From KSHB:
When additional medical evidence is needed to approve a disability benefits application with the Social Security Administration, the agency requires applicants to get a consultative exam with a doctor.
In the Kansas City region, Midwest CES is one of several contractors working with the government to provide the exams.
Shiron Norah visited one of Midwest CES’s locations in 2018 during her application process. The lifelong Kansas Citian says she can no longer work because of a series of ailments, including carpel tunnel in both wrists, hip surgery, pain in her neck and back, constant migraines and arthritis.
Norah said the doctor at Midwest CES spent less than 10 minutes with her and did not ask her a single question. The doctor’s report cited Norah’s ability to “use her fingers and hands to button and unbutton a shirt,” but Norah says she was not wearing a shirt with buttons during her exam. ...
Kyle Sciolaro, an attorney at BurnettDriskill, says he’s found roughly 250 other people in Norah’s shoes. They visited Midwest CES for a consultative exam and subsequent reports had similar language about buttoning their clothing or turning doorknobs - even though the exam rooms at Midwest CES’ North Kansas City office doesn’t have doorknobs.
In a series of civil lawsuits against the Social Security Administration, Midwest CES and doctors conducting exams, Sciolaro and his team allege fraud. ...
A lawsuit under the False Claims Act allows BurnettDriskill to file a case on behalf of the United States and its taxpayers. It alleges the Midwest CES knowingly submitted false information for payment. ...
President of Midwest CES Jake Johnsen responded to the claims. He calls the exams his company completes “a critical service” that helps prevent fraud. Johnsen pointed out Midwest CES does not know which results will lead to approval or denial of a claim. The government pays contractors like Midwest CES the same whether an applicant qualifies for benefits or not. ...
45 comments:
we need to weed out the bad providers. DDS is supposed to get the treating doctor but it i s very rare to have do them - they aren't familar with what is needed and don't want the fee allowed.
This type of what I call "drive-by" exam is common for CEs. In fact, it is the norm. And, I think the agency knows this and is fine with it. I get the impression that the agency really doesn't want an opinion from anyone other than their own DDS doctors. Unfortunately, often, the DDS doctors are not reviewing the records. But, this all leads to many denials and so, as long as the numbers are where they want them, the agency doesn't care. I think the agency knows if they were getting good solid exams and opinions, the number of allowances would increase. So, they like the system the way it is even though many claims do not get any meaningful review. As far as ALJs it makes their job simple if they can just point to the CE and DDS opinions without any real critical analysis of these opinions are the records. That is what we see more often than not.
I recently had a court order that the agency submit the interrogatories I had submitted to the DDS doctors. The responses I got back to specific questions about what evidence in the record supported their opinions were basically, the evidence that supports my opinion supports my opinion. It was painfully obvious that these alleged doctors had made no attempt to seriously review the evidence as they were unable to provide any substantive support, whatsoever, for their opinions. If anyone has any suggestions for a cause of action against these guys, please let me know.
Can SSA sue the GP that just fills out a questionnaire by just asking the claimant what they want them to say?
9:30 Use a little critical thinking instead of just spouting anti-claimant vitriol. These CEs are falsifying reports. They are saying x or y test was performed and the claimant had no difficulty performing x or y test. The CE's are also attesting under penalties of perjury that the examination report is accurate.
This isn't a doctor saying they believe the claimant can only lift 10 pounds without explanation or support. This is a doctor saying the claimant did something that the claimant did not do. That is not an opinion. That is criminal conduct under the agency regulations.
By the logic of 10:21 the GP is falsifying reports if they just put down what the claimant tells them to put down without testing. Get off your high horse, you cant have it both ways.
Good. We've seen similar discrepancies but my state shields CEs from liability.
@9:30
If the medical source is using their medical judgment when deciding whether to concur with what the claimant is telling them, that's not fraud. If the medical source is just parroting what the claimant is saying, possibly, but more often than not, ALJs just assume a medical source agreeing with what their patient is telling them renders the medical source's opinion equivalent to a claimant's testimony and therefore to be rejected out of hand (unless the claimant's testimony supports a denial obviously), which is absurd.
@10:21 - Any other doctors falsifying records would be nailed to a jail cell immediately. CE's? Naw.... not if it supports SSA and not the claimant. Why would DDS/SSA complain? The patient, on the other hand, needs to step up and say that they were mistreated by SSA and the CE by not having a THOROUGH exam done, even if the doctor says it was done. That's fraud, which is criminal, which is obviously illegal, which should be prosecuted regardless of the outcome of the CE or the outcome of the DDS's case. In more cases than not (apparently), nothing is done. It's like SSA's HQ is located on a beach in Florida. *Eyeroll*.
Just keep on keepin' on the way it is, illegal or not. *shrug*. I'm personally one that would DEMAND a further examination, or I would find a way to afford an attorney to go after the physician that provided likely false information to SSA. I would not stop until said doctors license was revoked, and I received an unlikely apology from SSA.
Wouldn’t it be more beneficial for the claimant to get a consultation by someone not contracted by the agency they’re trying to get benefits from?
Can their attorneys set up an appointment for them as part of the process and then submit the findings on the claimant’s behalf?
I don’t think I’d trust a government agency I’m trying to get benefits from to set me up with a doctor that would win the case for me.
I had a CE who missed the fact my client had cerebral palsy. Another kept referring to my client's above-the-knee amputation as below-the-knee. I heard a few years ago about a CE finding no pulse in a claimant's ankle, without noting the amputation.
@9:19… you sure it was DDS and not one of your client’s treating sources? Because it sounds an awful lot like the support a treating source puts on their MSSs.
Actually, never mind. That’s more support than a treating source typically provides on the forms that you want everyone to find persuasive and adopt.
@11:56
Absolutely, but often claimants are not aware of that concept at all, because SSA says they will first contact their treaters (they don't), and they are proceeding unrepresented so nobody tells them they can get their own doctors' statements.
@12:25
We had a CE say someone had 20/20 vision in both eyes, including the glass one.
@12:46
I would say in about 90% of DDS medical statements, there is literally no explanation provided, at best they give boilerplate reasons and/or cite non-medical evidence, like a claimant's statement report is not consistent with the objective medical evidence, so therefore they have exactly the exertional capacity to not direct an award under the medical-vocational guidelines. Odd how that works out. Almost like DDS doesn't was to get their "accuracy rate" lowered, which is part of our state's budgeting process considerations.
CE is a volume practice if the report is wrong tell the ALJ at the hearing. Treating sources have a financial interest and want satisfied patients who return and continue booking appointments. You might see a case paid relying on a CE, you'll never see a case denied relying on a treating source.
It still barely matters, ALJs are gonna do what they wanna do. The process grants enough discretion that almost any case can be paid or denied based on almost any evidence in most circumstances. The whole process is nonsense. Lawyers shouldnt be deciding medical cases. So called objective evidence often is not objective. One radiologist could look at an MRI and call it moderate degeneration while another may look at the same image and call it marked but we call it all objective and the characterization is never questioned. One examiner could rate strength 4/5 while another could rate the same strength at 3/5. Its mostly nonsense, its just if the alj wants to pay you or not.
11:40 doesn't understand that these CE's are billing the government for a service, not performing the tests described in the service agreement, and putting in the report that the service was performed and the claimant had no limitation in tests that were not even performed.
It is useful to see comments like 9:30 above because it is a window on what many within the Agency believe. You cannot assume that a doctor simply parrots what the patient tells them, although for sure, some of them do.
The reason we don't usually pay for our own exams of clients is because the ALJ won't believe them either. It is a waste of money and time.
What I would love to see is a treating physician sit down and write a narrative report with references to the record as to why they believe what they say. But very few are willing to do that, even if you pay them.
Like every one else, I can recite CE reports that make reference to things that did not happen in the exam including things that could not happen My client with one hand could not grip objects in that hand.
The Agency wants reports quickly and cheaply and this is what they get.
If the agency is not holding its contractors accountable for paid services then oversight is needed, either from the Courts or the agency assigned to perform that oversight. Does anyone know if these incidents were reported to OIG, and whether it is doing anything about them?
Some of the commenters here show the agency's significant and unjustified bias against the opinions of treating physicians. The Social Security Act (the law for the those of you who work for the agency) actually places significance on information from the treating physician. But the agency is above the law so it chooses, very often, to ignore this evidence based on an irrational bias. However, even if the agency's bias against treating physician's were justified, how can they justify reliance on the DDS doctors who don't review the evidence? Why do we see so few ALJs (or decision writers) who actually analyze these opinions (both the DDS and treating doctors) for consistency AND supportability? They simply make conclusory statements most often that the opinion of the treating physician is not consistent with the evidenced and the DDS opinions are. And, I love it when I see the opinions of treating physicians rejected as they are on "check-box" forms when they actually contain more substance that the DDS opinions. Many ALJs are either too lazy to do the real analysis, or simply want to please the agency with denials. For those of you who work for the agency and think all of these thousands of physicians are willing to lie for claimants, do you think the DDS consultants are not being influenced to deny claims?
Why do the DDE forms not contain an attestation statement affirming, under oath, the the DDS doctor reviewed all of the evidence? Why are the DDS doctors qualifications never made part of the record?
@9:09 AM: "As far as ALJs it makes their job simple if they can just point to the CE and DDS opinions without any real critical analysis of these opinions."
And that is exactly what 90% of them do, because there are no consequences for doing the job wrong, and no incentives to spend time doing it right. Then a writer making a fraction of the ALJ's salary gets to either struggle for hours to find some way to support the ALJ's finding, or perform a quick, haphazard review of the medical records, cherry pick a few shreds of supportive evidence, and throw together a haphazard argument, knowing that 90% of the ALJs don't review the decisions they sign either. Guess what most writer's do? So, garbage in; garbage out.
EVERYBODY above is correct. I get reports from certain CE doctors and I pretty much know what is going to be in there. I get reports from certain doctors to whom claimants have been sent by their reps - and I know pretty much what is going to be in there. There are a few doctors whose names I like to see on the CE reports because I know they are going to be thorough reports with real testing done, and that helps me to make a better decision. Most of the reports I see contain very little explanation and very little in the way of citation. I would prefer it if we sent people to physical therapists who tend to do a much better job at actually testing people for workplace functioning. I would also like to have internal support from real writers versus clerks who have spent enough time in the agency so that some manager thinks they now deserve a promotion. All of this costs more money - - and there still is no guarantee that any of us will arrive at the absolute truth of the matter concerning a claimant's residual functional capacity.
C'mon, guys. Can't you understand the obvious? They're paid to give SSA a denial! They're not looking for the TRUTH. They know that, SSA knows that. Haven't rheir employees told you enough about fair? They tell you that's where you find the pigs.
Fear of consequence is a powerful motivator. When there is no fear of consequence people tend get sloppy and lazy in their work. One big difference between treating sources and CEs is that the law places a duty of care to the patient on treating sources, while it does not for CEs. Miss spotting a cancer? Treating source is liable. Same mistake, the CE is not, and they know it. They don’t have to be as careful to avoid consequences. If you add insufficient government oversight of CEs it makes it worse. Lawsuits like the one featured are badly needed.
“there are no consequences for doing the job wrong, and no incentives to spend time doing it right”
You just summed up the agency as a whole with that comment. This is true at all levels. I hate it.
My favorite is those cases where the CE actually says the claimant is disabled and DDS (who ordered the CE exam) denies the case anyway because the DDS doctor says the CE's findings aren't supported by the evidence. If the evidence supposedly indicates a denial should be issued regardless of what the CE would say, then exactly why did SSA order the CE in the first place then? These cases make for wonderful Federal Court cases with wonderful EAJA fees to be awarded if the ALJ affirms the DDS denial.
Fraud is fraud. Based on the above comments, I'm now more concerned than ever that some at SSA have no problem with this.
If you order thousands and thousands of CEs through a particular provider, and that provider uses the exact same boilerplate language over and over about the claimant being able to button a shirt and turn doorknobs, you should catch on that these CEs are of little to no value. When these CEs get used over and over to discredit a claimant's allegations, it casts doubt on the fairness of the system.
It's a scary day when SSA employees start saying "it's fine that we do this because we think the forms you guys submit aren't credible."
Our system of government only works when there's faith that the system isn't corrupt. Comments on this post destroy that faith.
They order the CEs because they’re too lazy to read the treatment notes.
@505 Just a claims representative so don't know much about CEs but was told by DDS examiner that some CEs are mandated to rule out something that isn't that disabling for the claimant. At one time if they alleged any kind of mental impairment (anxiety for instance) those had to be addressed by CE if no treating sources. That may not be correct but that was what we were told on a DDS visit.
Regular FO employees have no contact with CE’s or are even involved in the process at all.
CS’s take claims and send them to DDS…period. We don’t schedule CE’s, we don’t recommend a CE and we have no clue if a claimant has a CE scheduled unless DDS can’t contact the claimant and asks us to try and make contact.
I’ve read maybe a handful of CE’s in almost 20 years because it has no impact on what we do in the field office.
All I do know, is when someone files a claim for disability and has zero medical sources, I have very little hope they will get approved. They usually ask if the agency will send the to a doctor to get evaluated and my response is always the same: I have no idea. That up to the DDS examiners.
I tell my clients you usually get a fair CE about 20-30 percent of the time. At a hearing, you usually get a fair ME about 50-60 percent of the time because they review all the records so it is harder to come up with an extremely bogus RFC.
The SSA should quick to the pretense. They gravitate the contracts to DDS and CE doctors that tend to deny. But in reality, the SSA does ultimately only really care about churning out cases as quick as possible. Same applies with ALJs. ALJs are favored more for blowing through cases than their denial rate.
It's a game.
To reps out there - why do you let your client's attend these CEs with bad doctors? A couple of years ago we started saying no. At first we got a lot of pushback from DDS. They were shocked that we would say no to them. Eventually, they got used to it. What we try to do when they ask for a CE is to get a physical by a treating doctor. We do have a few CE providers that we will let our clients go to. Even if we can't get something from a treating doctor we'd rather have a denial based on insufficient evidence than a bad report that some of the ALJs will then rely on. Seriously, if you are letting your client's go when you know how the report is going to come back ....
@11:02
Maybe because there's fear of a denial for failure to cooperate. I like the idea you present, though. If the treating doctor will perform the physical, this is much better than a CE that will probably have boilerplate language later used to deny the case.
Technically, the cannot deny for failure to cooperate. I think they can on a continuing review but not on an initial claim. Some DDS folks think they can and will cite the regulation on the continuing review. The regulation says they are supposed to make a decision on the information they have but you may get a denial on insufficient evidence which, again, is better than having that bogus CE report in the file.
It is also interesting when they say they could not get an opinion from the treating physician but then we get one. The regulation say they should try to get the opinion from the treating physician but they don't. I've even had some DDS examiners tell me they want the opinion from "their" doctor. I find it amazing how many DDS examiners, ALJs and decision writers don't know the regulations they are supposed to be applying every day.
I just have to ask the "obvious" question. ALJs do know that these are "drive by" "exams," designed not to find truth, but only to give THEM supposed "evidence" to support a denial, right? As such, it give them an excuse to deny... However, integrity requires a JUST decision, not a legally supported denial. ALJs do understand they will be judged on their decisions, right?
@Tim: Of course they know. But ALJs are mostly with whether a claimant "deserves" benefits, which is a calculation based largely on race, and (to a lesser extent) age, whether the claimant uses drugs or alcohol, and whether the claimant's work history shows they have a "good American work ethic." If you don't believe me, look at the data. And top brass are well aware of this. Why do you think SSA stopped publishing data about the race and ethnicity of claimants right after GAO issued a report on the subject?
We had one really bad outfit that did these exams, but after numerous complaints, they were no longer used.
When ordering CEs in the DCPS system, one has to click 2 boxes. 1. Why are you ordering a CE? 2. Why aren’t you using the treating physician? Training glossed over this as largely unimportant, suggesting choosing lack of evidence for 1 and for 2, the treating physician is unqualified to perform the CE.
As for medical opinions and consistency, we all have collections of statements that we use repeatedly, with necessary changes. In fact, a good deal of what we do relies on using canned statements passed on from trainers that we paste into claims. We have to in order to keep up with the workload.
@910 10/21 "If anyone has any suggestions for a cause of action against these guys, please let me know." I have would love to discuss this further with you, since I assume you're the fighter bringing this articles complaints to light. How do I get in touch?
Not sure if that comment was intended for me, but if it was, feel free to email at ksciolaro@burnettdriskill.com
It would be nice if the cases mentioned in the article would substantiate into something meaningful, since the process needs overhauled. Why go after the individual GPs mentioned in the article and not the contractor mentioned? The GPs are described as residents physicians, is that true? are they insured? Seems like they would not be the best person to get money from in trial.
@440 Hopefully change comes out of the lawsuits; as reform in this process is needed at all levels. Has the outfit in your region ceased? The article mentions the providers are resident physicians; why not go for the contracting company? Seems like that would be a more fruitful endeavor both for making an impact statement towards the ssa process and for your time/services/money.
Yes, we are also going after the company. We have a qui tam matter pending, as well as other causes of action. There's insurance, but also coverage disputes. The company still operates, but their practices have changed some. We've also pursued this diligently at the administrative level (requests for subpoenas, client statements, submission of redacted reports illustrating the scheme, and correspondence from the owner where he instructs examiners to "cut claimants off" and to stop at 20 minutes.) We're also presenting the argument at the district court level against the Commissioner. We've seen five remand orders so far for new hearings. The examiners are almost always residents (typically in a field unrelated to orthopedics, neurology, physiatry, etc.). Some are NPs.
Fascinating. Hopefully you accomplish change, as it’s needed. I hope the resident doctors learn a valuable lesson for their future careers, since based on the rhetoric in the article and comments above, it seems like you’re trying to scare them from working in this capacity.
Whats the status of these? Im sure the law firm that filed these is doing quite well now; since they took out the "largest" CE provider in Missouri. probably intentional to maximize client's backpay and therefore firm fees.
Still pending. Complicated. Just gave an update here at NOSSCR. My email is ksciolaro@burnettdriskill.com. Happy to talk.
Reading this article and others that google took me too. It looks like one of the doctors alleged (Dr. Tran) was resident in physical medicine and rehabilitation. I didn’t even know that speciality existed and the CEs my firm received were by someone that is not just one foot out the retirement door of medicine. The alleged doctor looks to still be practicing medicine, which is hard to believe given the allegations being made. Hopefully someone took these allegations serious and investigated them. Although I find the premise of the articles premise that these doctors were defrauding the government, a little hard to believe. But if true is huge; if not the law firm sure injected enough poison and doubt into their local field office, alj, and district courts that now they can get a “get out of jail free” card for each of their clients. Maybe more lawsuits like these can come out across the country to promote a change?
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