From a report by the Government Accountability Office done at the behest of the Chairman of the House Social Security Subcommittee and the Ranking Member of the Senate Finance Committee:
The Social Security Administration (SSA) has policies and procedures in place for detecting and preventing fraud with regard to disability benefit claims. However, GAO identified a number of areas that could leave the agency vulnerable to physician-assisted fraud and other fraudulent claims:It could be that there really isn't much fraud and that extensive efforts to find it wouldn't be cost effective.
- SSA relies heavily on front-line staff in the offices of its disability determination services (DDS)—which have responsibility for reviewing medical evidence—to detect and prevent potential fraud. However, staff said it is difficult to detect suspicious patterns across claims, as directed by SSA policy, given the large number of claims and volume of medical information they review. Moreover, DDS offices generally assign claims randomly, so staff said it would only be by chance that they would review evidence from the same physician.
- SSA and, in turn, DDS performance measures that focus on prompt processing can create a disincentive for front-line staff to report potential fraud because of the time it requires to develop a fraud referral. Four of the five DDS offices GAO visited count time that staff spend on documenting potential fraud and developing fraud referrals against their processing time. Some staff at these DDS offices said this creates a reluctance to report potential fraud.
- The extent of anti-fraud training for staff varied among the five offices GAO visited and was often limited. SSA requires all DDSs to provide training to newly hired staff that includes general information on how to identify potential fraud, but does not require additional training. The five DDS offices GAO visited varied in whether staff received refresher training and its content—such as how to spot suspicious medical evidence from physicians—and staff at all levels said they needed more training on these issues.
SSA has launched several initiatives to detect and prevent potential fraud, but their success is hampered by a lack of planning, data, and coordination. For instance, SSA is developing computer models that can draw from recent fraud cases to anticipate potentially fraudulent claims going forward. This effort has the potential to address vulnerabilities with existing fraud detection practices by, for example, helping to identify suspicious patterns of medical evidence. However, SSA has not yet articulated a plan for implementation, assigned responsibility for this initiative within the agency, or identified how the agency will obtain key pieces of data to identify physicians who are currently not tracked in existing claims' management systems. Furthermore, SSA is developing other initiatives, such as a centralized fraud prevention unit and analysis to detect patterns in disability appeals cases that could indicate fraud. However, these initiatives are still in the early stages of development and it is not clear how they will be coordinated or work with existing detection activities.
- SSA has not fully evaluated the risk associated with accepting medical evidence from physicians who are barred from participating in federal health programs. Although information from these physicians is not necessarily fraudulent, it could be associated with questionable disability determinations.
7 comments:
If the GOP wants to find people cheating the government, they should give more money to the IRS to detect tax cheats. That would be cost effective.
the problem isn't finding fraud, it's all over. It's having effective resources to fight it. Right now, we really on referral to the OIG, which only takes high-value cases and then passes them to the US Attorney. SSA should be given resources/authority to chase these on their own and cut/suspend benefits when it is found.
Charles can you really be that naive. Disability fraud is rampant in both RSDI and SSI. It has been rampant for years. However the next big scandal will be increased allowances across the board now that almost every case--initial and appeal has representation.
Social Security is rife with fraud, but it is overwhelmingly non-disability related. The field offices try to pursue it, but get no help nor cooperation from OIG nor any other components. Trying to downplay its existence as Charles does is as bad as misrepresenting its true nature and extent.
@ 1:28 - if that is the case, how do you explain the hard data of allowances steadily declining, not to mention the anecdotal (but intuitive) evidence of reps taking less and less cases due to the declining allowance rates?
It's easy to explain declining allowance rates. For years the Agency encouraged ALJs to pay cases to move them. They went to Congress and bragged about how their superior management skills would save the day and reduce the backlog. Now that congress has finally caught on to the huge allowance rates of some ALJs and the resultant cost, the Agency has begun to emphasize (tongue in cheek here) quality. Outlier judges are being throttled back and most other judges are more aware that they'd better have a good basis for paying a case.
At least the report draws attention to the dearth of resources on the front lines. SSA has had *plenty* of resources to limit fraud, but it has been putting all those resources at the butt end of the disability process - the Appeals Council - instead of addressing fraud as earlier in the process as possible.
It suits the Agency politically if it squeezes resources at the DDS level to make it look like the Agency is underfunded. But trace the flow of funding going to fight fraud at the very end of the disability administrative process, and you'll see thousands of new attorneys hired over the past few years being used to review the mistakes made by the underfunded components that are evaluating claims at earlier stages of the process. The whole system is messed up.
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