Fraud Fighters Weekly: Claim File Intelligence – Detecting Fraud Between the Lines

Welcome back, Fraud Fighters! Before the red flags, interviews, or surveillance videos, every investigation starts in one place: the claim file. It’s more than paperwork—it’s a forensic trail that can expose manipulation, inconsistencies, and coordinated schemes… if you know where to look.

This week, we’re showing you how to dissect a claim file with investigative precision, using patterns, documents, and practical tools to identify fraud early and decisively.

📁 The Claim File Isn’t a Stack of Papers. It’s a Map.

The best investigators don’t just read the claim file—they mine it.

Key Documents to Prioritize:

• First Report of Injury / Loss (FROI)
• Initial medical reports
• Recorded or written claimant statements
• Wage statements / employer reports
• Surveillance referrals and prior adjuster notes
• Payment logs and benefit calculations
• Index searches (e.g., ISO ClaimSearch, EAMS lookup)

Each of these tells a piece of the story—but it’s the inconsistencies between documents that reveal the fraud.

🧠 Red Flags That Hide in Plain Sight

📄 Document vs. Document

FROI vs. Claimant Statement

Time or mechanism of injury changes (e.g., “lifting boxes” becomes “slipped on stairs”).

Medical Report vs. Activity Restrictions

Treating doctor says “no lifting,” but claimant reported “walking dog daily” to nurse case manager.

Witness Statement vs. FROI

Employer says incident wasn’t witnessed, but claimant named coworkers who “saw everything.”

Payment Logs vs. Work Status

TTD benefits issued while the claimant was working elsewhere.

⏳ Timeline Gaps

• Injury reported after termination, demotion, or disciplinary action.
• Medical treatment begins long before or after injury report.
• Claim filed shortly after policy change or coverage start date.

🔎 Advanced Claim File Techniques

1. EAMS Search for Prior Comp Cases (California) Use EAMS Public Search to uncover prior cases filed under the same name, employer, or address. Look for patterns or repetitive body parts.
2. ISO ClaimSearch Essential to detect prior claims with other carriers—including auto, GL, disability, and comp. 🔗 ISO ClaimSearch Info
3. Compare CPT Billing Against Diagnosis Repeated billing of high-cost CPT codes (e.g., 99215, 97799) for low-impact injuries = red flag. Use AMA’s CPT Code Guide for reference. 🔗 AMA CPT Reference
4. Social Media Scan for Claimant Behavior Run a basic OSINT scan for: Public profiles showing travel, activity, or employment. Photos/posts that conflict with the claimed limitations. Tools: Google Advanced Search, Pipl, Spokeo, TikTok/Instagram/Facebook tags

🧰 Investigative Tip: Use a “Claim Pattern Matrix”

Create a one-page grid that compares the following:

• Date of injury
• Date reported
• First treatment date
• First medical restriction
• Claimant’s job status at injury
• Surveillance or social media observations

Inconsistent or suspicious entries will pop out—giving you a fast, defensible argument to dig deeper.

Case Snapshot: The “Weekend Warrior”

A claimant filed a back injury claim on a Tuesday, stating the incident occurred Monday morning. Claim notes revealed he’d just been written up for poor attendance the prior Friday.

The FROI said “bending over to pick up tools.”

The medical intake report said, “twisted while lifting a heavy item.”

A quick social media scan showed him dirt biking on Sunday.

Outcome: Denied for lack of credibility + referred for potential misrepresentation.

📌 Action Checklist: Before You Escalate

✅ Read claim file like an investigator, not a processor

✅ Cross-verify statements, timelines, and codes

✅ Run EAMS and ISO for claim history

✅ Compare treatment to injury scope + job description

✅ Prepare timeline for internal SIU or legal review

✅ Flag for surveillance or field investigation if needed

What’s Next?

In next week’s issue, we tackle Red Flags in Employer-Level Fraud—misclassification, premium evasion, fake job offers, and coverage gaps that create fertile ground for false claims and cost-shifting schemes.

Until then, don’t just read the file—investigate it. The story is already there. You just have to connect the dots.

- Chris