Fraudulent and questionable claims under the Federal Employees’ Compensation Act (FECA) not only drain agency resources but also undermine the integrity of a critical program designed to support injured federal employees. As a claim’s professional, detecting and addressing FECA claims fraud requires strategy, precision, and close collaboration with investigative experts.
1. Prioritize Thorough Documentation in FECA Claims
Comprehensive documentation is the foundation of every fraud investigation. A well-documented case file ensures suspected FECA claims fraud is assessed fairly and helps investigators act quickly.
- What to Do:
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Gather detailed medical records, employment details, and witness statements.
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Share all relevant information with the Office of Workers’ Compensation Programs (OWCP) so Second Opinion Exam doctors have the complete picture.
- Why It Matters:
Accurate documentation confirms whether a claim meets legal and medical requirements. It also prepares cases for the Office of Inspector General (OIG) if a criminal fraud investigation becomes necessary.
2. Recognize Red Flags in FECA Claims
Fraud often reveals itself through irregularities. Spotting these red flags early helps claims professionals identify potential abuse.
- Common Red Flags:
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Delayed claim reporting after an injury.
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Inconsistent explanations of how the injury occurred.
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Pre-existing medical conditions that raise doubt.
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Claims filed after discipline, denied time-off, or near retirement.
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A pattern of multiple claims from the same individual.
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Seasonal or temporary work ending.
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Physical activities inconsistent with reported restrictions.
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Tips from co-workers, social media, or news reports.
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Outside employment or unpaid volunteer work.
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Claimant using a post office box address.
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Lifestyle inconsistent with benefit level.
- Next Steps:
Use red flags as starting points for deeper investigation. Collaborate with investigators to confirm or dismiss suspicions.
3. Leverage Data Analytics and Surveillance to Detect Fraud
Modern investigative tools, such as data analytics and surveillance play a vital role in uncovering FECA claims fraud.
- Data Analytics:
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Cross-check claimant details with public records to reveal hidden employment or assets.
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Spot claim trends connected to specific medical providers or geographic regions.
- Surveillance:
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Collect video evidence showing activities that contradict reported restrictions.
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Document claimants engaging in sports, heavy lifting, or other strenuous activity.
- Application Example:
A federal employee runs a side business while receiving FECA benefits. Surveillance captures them performing physically demanding work, leading to benefit theft charges.
4. Investigate Signs of Malingering and Abuse
Fraud often includes exaggerated symptoms or false injury reports. Detecting malingering requires sharp observation and careful documentation.
- What to Look For:
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Claimants using crutches or canes only during evaluations.
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Subjective complaints without medical proof.
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Activities beyond restrictions, such as heavy yard work or recreational sports.
- How to Respond:
Work with investigative partners to record inconsistencies. Share findings with physicians and examiners to support claim denials or terminations.
5. Validate Claims Against Legitimacy Criteria
Every FECA claim must meet specific conditions to be valid. Ensure each claim fulfills the following criteria before advancing:
- Time: Was the claim filed within the required time frame?
- Employee Status: Is the claimant an eligible federal employee?
- Fact of Injury: Did the reported injury occur as described?
- Performance of Duty: Was the employee performing work-related duties at the time of the injury?
- Causal Relationship: Is there a clear medical connection between the reported injury and workplace duties?
Claims that fail to meet these criteria should be scrutinized further with investigative support.
Pay particular attention to Fact of Injury, could the injury happen as described? Was the claimant actually on duty on the date of injury or during their tour of duty? Does the agency have any surveillance cameras where the injury was reported to have been?
Performance of Duty is another key element to investigate. Did the event occur on the premises and was the claimant performing assigned duties or in activity incidental to employment such as while on authorized break. Was the claimant acting within the scope of their employment?
Fact of Injury and Performance of Duty may require additional fact finding specifically when the injury does not appear plausible or appears questionable.
6. Collaborate with Investigative Experts
Administrative investigations and inter-agency collaboration are invaluable when addressing complex or high-risk claims. Specialists can leverage the expertise of investigative services to uncover feca claims fraud more effectively.
- What to Expect:
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Detailed investigative reports and evidence.
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Professional analysis of fraud risks and impact.
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- Why It Matters: Joint efforts save resources, boost credibility, and strengthen cases for legal or administrative action.
Conclusion
Addressing fraud in FECA claims fraud is a critical responsibility for claims professionals. By employing strategies such as thorough documentation, recognizing red flags, leveraging advanced tools like data analytics and surveillance, and collaborating with investigative experts, claims specialists can protect program integrity and ensure fair outcomes.
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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.