Reduce a barrier to access of FECA claims benefits: investigate any and all red flags


For an employee to trust an organization’s claims processes the organization must be ethical and trustworthy.  For an organization to be considered ethical, and for employees to have the trust and confidence that fairness will prevail, it is important that there is a diligence in the application of the rules.  An organization must use all of the claims handling tools available so that an employee can trust in the organization’s competency.

To be invested in an employee’s medical recovery, rehabilitation and return to work is a morale booster to the employee and the entire organization.  The injured employee is dependent upon direction from others or on the clues their actions provide in order to know how to act.  When guides are provided, the injured worker can predict with greater certainty what he or she and others can expect; thus there is a greater satisfaction in the process.  The injured employee can be confident that they were not the fool for not taking advantage of the additional benefits that a porous system of oversight provides, or allows through default.  No amount of malingering, abuse or even outright fraud is ever done without a person’s justification that it is somehow allowed; necessary; or without risk.   An environment of non oversight creates confusion concerning the positive and negative effects of what is acceptable. When claims are administered from an objective position, with as much information as possible, and there is even-handedness applied, the Claims Handler and the injured worker will achieve a group effectiveness in the claims process. The results is lower costs paid to undeserved beneficiaries and increased moral of all employees.

It is a Claims Handlers responsibility to ensure that they are not creating barriers to benefits.  Field investigations of claims do not create a barrier to benefits as they do not obstruct legitimate access.  Field investigations are; however, a filter to screen out abuses of the system. Some organizations justify not investigating claims by stating that they don’t have to, because they trust their employees.  A Claims Handler may trust employees not to abuse the system, just like the employees are trusted to drive safely, but still they are required to wear seat belts. Outside factors can interfere and impede.

The degree to which an organization trusts an employee is a measure of belief in the honesty, fairness, and confidence in the employee to understand the situation, expectations and penalties for infractions. An employee needs to be able to trust the organization too.

A fair and effective program that investigates claims is advantageous for the entire work force.

  • Employees with legitimate injuries are no longer lumped in with the abusive, malingering and fraudulent claims.
  • The morale of co-workers and supervisors who are left picking up the slack of an out-of-work employee is increased as they have confidence that the system will ensure that their added load is necessary.
  • There is no air of suspicion cast upon the injured nor the stigma that needing the benefits is just a scam or manipulation to get more than what is entitled at the expense of remaining co-workers.
  • There is no perception that the organization is too slow, distracted or uncaring to react.

There is a great effort by society to reduce the stigma of collecting a needed benefit; some benefits are frequently renamed when over time the benefit becomes associated with a particular stereotype of behavior. (Think the renaming of Food Stamps). There is no better way to legitimize the collecting of a benefit than to diligently validate and continue to validate those who are collecting it.  When there is knowledge by society of the level to which the non deserving are culled from the rolls, then there will be trust that a collector of the benefit meets the minimum standards for qualification and continues to do so.


A Focus on Social Responsibility

Crowd under clocksLargeThere is increased public scrutiny cast upon the claims industry. Very few insurance companies can afford to subscribe to the “we don’t want to know how you got the information” line of thinking anymore.

Companies want to be a good social partner, so try to find investigation companies with high ethical standards.  Bad investigations can cost a claims organization money; unethical investigations can cost them moral integrity, reputation and heavy handed legislation.

Assumedly, most investigations fall within the laws and rules of the jurisdiction in which they are conducted, but that is a minimum measure of ethics.  Being legal is not an ethical standard. Practices can be employed that technically do not violate applicable laws, but to local sensibilities are cumulatively corruptive to producing a fair and just investigation.

SIU departments are educating their claims people, and the metrics of claims organizations is changing so as not to penalize an investigation company or the SIU for saying no to a request.

It often takes longer in an investigation to get the results while maintaining a high ethical standard with honesty and honest practices: using legitimate means to access information and documents; being nonintrusive with surveillance to remain objective and non manipulative with subjects; not using threatening or intimidating questioning and providing a professional openness to reveal common practices.

An investigator’s honesty with SIU in how and where information was obtained has to show the warts and all.  A transparency of effort does not require the disclosure of any confidential information, special technique, or business alliance.  An investigative agency can still be shrewd and competitive, but must be honest for the sake of the investigation to be above reproach.  Insurance companies want investigations that evoke reciprocity of goodwill from the community.  Goodwill is earned through integrity.