SSA Office of Inspector General issues Semiannual Report to Congress

Last week the Social Security Administration Office of the Inspector General (“OIG”) issued their Semiannual Report to Congress.  It summarizes their auditing activities within the last six months and provides statistics on their investigations.

Does it seem like there are a lot of Continuing Disability Reviews in California?  It is because there are.  The OIG has a unit called Cooperative Disability Investigations (“CDI”) in which they work with State Disability Determination Services (“DDS”) and local law enforcement to identify and resolve issues of fraud and abuse in continuing disability claims.  The OIG received 570 allegations in California alone, more than in any other state.  Of those cases, 183 of them were denied.  I.e., benefits were terminated.  The OIG estimated that this resulted in a $12,505,334 savings to SSA. So interestingly, less than half of them resulted in benefits being terminated but would explain why it seems we are seeing many continuing disability reviews.  (See p. 21 of the report.)  (It should be noted that these statistics reflect only those allegations that the OIG acted upon.  SSA conducts more that are not initiated by OIG.) Continue reading

Report on California Disability Determination Services shows failure to properly adjudicate

On May 25, 2011, the Social Security Office of Inspector General published a report entitled., “Failure to Cooperate Denials and Initial claims Backlog at the California Disability Determination Services.”

As background, the Disability Determination Services (DDS) in each state performs the disability determinations under the Social Security Administration’s (SSA) Disability Insurance and Supplemental Security Income Programs.  The determinations are required to be performed in accordance with federal law and regulations.

The Commissioner of Social Security requested that OIG investigate the California DDS based on testimony presented to a Congressional committee that the CA DDS may have been improperly denying the claims of disability applicants who failed to return a 25-page form within 20 days.  (A claimant is required to cooperate with DDS in obtaining evidence about impairments from medical and non medical sources.)  When an individual fails to cooperate (“FTC”), the DDS will make a decision based on available information.  The testimony also questioned whether the CA DDS might have been concealing its backlog of initial claims by assigning them to fictitious employees.

The OIG reviewed 165,000 CA DDS claims for the period of July 1 through December 11, 2009.  Of these decisions, approximately 6,600 (4 percent) were FTC denials.  The Stockton and Sacramento branch offices had the highest FTC denial rates – 11 and 6 percent, respectively.  For their audit, the OIG randomly selected 150 FTC denials for review:  50 each from the Sacramento and Stockton branch offices and 50 from the remaining 9 branch offices.

Based on their review of 150 FTC denials, the OIG found 37 (24.7) percent did not comply with SSA’s policies and procedures.  Specifically, CA DDS did not:

  • evaluate and follow up on medical evidence submitted for 18 claimants;
  • request evidence, when required, for 7 claimants; and
  • contact third parties for 12 claimants who required special assistance because of mental impairments.

OIG also found that “CA-DDS branch offices’ interpretations of the FTC polices resulted in an inconsistent level of service for disability applicants.”  They “found no evidence that CA-DDS understated the size and age of its initial claims backlog.”

“The inappropriate FTC denials generally occurred because CA-DDS did not have adequate controls to ensure its employees complied with SSA’s policies and procedures.”

The OIG made specific recommendations on how to improve DDS’ adjudications and the Social Security Administration agreed to the recommendations.

You may read the entire report and find out what happened to the claims wrongly decided by clicking on this link: Failure to Cooperate Denials and Initial Claims Backlog at the California Disability Determination Services.

I think what we can learn from this type of report is that it is always worthwhile to appeal an adverse decision.  The OIG was only looking at a very narrow selection of cases.  We all know initial and reconsideration denial rates are high.  Chances are, some of them are incorrectly decided.