Administrative investigations play a critical role in the FECA claims process, helping federal agencies detect fraud, ensure compliance, and protect public trust. Federal government claims are often at risk of fraud, abuse, and malingering, which can lead to significant financial losses. According to the U.S. Government Accountability Office (GAO), the federal government loses between $233 billion and $521 billion annually to fraud. This staggering figure highlights the need for strong risk management strategies to safeguard federal resources and ensure fair outcomes.
Here’s how claims specialists can effectively utilize administrative investigations to streamline their workflow and strengthen claims processing.
1. Uncovering Critical Facts Through Investigations
Administrative investigations help gather the objective evidence necessary to support or refute claims. Whether it’s verifying a claimant’s activities, identifying inconsistencies, or confirming compliance with medical restrictions, these investigations provide the factual foundation needed to proceed confidently.
Key Techniques Include:
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- Conducting surveillance to document physical activities inconsistent with reported limitations.
- Reviewing social media and public records to identify discrepancies or unreported activities.
- Performing surveillance to confirm claimants’ whereabouts and physical status.
By leveraging these investigative tools, claims specialists can address unclear detials in the claims process, ensure accurate adjudication and support program integrity and oversight.
2. Supporting Program Integrity with Data and Analysis
Claims specialists can rely on administrative investigators to use data analytics to identify patterns or anomalies that suggest fraud. This proactive approach ensures that resources are directed to claims with the highest likelihood of issues, saving time and money.
Examples of Data Insights:
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- Detecting clusters of claims tied to specific providers.
- Identifying claimants with histories of multiple claims or delayed reporting.
- Cross-referencing public records for discrepancies.
These insights not only support individual investigations but also help improve broader program integrity.
3. Aligning with OWCP Standards and Building Credibility
Effective communication with the Office of Workers’ Compensation Programs (OWCP) is critical. Administrative investigations provide the documentation and evidence needed to align claims processing with OWCP standards.
What Investigators Provide:
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- Comprehensive Reports of Investigation detailing findings and evidence.
- Clear, factual documentation that facilitates second opinion exams or challenges to claims and fruad referrals to the Office of the Inspector General (OIG).
- Objective data that supports agency requests for specific actions.
By presenting concise, evidence-based findings claims specialists can ensure that their recommendations are credible and persuasive.
4. Enhancing Cost-Effectiveness and Operational Efficiency
Administrative investigations reduce the financial burden on federal programs by detecting and addressing fraudulent or undeserving claims early in the process.
Cost-Saving Benefits:
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- Identifying ineligible claims before resources are allocated.
- Streamlining the adjudication process by providing complete evidence packages upfront.
- Supporting timely return-to-work efforts through accurate assessments of medical restrictions and capabilities.
- Identifies potential fraud specifically when a claimant is not reporting income from other employment.
- Supports medical billing and travel reimbursement submissions.
5. Strengthening the Claims Process with Collaboration
Collaboration between claims specialists and administrative investigators ensures a holistic approach to managing claims. Investigators bring specialized skills such as surveillance, record reviews, and data analysis, while claims specialists provide the expertise needed to interpret and apply findings effectively to provide OWCP with documentation to support a requested agency action.
Key Areas of Collaboration:
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- Developing strategies to investigate red flags in claims.
- Working with other agencies and stakeholders to share information and best practices.
- Providing evidence to build stronger cases and support decision-making.
Conclusion
Administrative investigations are invaluable tools for claims specialists navigating the complexities of FECA claims. By uncovering facts, supporting program integrity, and aligning with OWCP standards, these investigations ensure accurate, fair, and efficient claims processing and management oversight.
Investing in thorough administrative investigations not only protects the integrity of the claims process but also upholds the trust placed in federal compensation programs. For claims specialists, leveraging these tools is a strategic move that benefits both employees and the agencies they serve.
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Frasco® Government Services delivers ethical and efficient solutions tailored to your needs. Have questions or want to discuss your investigative needs further?
Schedule a call with Craig DeMello, a nationally recognized expert in Federal Workers’ Compensation. With over 30 years of experience in public service, Craig provides practical insight and proven expertise to help clients navigate complex federal claims. As a Government Services Specialist at Frasco, he is dedicated to delivering clear answers and effective strategies to support your agency’s goals.
Disclaimer: This blog post is for informational purposes only and should not be considered legal advice. Please consult your general counsel for specific legal guidance. Frasco investigators are licensed, and our operations comply with US industry, federal, state, and local laws.