In managing claims under the Federal Employees’ Compensation Act (FECA), precision and evidence are critical. An Administrative Investigation Program bridges the gap between clinical reviews and criminal investigations by providing objective, actionable evidence to help claims specialists and agencies make informed decisions. Unlike purely medical reviews or formal criminal fraud investigations, administrative investigations focus on real-world assessments and meticulous documentation to support administrative action or referrals to the Department of Labor (DOL) and Office of Workers’ Compensation Programs (OWCP).
This blog explores the importance, structure, and results of an effective Administrative Investigation Program.
What Is an Administrative Investigation?
Administrative Investigations focus on documenting facts, uncovering inconsistencies, and providing a clear picture of a claimant’s activities. They are not criminal fraud investigations but often serve as a necessary first step in identifying and addressing issues such as malingering, abusiveness, or fraud.
- Purpose: To provide sufficient objective evidence that allows the agency or DOL/OWCP to make informed decisions about continuing, modifying, or terminating benefits.
- Scope: Administrative Investigations provide documentation of:
- The claimant’s current activities.
- A historical composite of past behaviors and patterns.
- Any external influences impacting the claimant’s recovery or return to work.
An Administrative Investigation will not:
- Make someone active who is truly inactive.
- Find fraud where it does not exist.
However, it will provide detailed, evidence-backed reporting that can uncover abuse or fraud when it occurs.
Why Claims Specialists Need Administrative Investigations
Claims Specialists are tasked with ensuring that benefits are distributed properly and that claimants continue to meet eligibility requirements. Yet the sheer volume of claims and the lack of time and resources make it impossible for Claims Specialists to perform desktop investigations on every questionable case.
- Once a claim has been accepted, overturning it requires clear evidence of inconsistencies or fraud.
- The DOL cannot act on suspicion alone—it needs well-documented, relevant information with tangible fiscal impact to justify further investigation.
An Administrative Investigation Program ensures that claims suspected of abuse or fraud are packaged and presented with the necessary evidence to support action, whether administrative or criminal.
The Objective: A Plan of Action
The success of an Administrative Investigation Program begins with a clear, scripted Plan of Action. Reactive measures alone, such as surveillance on highly visible claims, are insufficient. Just because a claim seems troublesome does not mean it is fraudulent. A deliberate, methodical approach is essential:
- Source Vetting: Validate the concerns or suspicions surrounding the claim. Claims must meet specific thresholds for cost savings, evidence of abuse, or clear inconsistencies before resources are committed.
- Preparation: Plan investigative actions carefully—determine where and when resources should be deployed, such as surveillance, record reviews, or interviews.
- Expectations Management: Results take time. An investigation does not always yield immediate or dramatic findings. A thorough and objective inquiry is the ultimate goal.
By avoiding impulsive responses and focusing on evidence-based results, administrative investigations can deliver real value to the claims process.
Tangible Results: What to Expect
While investigations cannot guarantee specific outcomes, agencies can expect thoroughness and clarity. Administrative Investigations identify:
- Claimant Activity Levels: The current physical, professional, or social activities of a claimant—critical for assessing consistency with medical restrictions or claims of incapacity.
- Indications of Fraud: Activities or evidence that suggest fraud, abuse, or malingering, such as working while claiming total disability.
- External Influences: Any outside factors, such as financial pressures or familial obligations, that might impact a claimant’s recovery or return to work.
These tangible results have lasting impacts:
- Identifying and Removing Abusers: Administrative Investigations uncover abuse and ensure that undeserving claimants are removed from the FECA system.
- Return To Work: A quicker determination of a medical end results can bring the employee back to a full employment status sooner.
- Swift Resolution of New Issues: Early identification of problems enables faster intervention, saving time and resources.
- Cultural Change: A proactive approach sends a message that abuse will not be tolerated. This can foster a self-policing culture, discouraging potential malingers from gaming the system.
The Role of Administrative Investigations in the Bigger Picture
While fraud investigations are inherently criminal in nature, administrative investigations play a preliminary and supportive role. They create detailed, evidence-backed reports that agencies, the DOL, and stakeholders need to justify further actions.
- Objective Documentation: Provides factual, unbiased evidence to assess the validity of a claim.
- Fiscal Impact Statements: Quantifies the cost implications of continuing, modifying, or terminating benefits.
- Referral Support: Packages the findings clearly, enabling further review by OWCP or the DOL for criminal investigation consideration.
Administrative Investigations give agencies a practical way to manage claims efficiently and provide the DOL with the tools it needs to act on cases of fraud or abuse.
Conclusion: Strengthening the Claims Process
A well-defined Administrative Investigation Program is an indispensable tool for claims specialists and agencies managing FECA claims. By combining thorough investigations with clear documentation, these programs ensure:
- Proper distribution of benefits to those who qualify.
- Swift identification and removal of abusers from the system.
- Shorter RTW cycles.
- Tangible cost savings and cultural improvements within agencies.
Administrative Investigations are not about assumptions or hunches, they’re about evidence, accuracy, and results. By taking a deliberate, methodical approach, agencies can protect program integrity, reduce abuse, and ensure that the claims process serves its intended purpose: to support employees who genuinely need it.
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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.