Investigations and Fraud

July 1, 2022 and still in effect

7.3

Purpose

This policy provides information on how investigations are carried out by board staff and what constitutes fraud.

Definitions

board means the Workers’ Safety and Compensation Board

employer means every association, corporation, individual, partnership, person, society or unincorporated organization or other body having in their service one or more workers in an industry and as further defined in section 77 of the Act

fraud means knowingly misrepresenting information through deceit, falsehood or other deceptive means with the intent to defraud

worker means a person who performs work or services for an employer under a contract of service or apprenticeship, written, or oral, express or implied and as further defined in section 77 of the Act

Policy Statement

1. General

An Investigation Unit has been established to conduct and co-ordinate the board’s investigation activities. The Investigation Unit’s primary objective is to gather accurate and relevant primary information in a timely manner. This information will be used to facilitate decision-making and improve customer service.
Specifically, the Investigation Unit will work to:

    a. ensure compliance with the Act and board policies;

    b. improve the quality of board decisions; and

    c. ensure the validity of assessment reporting, employer registration, claims for compensation and service provider billing.

 

2. Types of investigation

2.1 Information for decision making

The investigation function works to improve the speed and thoroughness of decision-making in the areas of employer registration, case management, employer assessment, service provider payments and claims adjudication. The need for gathering additional information will be identified by an appropriate decision-maker, who will refer the issue to the Investigation Unit. A report will be provided to the decision-maker and placed on the employer’s, injured worker’s or service provider’s file once the relevant information has been gathered. The focus of this investigative role is to gather accurate and relevant primary information and improve customer service.
 

2.2 Investigation of alleged violations of the Act or policy

The Investigation Unit may assist a decision-maker in gathering information to ensure that all employers, service providers, injured workers and staff are meeting the requirements of the Act and related policies. When an investigation is concluded, a report will be provided to the appropriate decision-maker and the Director of Legal Services. The consequences associated with violating legislation or policy will be determined by the appropriate internal authority, based on the provisions of the applicable Act, regulation, or policy.
 

2.3 Investigation of alleged fraud

Fraud investigations ensure that:

    a. service providers appropriately bill for products and services rendered to the board;
  
    b. all employers pay fairly into the compensation fund;

    c. Board staff act in accordance with the terms and conditions of their employment; and that 

    d. workers and employers receive the benefits and services to which they are entitled to under the Act.

The Investigation Unit will investigate each allegation of fraud made against staff, providers, employers, workers or members of the board of directors. These allegations may be made known through internal referral, external identification or through the work of the Unit itself.

The first step in an investigation is to refer the file to the appropriate board decision-maker in order to determine whether the reported activity or information warrants investigation.

Once the investigation is complete, the Director of Legal Services will review the investigation file and will, in consultation with the president, determine whether to pursue a remedy through a criminal or administrative process.

This determination is made on the basis of the evidence at hand. The individual(s) affected will be presented with the outcome in order to ensure an accurate understanding of the facts related to the matter.

 

3. Documentation

Potential fraud investigation reports will not be placed on the injured worker’s, employer’s, service provider’s, staff personnel’s or board of directors’ file unless requested by the individual. However, the investigation report would be viewable by the individual, if requested. If it is determined that an investigation report must become part of the permanent record, the party under investigation will be notified in writing and given an opportunity to respond.

 

4. Investigation techniques

Investigators must conduct themselves in a professional manner at all times, operating both within the law and within the procedural standards established by the board.
Investigation techniques will vary in accordance with the type of investigation required and the circumstances of each case. Investigation techniques may range from electronic searches and paper file review, to actual field work as determined by the president.

 

5. Reporting

The president will report periodically to the board of directors on the activities of the Investigation Unit.