AWC Blog

The Affordable Care Act’s Impact on Workers’ Compensation

Between millions of people becoming insured and the prevalence of higher deductible plans thanks to the Affordable Care Act (ACA), there is concern in the business world that the ACA will have a negative impact on workers’ compensation – and that maybe it already has.

Employers should not have to pay higher costs in their workers’ comp policies because employees delay returning to work or file fraudulent claims. Understanding the impact of the ACA and what to watch out for will help you control your workers’ comp coverage.

Delayed Return to Work

In the short time that the ACA has been in effect, more than 16 million previously uninsured people have joined the ranks of the insured, leaving many to wonder if there would be a shortage of access to care. In the world of workers’ compensation insurance, many wondered if this would increase the amount of time it would take for employees to receive treatment, keeping them out of work longer, and increasing the costs of workers’ compensation insurance premiums.

In an access to care study conducted by the National Council on Compensation, the biggest driver of a delay in the time of treatment is not the number of medical providers available, it is the behavior of the injured worker – delays in reporting injuries or filing claims resulting in a delayed return to work. Employees may be better served with a greater understanding of the workers’ compensation process to prevent this delay from occurring.

High Deductible Plans

Many newly insured people have found that higher deductible plans lead to lower monthly premiums. In an effort to save a little money, they take this route, quickly finding that they cannot afford to see a doctor when they become injured. As a result, workers’ compensation fraud has been on the rise.

Workers’ compensation fraud is hardly a new phenomena. Before the ACA, it was seen mostly from the uninsured. Now the claimants have insurance but they still can’t afford to go to the doctor. To prevent fraud, it’s now more important to know the cause of injury more than any other factor. Making matters worse, a physician may take an employee’s explanation at face value without asking deeper questions, because reimbursements for workers’ comp claims have higher payouts than reimbursements under traditional insurance.

How to Prevent Fraudulent Claims

Unfortunately, the burden of preventing fraudulent workers’ comp claims is going to lie with you as the employer, but with a few tips, you may be able to weed out the fakers from those truly injured on the job.

Be aware of typical red flags:

  • Soft tissue injuries to the back, neck, or other parts of the body that aren’t easily visible
  • Accidents that occur at the beginning of the work week when the employee was working alone
  • Employees with prior bad behavior or work-related incidents


Once an accident is reported, have a step-by-step system in process to document the claim:

  • Have the employee put their account of what happened in writing
  • Have a supervisor walk through the area where the accident was said to occur, taking pictures, and walking through the details given by the employee in their written statement, noting anything the find that doesn’t match with the statement given.
  • Talk to other employees to find out if the claimant mentioned any injuries or pain earlier in the day
  • Consider the prior behavior of the employee. If this is a problem employee who is prone to breaking the rules, bending the truth, or causing problems, this is a definite red flag.
  • Document the use (or lack thereof) of any safety equipment
  • Check video surveillance – if available
  • Check social media accounts – if this employee was involved in any activities that could cause injury over the weekend and posted it to their social media, this should be noted.
  • Ask the employee to repeat their story. Details tend to change when the story is false. Compare this account to the original one and what the physician reports.


If you detect fraud, contact your workers’ compensation insurance agent immediately.

Not every employee who makes a claim is lying to you, but it’s important to note the impact the ACA is having on workers’ compensation claims and how to protect yourself from fraudulent claims.

If you’ve got questions about fraudulent claims or your workers’ compensation policy, contact us today.

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