Every workers' compensation adjuster knows the files that do not add up: an injury reported days late with no witnesses, an incident described one way on the claim form and another way to the treating physician, a back strain filed first thing Monday morning. In California, each of those claims still has to be accepted or denied inside a 90-day window.
This carrier writes coverage for employers in physically demanding industries, and its claims team was carrying more than 300 open files when a growing share of them started to look like that. This case study covers how Encyphir's AOE/COE investigations gave its adjusters documented answers, and what 18 months and 64 referred claims produced.
Why the old approach left adjusters guessing
Before Encyphir, questionable claims went to a vendor that ran database checks and, when budget allowed, a single day of surveillance. Results came back inconclusive more often than not. That left adjusters with two bad options: accept a claim they doubted, or deny it without documentation and invite penalties, litigation, and a Workers' Compensation Appeals Board hearing they were likely to lose.
The cost ran in both directions. Unsupported claims were being paid, and injured workers with legitimate claims waited weeks longer than they should have while their files sat in review. The goal was never to deny more claims. It was to decide every claim on the facts, inside 90 days.
How Encyphir investigates AOE/COE claims
Each referral was assigned to a senior licensed investigator within one business day. The first step was always recorded statements from the claimant, coworkers, and the supervisor on shift, taken while memories were fresh.
Investigators then rebuilt the timeline, checking timekeeping records, schedules, badge data, and the scene itself against every account. Where the facts called for it, they ran lawful activity checks and surveillance and reviewed prior claims, other employment, and public online activity. Every file closed with a court-ready report: what happened, how it was verified, and what would hold up if the claim was litigated.
- A senior licensed investigator assigned within one business day
- Prompt recorded statements from the claimant, coworkers, and supervisor
- The timeline rebuilt from timekeeping, schedules, badge data, and the scene
- Lawful activity checks and surveillance only where the facts called for it
- A court-ready report written for the adjuster and defense counsel
What 64 claim investigations found
Of the 64 claims referred, 19 were denied on documented, admissible findings and 11 were resolved by compromise well below their reserves. Together they account for $684,000 in avoided indemnity and medical exposure, roughly eleven times what the investigations cost. The average referral reached a decision in 41 days, well inside the 90-day window.
Just as important, 34 claims were confirmed as work related and accepted weeks sooner than before. The full case study includes a representative file, a Monday morning lifting injury, and shows how statements and timekeeping records settled the question.
What claims teams can take from it
An AOE/COE investigation is not a denial tool. Done promptly and documented properly, it is how a carrier pays good claims faster and defends the decisions it makes on the rest.
The difference in this program was speed and substance: statements taken in the first days of a claim, a timeline checked against records instead of recollection, and a report written to hold up in front of the WCAB. Inconclusive results cost money whichever way the adjuster decides.
