ALJs and OIG Investigations

Social Security's Office of Inspector General (OIG) has issued a report on a study it did on cases in which OIG had investigated a claim and, in essence, ordered it denied, yet an Administrative Law Judge (ALJ) later allowed the claim. The study showed:

...ALJs may not have always been aware that a CDI unit investigation was conducted and may not have always considered the investigative report in making the disability decision. These circumstances may have resulted in the allowance of benefits when a prior investigation by a CDI unit contributed to a denial decision. Specifically, our review of case folders for 100 ALJ decisions found:
• 97 case folders were not clearly marked to indicate an investigation was conducted and that the investigative report was included in the case folder;
• 40 investigative reports were missing from case folders;
• 28 investigative reports were not included on the exhibit list used to identify documents for consideration at the hearing; and
• 59 investigative reports were not discussed in the ALJ case decision write-up.

Administrative Law Judges made the following comments upon OIG's report that indicate problems with the OIG investigations themselves:

The ALJs also provided suggestions on some areas of the investigation that would make them even more beneficial to their disability decisions. Specifically:
• A longer period of surveillance tailored to the claimant’s alleged impairments would provide more complete evidence on some cases.
• Only factual observations about the claimant’s abilities identified during the investigation should be included in the investigative report. For example, when the claimant is observed walking only one block, the investigative report should not conclude the claimant can walk long distances.
• Specific details of the investigation, such as the length of time the claimant was observed, the distance the claimant walked, or the size of objects lifted should be reported in the investigative report.
• Standards applied to the CDI Unit’s observations should be placed in proper perspective. For example, investigative reports that indicate the claimant’s pace and gait were normal should provide a context for normal, such as pace and gate were similar to other people walking near the claimant.
• Documents that support statements made in the investigative report should be presented for consideration. For example, the investigative report states that medical evidence submitted by the medical provider for a different claimant was very similar to the medical evidence for the claimant under investigation, which could indicate duplicative use of medical evidence. Therefore, the CDI unit should provide the medical evidence from the other case to support their statement.