FECA Claims Specialists- Should You Utilize Alive and Wellness Checks?

Annually confirming that a beneficiary is alive is a critical task for claims specialists under the Federal Employees’ Compensation Act (FECA). Given the increasing complexity of verifying beneficiary status, particularly among high-risk populations, outsourcing these checks to contracted administrative investigators offers an immediate, practical, and efficient solution to extend resources, meet government mandates, and uphold public trust. Here’s how Alive and Wellness Checks enhance program integrity.

The Critical Role of Alive and Wellness Checks

Alive and Well checks ensure that:

• Benefits Reach the Right Recipients: They confirm that beneficiaries are alive and still meet eligibility requirements.
• Fraud and Abuse Are Minimized: Fraudulent claims, such as payments continuing for deceased individuals, are identified and stopped promptly.
• Program Integrity Is Maintained: These checks build public confidence in the fairness and accuracy of compensation programs.

Despite the government’s goal to share death records across agencies and many platforms, there is no complete system yet in place to make it happen.? So, how does a claims examiner keep compliant with 20 C.F.R. Part 10, as payments to deceased individuals are explicitly forbidden under FECA, and agencies must verify that recipients are still living?

Claims Specialists from many agencies use contracted administrative investigators.

A contracted workforce is more nimble and ready to be used when needed but not a burden on budgets when not. Once technology and agencies link, the need for a contracted administrative investigator will be reduced, but until then, you can count on them for expertise and specialization.?

1. Expertise and Specialization Contracted investigators bring a unique skill set tailored to handle complex verification processes efficiently. They specialize in conducting field visits to confirm a beneficiary’s presence, validating documentation with keen attention to potential discrepancies, and collaborating with local resources like medical facilities or state registries to cross-check information.
2. Enhanced Efficiency Administrative investigators alleviate the workload for claims specialists, allowing them to focus on other critical aspects of case management. Outsourced investigators provide timely, detailed reporting, efficient resolution of pending verifications, and accurate identification of fraud indicators.
3. Technology Integration Many contracted investigators leverage advanced tools like AI, real-time data verification systems, and death registries. These technologies streamline the verification process, providing accurate results faster than traditional methods.
4. Cost Savings and Fraud Prevention While hiring contractors is an upfront cost, the long-term savings far outweigh these expenses. By identifying errors and fraud before payments or unnecessary billing, contracted investigators help reduce improper payouts and enhance financial accountability.
5. In-Field Presence For beneficiaries in remote areas, nursing homes, or assisted living facilities, contracted investigators can conduct in-person checks, which are impractical for claims specialists. Their physical presence ensures a thorough and reliable verification process. Contact with a beneficiary or caregiver can improve future communication and assistance with services provided.

Prior Outcomes

Case Study 1: Fraudulent Billing Prevention, A contracted investigator uncovered that durable medical equipment providers continued billing for services long after a beneficiary had passed away. By identifying and resolving the issue, the agency saved the improper payments from being made.

Case Study 2: Swift Fraud Detection An investigator’s field visit revealed that a deceased beneficiary’s family had been cashing benefit checks for over a year. Immediate action saved the program from further losses and underscored the importance of in-person verification.

How to Maximize the Value of Contracted Investigators with Alive and Wellness Checks

1. Define Clear Objectives Establish specific goals for each Alive and Well check, ensuring investigators have clear instructions and parameters as to what documentation is needed.
2. Foster Collaboration Maintain open communication between claims specialists and contractors. Sharing insights and red flag indicators enhances the effectiveness of investigations.
3. Utilize Advanced Tools Work with contractors who employ AI-driven fraud detection tools and have access to cross-referenced databases, both public and proprietary.
4. Monitor and Evaluate Regularly assess the performance of contracted investigators to ensure consistent quality and return on investment.

A Strategic Partnership for Better Outcomes

Outsourcing Alive and Well checks to contracted administrative investigators is a strategic move that extends resources, enhances efficiency, reduces fraud, and ensures the integrity of workers’ compensation programs. By leveraging their expertise and resources, claims specialists can ensure that benefits serve their intended purpose.