Fraud Fighters Weekly: The Investigator’s Toolkit

Welcome back to Fraud Fighters Weekly! Today we’re getting tactical. If you’re investigating a claim—whether it’s workers’ compensation, disability, personal injury, or auto—your ability to detect fraud hinges on solid processes, credible sources, and timely action. In this issue, we break down how to build an investigation from the ground up, with practical steps and tools that seasoned fraud fighters use daily.

🕵️♂️ Step 1: Dig into Claim History

Why it matters: Fraudulent claimants often have a pattern. Your first step should be verifying whether this is a one-off incident or part of a string of suspicious claims.

🔎 Tools to Use:

• EAMS Public Search (California Workers’ Comp)
• ISO ClaimSearch (ISO/Verisk)
• WCIRB’s X-Mod History (California)

⚙️ Step 2: Gather and Verify Evidence

No fraud case is built on suspicion alone. Strong investigations rely on verifiable facts.

What to Collect:

• First Report of Injury (FROI)
• Medical documentation
• Surveillance footage
• Witness statements
• Claimant statements (recorded or signed)

What to Do:

• Cross-reference injury timelines with payroll records, job duties, and shift schedules.
• Analyze medical reports for inconsistencies (e.g., diagnosis not aligning with mechanism of injury).
• Monitor treatment progression. Exaggerated claims often lack improvement or show excessive, unnecessary care.

💡 Tip: When medical reports appear templated or vague, run them through plagiarism-detection tools or look for repeated language patterns across different claimants.

🚗 Step 3: Dig Deeper on Personal & Commercial Auto Claims

Fraud in personal and commercial auto cases is often linked to staged accidents or inflated damages.

Practical Checks:

• Photos don’t match the reported damages? Run metadata on images to confirm dates, locations, and if they’ve been altered.
• Verify repair records with known body shops. Fraud rings often cycle through the same vendors.
• Compare injuries to impact: Use biomechanical analysis or crash reconstruction experts to challenge injury claims inconsistent with the damage.

💡 Step 4: Social Media & OSINT

Modern claimants often post things that contradict their claims. This is where Open-Source Intelligence (OSINT) becomes vital.

Tools & Tactics:

• Google Reverse Image Search: Confirm if photos submitted with the claim are pulled from elsewhere.
• Search social platforms (Facebook, TikTok, Instagram, LinkedIn): Look for posts, check-ins, or tagged photos that contradict medical restrictions.
• Spokeo, BeenVerified, Pipl: Dig into aliases, emails, or linked phone numbers.

🧠 Step 5: Know When to Escalate

If red flags mount and fraud seems likely:

• Consult your SIU or external investigator immediately. Time is critical—especially for surveillance or scene inspections.
• Report to the California Department of Insurance (CDI) via Fraud Reporting Portal.
• Notify the District Attorney’s Office if evidence supports prosecution.

🧰 Bonus: Checklists You Can Use Today

1. Workers’ Comp Claim Red Flags Checklist

• Late report of injury

• No witnesses to the incident

• Monday morning injury

• Inconsistent medical narratives

• History of prior claims (verified through EAMS or ISO)

2. Auto Claim Red Flags

• Repeated use of same body shop

• Minimal vehicle damage with major injury claim

• Passengers all claim injury

• Medical treatment begins same day as accident with same provider across multiple claimants

What’s Next?

Next week, we’ll spotlight common fraud tactics used by medical providers—from billing for ghost procedures to colluding with claimants. You’ll get insight into what to request, how to audit, and what patterns scream “fraud.”

Until then, keep the pressure on. Fraud isn’t just a claim problem—it’s a system threat. And thanks to fighters like you, it’s a battle we’re winning one claim at a time.

Chris