THE NATIONAL ASSOCIATION OF DISABILITY EXAMINERS
THE UNITED STATES HOUSE OF REPRESENTATIVES
COMMITTEE ON WAYS AND MEANS
SUBCOMMITTEE ON HUMAN RESOURCES
The National Association of Disability Examiners (NADE) commends the Subcommittee on Human Resources for focusing public and congressional attention on ” Fraud and Abuse in the Supplemental Security Income Program” and on what is being done, and what needs to be done, to combat this problem. We appreciate this opportunity to present our perspective on this topic.
WHO WE ARE
NADE is a professional association whose mission is to advance the art and science of disability evaluation and to promote ongoing professional development for our members. The majority of our members are employed in the State Disability Determination Service (DDS) agencies and are responsible for the adjudication of claims for Social Security and Supplemental Security Income (SSI) disability benefits. Our membership also includes personnel from Social Security’s Central Office and its Field Offices, claimant advocates, physicians, attorneys, and many others. This diversity, combined with our immense program knowledge and our “hands on” experience, enables NADE to offer a unique perspective that is reflective of a pragmatic realism.
THE PROBLEM
While the vast majority of applicants are not out to defraud the program, the designation of the SSI program as “High Risk” by the General Accounting Office is well deserved. For several reasons the SSI disability program is more labor intensive and difficult to administer than the Title II disability program. Both medical eligibility and exact payment amounts are determined by complex rules. Individuals applying for SSI disability benefits are among the most vulnerable of this country’s population. They are, by definition, very poor. Most have little or no ongoing medical treatment or treating sources able to provide comprehensive records. Many do not speak English and/or have little education. These individuals are strong candidates for manipulation by others for financial gain. They are often the victims themselves of others whose mission is to defraud the SSI program. Every disability examiner is aware of at least some level of questionable activity on the part of some applicants and/or their representatives.
NADE believes that the efforts undertaken by SSA and supported by Congress to combat fraud are cost-effective and also provide valuable protection to the victims of those who purposely attempt to defraud the program.
PROGRAM INTEGRITY AND THE DISABILITY CLAIMS PROCESS
For the past decade, SSA has attempted to redesign the disability claims process in an effort to produce a new process that will result in more timely and more accurate decisions. Their success in this endeavor thusfar has been minimal. NADE believes that the key to program integrity lies in the basic design of the claims process itself. We believe one of the most important challenges facing the Commissioner of Social Security is the development of an effective and affordable disability claims process. Any process must necessarily take into consideration the need for fair and timely decisions and the need for the American public to have confidence that only the truly disabled are awarded benefits. The basic design of any new disability claims process should ensure that the decisions made by all components and all decision-makers accurately reflect a determination that a claimant is truly disabled as defined by the Social Security Act.
Securing the necessary medical, vocational and lay evidence to assess claimant credibility and fully document a claimant’s subjective complaints and then accurately determine the degree of functional restrictions is currently a complex, time-consuming process. It will be made even more so in the future if SSA continues with plans to increase the focus on functionality in the medical listings. SSA and the Congress must realize the tremendous impact that increasing the need to assess claimant function will have for decision-makers in terms of time and resources. NADE is not opposed to such inclusion but the necessary resources must be provided to adequately cover the additional time and personnel that will be necessary to evaluate claims.
Pain and fatigue are legitimate restrictions that can affect an individual’s ability to work. As a result, their severity is often the deciding factor in the decision as to whether disability benefits should be awarded. Unfortunately, the lack of any objective method to measure the severity of these symptoms creates opportunities for fraud and abuse. Knowledgeable, well-trained and experienced staff is required in the Field Offices and in the DDSs to investigate and accurately assess the severity of symptoms such as pain and fatigue. There has been insufficient training of current staff to consider potential fraud and there has been too little attention devoted to the need to retain experienced staff so as to not only provide the level of customer service that claimants have a right to expect, but also to provide a front-line defense for fraudulent claims. NADE firmly believes that the decision as to whether a claimant is disabled is a medical decision that is made within the parameters defined by law and SSA regulations. As such, these decisions should be made only by those especially trained to make such decisions. Disability is based on a physical or mental medical condition and the assessment of how such a condition impacts on a claimant’s ability to work must be based on an understanding of how such conditions normally affect an individual’s ability to function. Making disability decisions can be extremely difficult without sufficient medical training. Claimants and/or their representatives could possibly present a convincing argument that the claimant is more disabled than is really the case. Consequently, NADE supports requiring similar medical training for all decision-makers at all components in the disability claims process.
Efforts launched by SSA in the past decade to bring DDS and ALJ decisions closer together have been unsuccessful. Process unification was the cornerstone of this effort. Decision-makers in the DDSs and OHA were brought together in 1996 for joint training. However, SSA’s failure to follow up on this training initiative in the years since have eroded any potential benefits that may have been derived. NADE believes that such joint training is critical to the ultimate success of anti-fraud efforts and we concur with the opinion expressed by the Social Security Advisory Board in a recent report issued by that body: “The most important step SSA can take to improve consistency and fairness in the disability determination process is to develop and implement an on-going joint training program for all…disability adjudicators, including employees of the State disability determination agencies (DDSs), Administrative Law Judges (ALJs) and others in the Office of Hearings and Appeals (OHA), and the quality assessment staff who judge the accuracy of decisions…” (see Social Security Advisory Board report, August, 1998, p.19)
PROGRAM INTEGRITY AND QUALITY ASSURANCE
Program integrity requires accurate and consistent disability decisions from all components in the adjudication process. An effective quality assurance process provides an effective deterrent to mismanagement and fraud in the SSI program. NADE believes that SSA must incorporate a more uniform quality assurance process into the basic disability claims process to ensure program integrity. We are concerned with recent SSA and congressional initiatives to require pre-effectuation reviews in 50 percent of State agency allowances of SSI adult cases “in order to correct erroneous SSI disability determinations …”. The decision regarding an individual’s eligibility for disability benefits should be objective and unbiased. For that reason NADE has long advocated review of an equal percentage of allowances and denials. Realistically, however, without additional resources any increase in the percentage of allowances reviewed will result in a corresponding decrease in the number of denials reviewed. While we support increased reviews of decisions at all levels, we are concerned that an increased focus on DDS allowances may reduce objectivity and compromise program integrity. In addition, without a corresponding review of OHA allowances it is unlikely that the projected program savings will be realized.
Any increase in the number of decisions reviewed should also include childhood claims. While it is not true for the majority of applicants it is, unfortunately, not unheard of for parents or legal guardians to deliberately coach children to feign disabling conditions or to use other means to create circumstances where a child’s true condition will be misdiagnosed.
INITIATIVES TO COMBAT FRAUD AND ABUSE
Anti-fraud efforts such as the Cooperative Disability Investigative (CDI) units which effectively utilize the strengths and talents of OIG, disability examiners, and local law enforcement, offer a visible and effective front-line defense for program integrity and serve as a visible and effective deterrent to fraud. Our members have a unique opportunity to observe and assist in the process of detecting fraud and abuse within the SSI program. SSA’s Inspector General, Mr. James Huse, Jr. has attributed the success of the CDI units to investigate fraud allegations to the efforts of, “…those most qualified to detect fraud – DDS adjudicators.” NADE supports the continued expansion of the CDI units to combat fraud and abuse in the disability program.
NADE supports SSA’s plans to increase the number of re-determinations to ensure greater payment accuracy. This would help ensure that claimants receiving SSI benefits are, in fact, eligible to do so. We caution that adequate staffing will be needed to ensure that this effort is a true exercise in combating fraud and not a mirror and strings approach to conceal the fact that SSA is not equipped to pursue such anti-fraud efforts. Field Offices have a great responsibility in ensuring program integrity and they should be supported with the sufficient staffing level required for this effort.
An experienced disability examiner can be one of the most effective deterrents to fraud and abuse. NADE urges Congress and SSA to take the necessary action to ensure that the experience level in the DDSs can be maintained. SSA has made the commitment to process record numbers of continuing disability review cases (CDR’s). Adequate resources should be allocated to the DDSs to reward experience and maintain a highly knowledgeable, well-trained, and fully equipped staff.
NADE supports increasing the penalties for unintentional and intentional acts of fraud. Penalty amounts of $25 for a first offense, $50 for a second offense and $100 for subsequent offenses should be increased substantially for unintentional acts of fraud as a deterrent to repeat offenses. NADE supports increasing the suspension of benefits for intentional acts of fraud to include the permanent suspension of benefits for a third offense. NADE believes that all intentional acts of fraud should be referred to the proper judicial authority for criminal prosecution.
NADE also supports the immediate suspension of benefits in CDR claims where the DDS proposed a cessation of benefits because the claimant has failed to cooperate or cannot be found. Currently, claimants can appeal these decisions and elect to continue receiving benefits under the benefit continuation provisions. By failing to cooperate with the DDS, claimants can continue receiving benefits for years. While this may not be viewed as fraud, it is abuse and it should be eliminated to ensure program integrity.
CONCLUSION
NADE supports the removal of SSA’s administrative budget from the domestic discretionary spending caps. Congress would continue to retain oversight authority of SSA’s administrative budget but it would not have to compete with other programs for limited funds. It would allow for the growth necessary to meet the increasing needs of the baby boomer generation for SSA’s services while allowing the Agency to expand its anti-fraud efforts to ensure program integrity.
Maintaining program integrity is a vital part of effective public administration and a major factor in determining the public’s view of its government. The Social Security Administration must provide more direction in the development of anti-fraud policies and these policies should reflect pragmatic reality that will make them enforceable. SSA must recognize that more direct guidance is needed from its top levels of management if fraud and abuse are to be effectively curtailed. It is also critical that SSA should be given the congressional support necessary to make the appropriate changes that will recommit the Agency to its primary purposes of stewardship and service.