expose photos or posts showing physical activities inconsistent with the claimed disability. AI is also used to review written statements and medical reports for red flags. By automating these processes, AI enables investigators to improve the speed and accuracy of fraud detection while reducing false positives.
Stay vigilant to protect employees
RTW programs offer significant benefits for you and your employees. These initiatives help injured workers reintegrate into the workforce more quickly, which can enhance recovery, reduce claims costs and boost employee morale. However, scams do exist. By staying vigilant, seeking professional advice, and refining policies, you can reduce fraud and foster a safe and supportive workplace for those employees who truly need workers’ compensation benefits.
For more information on returning employees to work and other risk management services, connect with OneGroup’s Risk Management team.
This content is for informational purposes only and not for the purpose of providing professional, financial, medical or legal advice. You should contact your licensed professional to obtain advice with respect to any particular issue or problem. Please refer to your policy contract for any specific information or questions on applicability of coverage.
Please note coverage can not be bound or a claim reported without written acknowledgment from a OneGroup Representative.
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