Questioning An Employee’s Medical Documentation

The vast majority of employees who file claims in the workers’ compensation system have a legitimate work-related injury and are entitled to compensation for that injury under the provisions of California law.  Even though the majority of claims are completely valid and compensable, employers should still be wary, as workers’ compensation fraud is a real problem, as can be seen by the recent efforts by the legislature, law enforcement, and district attorneys to legislate and prosecute fraud.  Employers should understand some common areas of fraud and how an employee’s medical documentation may relate to these areas in order to help protect the businesses from these risks.

Medical documentation of the injury is naturally an essential place for an employer to start.  An employer should carefully review the medical documentation surrounding the diagnosis and treatment of the injury to ensure it is consistent with the account provided to the employer at the time of injury.  Inconsistencies do not automatically mean the injury is fraudulent, but it is a definite red flag.  Once the medical provider determines the type of disability and the percentage of disability, if applicable, an employer should seriously consider requesting an “independent medical review.”  An independent medical review is a specific process within the workers’ compensation system which allows for a doctor who is not the same doctor who diagnoses and treats the employee to review the records and make an independent determination as to the type of disability and other pertinent medical issues.

An employer should also be on the look-out for pre-existing injuries mentioned in medical documentation.  Note that an employee may not be forthcoming with a physician treating him or her in the context of workers’ compensation about any pre-existing injuries.  For example, if an employee has sustained a knee injury during work, he may not tell the treating doctor about the knee injury he sustained two years ago while playing football.  Due to this possibility, an employer should always conduct discovery to inquire after previous medical records.  An employer should carefully review the medical records received during the discovery process to determine if there are pre-existing conditions that should be apportioned, thereby reducing the workers’ compensation award accordingly.


If you have questions about medical records in a workers’ compensation case, contact us today at (714) 516-8188We will discuss your case and what you need to look for to protect your business from fraud. 

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