Social Security Program Integrity Activities





By Terri Spurgeon, President

Chairman Shaw and members of the Subcommittee, thank you for this opportunity to present the viewpoint of the National Association of Disability Examiners (NADE) on the Social Security Administration’s program integrity activities. We appreciate your vigilant oversight of the Social Security program and willingness to obtain input from our Association and others with expertise in, experience with, and understanding of the issues facing the Social Security and Supplemental Security Income (SSI) programs at this time.

NADE is a professional association whose purpose is to promote the art and science of disability evaluation. Our members, whether they work in the state Disability Determination Service (DDS) agencies, the Field Offices, SSA Headquarters, OHA Offices or in the private sector, are deeply concerned about the integrity of the Social Security and Supplemental Security Income (SSI) disability programs. Simply stated, we believe that those who are entitled to disability benefits should receive them; those who are not, should not.

As we have stated in previous testimony presented to this Subcommittee – and again quoting Robert J. Myers, former Chief Actuary and Deputy Commissioner of Social Security, “…Proper administration of an insurance system -whether social insurance or private insurance-requires that administrative expenses should be neither too low nor too high. In the latter case, the funds available for benefits would be eroded. In the former case, inadequate service would be provided. In fact, in some instances weak administration could mean improperly excessive benefit payments due to fraud and abuse.” (emphasis added). We continue to urge the Congress to work with the Social Security Administration to provide sufficient resources to effectively administer the disability program, including appropriate staffing levels, ongoing training (for all components) and clear and complete instructions when program changes are promulgated. All of these are essential if we are to effectively administer the disability program and minimize fraud, waste and abuse.

Our members have a unique opportunity to observe and assist in the process of detecting fraud and abuse within the system. For years our members have been concerned with the growing public perception that there was rampant abuse. All too often we dealt with the phone call from a member of the public pointing out that their next door neighbor was collecting disability benefits while they were able to do all kinds of things, such as fixing up their houses or working on their cars and so on.

For too long that was a phone call we would listen to and try to provide the person with an outlet for their concern by directing them to the nearest Social Security field office even though we knew there was little, if anything, that would or could be done about it.

We strongly support SSA’s joint efforts with the Office of Inspector General (OIG) and the DDSs to create a growing number of program integrity/anti-fraud units that are focused on disability program issues. Such initiatives combine the knowledge and talents of OIG, SSA and DDS staff for a more visible and effective front-line defense for program integrity. While the vast majority of applicants for disability benefits are not out to defraud the program every disability examiner is aware of at least some level of questionable activity on the part of some applicants and/ or their representatives. Chairman Shaw has pointed out that, “We wouldn’t need to combat fraud if people were angels. Unfortunately, they’re not.” Our members have worked directly with staff from the OIG to report situations in which we believe there is an attempt to defraud SSA. We have also found the OIG very receptive to those calls that used to just frustrate our members and staff at the SSA field offices. The fraud hot-line is a great place to refer the phone callers that we talk with who have concerns about the activities of other members of the public who are receiving benefits illegally.

Individuals applying for Social Security or Supplemental Security Income disability benefits are among the most vulnerable of this country’s population. Many are poorly educated, do not speak English or have poor life coping skills. These individuals are often victims of those who are out to defraud the program. OIG and the anti-fraud units are not only cost-effective, they provide valuable protection to the victims of those who are defrauding the program.

While the anti-fraud units are an invaluable tool in identifying and combating fraud, program integrity also requires consistent and accurate disability decisions at all levels in the adjudication process. This has been an issue of ongoing concern for our members. There is a pervasive public perception that “everyone” is denied disability benefits twice and their claim is allowed only when they reach the Administrative Law Judge(ALJ) level. The Disability Process Redesign plan issued in 1994, with its emphasis on “Process Unification” and the “One Book” initiative, was intended to simplify the adjudication process and to address the growing disparity between DDS and ALJ decisions; to bring DDS decisions and ALJ decisions closer; to allow more claims earlier in the process (at the DDS level) and reduce the number of ALJ reversals. The “One Book” initiative specified that all policies were to be issued as Rulings, binding on both the DDSs and the ALJs. Extensive joint training was conducted in an effort to increase communication between the DDSs and the Hearing Offices and to assure that all adjudicators would hear the same message. Unfortunately, this joint training, necessary to maintain the process unification effort, has not been continued.

Various elements of the Disability Process Redesign plan were piloted across the country and in March 1999 Commissioner Apfel announced that a new process, combining several elements of that plan, would be prototyped in 10 states. This new process includes the elimination of the reconsideration level of appeal; increased claimant contact with the DDS decision maker; a claimant conference (contact with the claimant -generally by telephone-to complete the record and explain the process if a fully favorable decision can not be made on the claim) and increased emphasis on subjective complaints such as pain and fatigue. Except as mandated by law (mental impairment claims being denied and SSI childhood claims) physician sign-off is not required. Although DDS staff physician input is available, it is the disability examiner who is responsible for assessing credibility and determining the claimant’s ability to perform work related activity. The precepts of Process Unification are an integral part of this new process.

While NADE fully supports the principle that a claim should be allowed (if appropriate) as early in the process as possible we do have some concerns about the increased reliance on self reported subjective complaints when assessing an individual’s ability to return to work.

Pain and fatigue are legitimate restrictions and must be considered in any disability decision. However, assessing these complaints, and the extent to which they limit an individual’s ability to function, assessing credibility, and assuring uniform and consistent decisions, requires trained and experienced staff and a strong, nationally consistent quality assurance review process. Unfortunately, the reality is that nearly 50% of all disability examiners have less than two years of program experience. This increasing lack of experience creates many problems for the DDS’s and SSA, not the least of which is that efforts to combat fraud are often limited by the lack of sufficient resources to train new personnel in anti-fraud issues. The training budgets for most DDS’s are pushed to the limit just to keep up with their increasing number of new hires as more and more experienced DDS personnel leave. The combination of inexperience and lack of resources to maintain an efficiently trained staff is magnified by SSA’s fragmented and inconsistent quality assurance review process. This Association has commented previously regarding the quality assurance issue and we have also addressed our concerns to SSA, offering the expertise of our members should the Commissioner agree with our position that SSA’s quality assurance review process should be revised. To date, SSA has disagreed with our position, maintaining that their quality assurance review process does not need any revision or refinement. Unfortunately, SSA’s position is unrealistic and contributes to a growing lack of confidence in the program. DDS decisions are not reviewed consistently across Regions and DDS and ALJ decisions are not reviewed under the same standard. This subcommittee has asserted in its own prior comments that, “Maintaining program integrity is a vital part of sound public administration and a major factor in determining the public’s view of its government. More importantly, maintaining program integrity means protecting those who may not be able to protect themselves.” We wholeheartedly agree with this assessment. However, we wish to make clear the central point that program integrity cannot be maintained without extensive, ongoing training for all adjudicators and clear and consistent messages from the quality assurance review process.

Securing the medical, vocational and lay evidence to assess credibility, fully document subjective complaints and accurately evaluate functional restrictions is currently a complex, time-consuming process. It will be even more so in the future as SSA continues its revision of the medical listings that will place more emphasis on the claimant’s functional abilities, and proceeds with a national roll out of its new disability claims process. These two events will increase the responsibility on disability examiners to devote more of their time and energy to address these very subjective issues of pain and claimant credibility. Congress and SSA must realize that these increases in time and resources that must be devoted to each case must be matched with increases in personnel and financial resources to adequately and accurately address such issues.

We are including an attachment with our testimony that serves to highlight the problem with claimant initiated fraud. In this case, the CE provider to the DDS, quite by accident, discovered the claimant was a fraud. This example does highlight one of the problems that will become even more common as the public’s perception that committing fraud is easy and carries little or no risk of punishment. Again, we commend SSA and its OIG staff for their initiatives to combat fraud. It is real and the problem will only get bigger unless we invest sufficient time and resources to combat the problem now. The public must be made to perceive that fraud will be detected and will be punished. Cuts in SSA’s administrative budget will not help this situation. A poorly trained and inexperienced DDS staff will not help this situation.

Consistent and accurate initial disability decisions are essential to restoring and maintaining program integrity and public confidence in the disability program. Equally important are the continuing disability reviews (CDRs). Individuals who are no longer disabled should not be receiving benefits simply because resources are not available to conduct reviews. We commend Congress and SSA for the progress made in reducing the backlog of CDRs. This initiative has resulted in significant program savings. It makes sound financial sense for Congress to continue to appropriate resources so that the CDR backlog can be brought up to date and kept current.

We believe that SSA is taking a number of positive actions to address the issues of fraud and abuse. There are other areas within the system where we believe additional actions could be pursued. Unfortunately, budget cuts and downsizing of SSA staff in recent years will make it extraordinarily difficult to pursue these actions without additional resources.

Thank you for the opportunity to present this statement for the record. We remain committed to assist in any effort to improve the Social Security and Supplemental Security Income programs.