When to Deploy an Investigator for Workers' Compensation and FMLA Fraud

Immediate red flags that justify an investigation

When a claim shows inconsistencies—such as conflicting medical reports, repeated short‑term disability filings, or suspicious timing with known workplace incidents—an employer should consider hiring an investigator promptly.

Cost‑benefit analysis of investigative action

Weigh the potential recovery from fraudulent payouts against the expense of a professional investigation; if the alleged loss exceeds the investigator's fee by a reasonable margin, the investment is typically justified.

Legal and compliance considerations

Investigations must respect privacy laws, EEOC guidelines, and the FMLA's confidentiality requirements; involving legal counsel early ensures the inquiry does not create liability.

Typical scenarios prompting investigation

• Frequent or overlapping leave requests from the same employee
• Medical providers who are not licensed in the claim's jurisdiction
• Claims filed shortly after a known workplace injury
• Discrepancies between employee statements and surveillance footage

Choosing the right investigator

Select a specialist with experience in both workers' compensation and FMLA cases, preferably with certifications in fraud detection and a track record of successful recoveries.

Table: Factors influencing the decision to investigate