How does an adjuster determine if a claim is fraudulent?

An adjuster determines if a claim is fraudulent primarily by investigating inconsistencies in reports and records. This approach allows the adjuster to cross-reference information provided by the injured worker, medical reports, and any other documentation associated with the claim. Identifying discrepancies between these various sources can raise red flags, indicating potential fraud. For example, an inconsistency could manifest as differing descriptions of the incident, variations in injury severity, or conflicting medical findings.

While consultation with medical professionals and interviewing the injured worker are important parts of the claims process, they alone do not reveal inconsistencies that could indicate fraud. Similarly, relying solely on witness statements may not provide the comprehensive investigation needed to prove or disprove the legitimacy of a claim. Thorough analysis of the available records and reports is crucial for an adjuster to build a complete picture and make an informed determination regarding the possibility of fraud.