NC Industrial Commission Fraud Investigations Section

Our Mission

The mission of the Fraud Investigation Section is to serve the citizens of North Carolina by investigating potential criminal violations of the Workers’ Compensation act and ensuring compliance with the rules and regulations in a manner that fosters confidence in the Workers’ Compensation system and compliance with the law.

Who We Are

The Fraud Investigation Section is composed of two units, the Compliance Unit and the Criminal Investigation Unit.

Compliance

The Compliance Unit handles civil cases involving employers who are operating as non-insured employers in violation of N.C. Gen. Stat. §97-93 and N.C. Gen. Stat. §97-94. An employer is considered non-insured if the employer does not carry workers’ compensation insurance, is not self-insured, or cannot cover the medical costs and compensation due to the injured worker. The Compliance Unit investigates referrals to determine whether or not an employer is in compliance. Once an investigation is complete and evidence is gathered, it is presented during Industrial Commission non-insured penalty hearings. A Penalty Hearing in a non-insured case is held simultaneously with the underlying workers’ compensation case being heard. Civil penalties can be assessed covering the entire time-frame that the employer is not insured. The Compliance Unit also assists the Office of Attorney General with the enforcement and collection of penalty actions.

Criminal Investigation

The Criminal Investigation Unit operates as a law enforcement agency and is responsible for conducting criminal investigations into cases of suspected workers’ compensation fraud and violations related to workers’ compensation claims involving employees, employers, insurers, health care providers, attorneys, and vocational rehabilitation providers. Fraud Investigators investigate all criminal complaints filed with the Industrial Commission regarding failure of employers to maintain workers’ compensation insurance (N.C. Gen. Stat. §97-94(d)), fraud on the part of employees with regard to the collection or obtaining of workers’ compensation benefits (N.C. Gen. Stat. §97-88.2), fraud on the part of employers with regard to payment or collection of workers’ compensation premiums from employees’ salaries (N.C. Gen. Stat. §97-21), medical payment fraud, and any other claims arising out of violations of Chapter 97 by employees or employers. The Criminal Investigation Unit works with Judicial Officials and other law enforcement agencies throughout the state to resolve the above investigations in criminal court.

Please Note: The Industrial Commission does not provide legal or other advice, either express or inferred, and no warranty as to the accuracy or relevance of any articles or 3rd-party documents provided herein should be assumed. Any opinions expressed here or in any location on this web site are those of the individual author(s) and may not reflect any opinions of the Industrial Commission or any of it's employees.

Fraud Reporting Guidelines

Reporting fraud

If you suspect fraud that meets one of the above criteria, submit a complaint utilizing one of the following methods:

• Email at fraudcomplaints@ic.nc.gov,
• Call 1-888-891-4895 (in North Carolina),
• Fax: 919-715-0282 (Be sure to send it ATTENTION FRAUD SECTION CRIMINAL INVESTIGATION UNIT), or
• Mail the information to the Fraud Section Criminal Investigation Unit at:
      4340 Mail Service Center
      Raleigh, NC 27699-4340

Whether you submit the complaint via email, U.S. Mail, or call the fraud hotline, we will ask you to confidentially provide all of the information you have pertaining to the suspected fraud, including the following:

Complaint Checklist

Please provide as much of the following information as possible in matters that may involve fraud perpetrated by a claimant:

• Name and address of the person you suspect is committing fraud.
• Details about the improper or fraudulent activity you suspect such as:  exceeding physical limitations, working while receiving benefits, malingering, reporting false claims, or a staged accident in violation of N.C.G.S. §97-88.2.
• Type of injury and date of injury (if known).
• Name of employer at the time the injury was sustained (if known).
• Documentation that supports your complaint such as: videos, photographs, payroll records, additional witnesses, falsified documents, activity level with a vivid description of activity. (Please indicate if you have this documentation.)
• Name of employer or if self employed business location, and contact information.
• Other general information pertaining to the suspected fraudulent activity.
• Your relationship or involvement with the suspected person(s).
• Other agencies this incident has been reported to.

If the target is an employer, the complainant should provide as much of the following information as possible:

• Name and address of company or business.
• Relationship to business owner or company if any (employee, former employee, partner, etc).
• Details about the improper or fraudulent activity you suspect, such as employer fails to secure workers’ compensation insurance in violation of N.C.G.S. §97-94, employer deducts workers’ compensation premiums for employees wages in violation of N.C.G.S. §97-21, employer threatens employee prosecution for purpose of coercing or attempting to coerce the employee into agreeing to compensation or forgo compensation in violation of N.C.G.S. §97-88.2.
• Documentation that supports your complaint such as number of and names of employees, additional witnesses, or payroll records.
• Other general information pertaining to the suspected fraudulent activity.
• Other agencies this incident has been reported to.

If the target is a healthcare provider, attorney, or insurance agent/company, the complainant should provide as much of the following information as possible:

• Name and address of company or person suspected of committing fraud.
• Relationship to the company or suspected person.
• Details about the improper or fraudulent activity you suspect, such as health care provider who knowingly charges or otherwise holds an employee financially responsible for the cost of any services provided for a compensable injury involving of N.C,G.S. §97-88.3 (c),
• Documentation that supports your compliant such as copies of records, additional witnesses, copies of billing statements, copies of payment records.
• Other general information pertaining to the suspected fraudulent activity.
• Other agencies this incident has been reported to.

Fraud Contacts

The Fraud Investigations Section consists of three fraud investigators, one compliance officer and one secretary. The telephone numbers and e-mail addresses for the Fraud Investigations Section are as follows: