The Federal Employees’ Compensation Act (FECA) provides critical benefits to federal employees who suffer work-related injuries or illnesses. However, maintaining the integrity of the system requires a proactive approach to ensure benefits are provided only to eligible claimants. Administrative investigations serve as a critical tool for claims examiners and federal agencies, allowing for thorough evaluations and well-informed decisions. By adopting best practices commonly used by commercial insurance carriers, agencies can enhance their investigative processes, improve outcomes, and safeguard program resources.
Here’s a detailed look at the best practices for conducting FECA claims investigations effectively.
- Surveillance: A Foundation for Objective Evidence
Surveillance is one of the most effective tools in FECA claims investigations. Its goal is to provide objective, documented evidence—often in the form of video or photography—to assess a claimant’s physical activities and compare them to their reported medical restrictions.
- Key Goals of Surveillance:
- Document inconsistent physical behavior that contradicts reported limitations.
- Identify evidence that a disability has resolved or is no longer causally related to employment.
- Observe activities that match or exceed offered light-duty or full-duty work.
- Why It Works:
- Medical providers often rely on claimants’ subjective descriptions of pain or limitations because they have no clear evidence to challenge these claims. Surveillance footage provides a factual, unbiased record of a claimant’s physical abilities.
- Surveillance counters common defenses, such as the “good day” explanation, where claimants argue their observed activities were atypical.
- Real-World Examples:
- A parent may endure pain to pick up a crying infant or lift a child from a car seat, which is understandable. However, carrying a heavy pail of drywall compound or lifting cases of beer often points to behavior inconsistent with claimed limitations.
- Documenting activities like yard work, sports, or heavy lifting can provide medical professionals with the evidence needed to reassess a claimant’s readiness to return to work.
Surveillance helps ensure that benefits are aligned with a claimant’s actual physical capabilities and encourages honest reporting.
- Medical Canvassing: Uncovering Undisclosed Treatment
Medical canvassing is a proactive investigative tool that goes beyond standard claims index searches. While claims indexes rely on existing databases, medical canvassing involves direct outreach to medical facilities to determine if a claimant has received treatment that has not been reported.
- Facilities to Canvass:
- Primary Care Physicians: General treatment and ongoing care.
- Chiropractors: Common for musculoskeletal and back injuries.
- Imaging Centers: Facilities for X-rays, MRIs, or CT scans.
- Neurology Clinics: Often relevant for head injuries or nerve-related conditions.
- Orthopedic Clinics: Specialized care for bone and joint injuries.
- Optometry Facilities: Vision care related to head trauma or visual impairments.
- Podiatry Facilities: For foot and lower limb injuries.
- Why It’s Important:
- Not all medical treatments are reported to claims databases. Medical canvassing uncovers additional treatment information that may impact the validity or status of a claim.
- Canvassing provides a clearer picture of the claimant’s medical history, identifying treatments that were previously undisclosed or inconsistent with their reported condition.
By incorporating medical canvassing, claims examiners ensure they are basing decisions on complete and accurate information.
- Research and Record Retrieval: Extending the Examiner’s Reach
Administrative investigations act as an extension of a claims examiner’s reach, enabling the collection of critical records and data that may be scattered or difficult to obtain.
- Key Record Retrieval Efforts:
- Identifying non-FECA disability benefits that may offset workers’ compensation payouts.
- Confirming life events such as the death of a claimant or dependent, or verifying a divorce that may impact eligibility for benefits.
- Attending criminal court proceedings to confirm the outcome of cases involving claimants.
- Verifying if a claimant is incarcerated, which can disqualify them from receiving benefits.
- Why It Matters:
- Access to accurate and verified records allows claims examiners to adjust benefits promptly and prevent overpayments.
- This step ensures compliance with FECA guidelines while maintaining the integrity of the claims process.
- Best Practices for Surveillance and Investigations
To conduct FECA claims investigations effectively, it’s essential to follow a structured approach that mirrors the proven techniques used by commercial insurance carriers:
- Plan Investigative Actions Carefully: Avoid acting impulsively on claims that appear troublesome. Instead, vet concerns thoroughly before initiating surveillance or record reviews.
- Document Everything: A successful investigation depends on clear, objective documentation that supports administrative or legal actions.
- Compare Activities to Job Duties: Observed activities should be evaluated against light-duty or full-duty job descriptions to assess whether claimants are capable of returning to work.
- Manage Expectations: Not every investigation will uncover fraud or abuse, but thorough inquiries will ensure that claims are handled with fairness and diligence.
- Promoting Program Integrity and Accountability
A well-executed FECA claims investigation program fosters accountability and ensures fairness across the workforce.
- Benefits of Effective Investigations:
- Legitimizing Claims: Employees with legitimate injuries are validated, reducing stigma and suspicion surrounding their claims.
- Improving Morale: Co-workers and supervisors have confidence that only deserving employees are receiving benefits, reducing frustration caused by perceived abuse.
- Preventing Abuse: A transparent and consistent investigative process deters malingering and fraud, protecting program resources for those who truly need them.
Conclusion: Strengthening Oversight and Fairness
By adopting best practices such as surveillance, medical canvassing, and comprehensive record retrieval, federal agencies can enhance the integrity and efficiency of their FECA claims programs. These tools allow claims examiners to make informed decisions, validate legitimate claims, and address abuses promptly.
A fair and diligent investigation process promotes trust, accountability, and operational effectiveness, ensuring that federal resources are safeguarded and employees are supported through ethical, transparent claims management.
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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.