THE INSPECTOR GENERAL
SOCIAL SECURITY ADMINISTRATION
By conducting independent and objective audits, evaluations and investigations, we inspire public confidence in the integrity and security of SSA's programs and operations and protect them against fraud, waste and abuse. We provide timely, useful and reliable information and advice to Administration officials, Congress and the public.
The Inspector General Act created independent audit and investigative units, called the Office of Inspector General (OIG). The mission of the OIG, as spelled out in the Act, is to:
Conduct and supervise independent and objective audits and investigations
relating to agency programs and operations.
Promote economy, effectiveness, and efficiency within the agency.
Prevent and detect fraud, waste, and abuse in agency programs and operations.
Review and make recommendations regarding existing and proposed legislation and regulations relating to agency programs and operations.
Keep the agency head and the Congress fully and currently informed of problems in agency programs and operations.
To ensure objectivity, the IG Act empowers the IG with:
Independence to determine what reviews to perform.
Access to all information necessary for the reviews.
Authority to publish findings and recommendations based on the reviews.
We strive for continual improvement in SSA's programs, operations and management by proactively seeking new ways to prevent and deter fraud, waste and abuse. We commit to integrity and excellence by supporting an environment that provides a valuable public service while encouraging employee development and retention and fostering diversity and innovation.
Date: May 31, 2007
To: The Commissioner
From: Inspector General
Subject: Quick Disability Determinations (A-01-07-17035)
Our objectives were to (1) determine whether cases selected for Quick Disability Determinations (QDD) were processed within the guidelines established by the Social Security Administration (SSA) and (2) identify any possible improvements to the QDD process.
SSA established the QDD process under its new Disability Service Improvement
(DSI) initiative in the Boston region to enhance the Agency's current disability
determination process. QDD claims are initial disability claims that are electronically-identified
by a predictive model as involving a high potential that:
The claimant is disabled;
Evidence of the claimant's allegations can be easily and quickly obtained; and
The case can be processed within 20 calendar days of receipt in the Disability Determination Services (DDS).
As the DDS assesses the medical evidence to determine whether the claimant is disabled under the Social Security Act, the SSA field office staff assess the non-medical factors of eligibility, such as evaluating work activity or developing proof of age. If a claim is selected for QDD processing, the SSA field office is required to complete all necessary non-medical development as quickly as possible, with a goal of no more than 20 calendar days.
To perform this review, we obtained a file of all initial disability claims selected for QDD processing through October 31, 2006. We analyzed disability determination records, benefit records and electronic disability folder information for these 667 individuals. We also obtained a file of all claims-27,648 in total, including the QDD cases-designated as DSI cases through October 31, 2006 and analyzed disability determination records for these cases. (See Appendix C for additional information on our scope and methodology.)
RESULTS OF REVIEW
We found that SSA generally made medical determinations for claims selected for QDD processing within the standards established for the pilot. Additionally, based on feedback we provided during our review, the Agency is in the process of improving its controls over the development of the non-medical aspects of QDD claims. However, as SSA rolls out QDD beyond the Boston region, it should refine the selection process based on the results of the cases processed during the DSI pilot in Boston.
CASES SELECTED FOR QDD PROCESSING
As of October 31, 2006, about 2.4 percent (667 claims) of all DSI cases had been selected for QDD processing. As shown in Table 1, SSA made 79 percent of medical allowance determinations within the 20-day standard set for the QDD pilot in the Boston region-with an average processing time of 10 days (including quality reviews). However, SSA exceeded the 20 day standard for a portion (16 percent) of medical allowance decisions processed in the first few months of the pilot. Additionally, 5 percent of the claims were not medically allowed.
Table 1: Summary of QDD Medical Determinations for Claims Filed through October
Finding Cases Percent
Medically Allowed-20 days or less 527 79.0%
Medically Allowed-more than 20 days 107 16.0%
Not Medically Allowed 33 5.0%
Total 667 100%
Table 2 shows the breakout of the 667 cases selected for QDD processing though October 31, 2006 by SSA program-Disability Insurance (DI) or Supplemental Security Income (SSI)-and by State.
Table 2: Summary of QDD Medical Determinations by State
State CT MA ME NH RI VT Total By Program
Allowed 96 171 36 28 40 28 399
Not Allowed 3 10 0 1 3 2 19
Allowed 20 113 8 10 8 6 165
Not Allowed 2 6 0 2 0 0 10
Both DI and SSI
Allowed 17 38 0 6 6 3 70
Not Allowed 1 2 0 1 0 0 4
Total By State 139 340 44 48 57 39 667
Of the 667 cases selected for QDD, 142 had a terminal (TERI) case indicator. SSA or DDS staff may manually indicate a claim is a TERI case if the claimant has an impairment which medical records indicate is untreatable (i.e., the impairment cannot be reversed and is expected to end in death). Cases with a TERI indicator must be handled in an expeditious manner because of their sensitivity. Of the 142 QDD claims which were also TERI cases, 136 were allowed and 6 were not allowed.
Although only 5 percent of the 667 cases selected for QDD were not medically allowed, we analyzed these 33 cases further since one of the factors considered when selecting a case for QDD processing is its high potential that the claimant is disabled. Table 3 summarizes the reasons why these 33 claimants were not allowed benefits.
Table 3: Reasons QDD Cases Not Allowed
Able to perform past work 7
DI claim only - not disabled at date last insured for disability 6
Impairment(s) caused limitations but was not disabling 7
DI claim only - died during waiting period before decision was made 5
Impairment(s) not expected to remain disabling for 12 months 4
Returned to SSA field office for additional non-medical development 1
Able to perform work other than past employment 2
Impairment did not limit activities 1
Based on our review of these cases, it appeared that the claims were appropriately selected for QDD processing, based on information the claimants initially provided to SSA.
COMPARISON OF CASES SELECTED AND NOT SELECTED FOR QDD
From the file of all DSI cases, we isolated the claims not selected for QDD
processing that were medically allowed and compared the average DDS processing
time to that of cases selected for QDD-based on the most frequently occurring
diagnoses in the
QDD cases. The 361 claims selected for the QDD with 1 of the top 10 diagnoses (as shown in Table 4) were adjudicated in 13 days, on average, and those not selected for QDD-with the same diagnoses-were adjudicated in 50 days, on average.
Table 4: Primary Diagnoses of Allowed Cases Diagnosis Cases Selected for QDD
Cases Not Selected for QDD
Number of Cases Average Processing Time Number of Cases Average Processing Time
Lung Cancer 104 13 days 128 42 days
Premature - Birth Weight Under 1200 grams 44 5 days 93 35 days
Colon, Rectal or Anal Cancer 35 13 days 55 50 days
Breast Cancer 33 11 days 75 48 days
Chronic Renal Failure 33 20 days 84 49 days
Autistic Disorders 27 19 days 216 67 days
Leukemia 24 12 days 29 39 days
Ovarian Cancer 23 14 days 18 43 days
Liver Cancer 19 11 days 15 40 days
Kidney Cancer 19 15 days 12 39 days
Total 361 13 days 725 50 days
PAYMENTS WERE NOT ALWAYS EXPEDITED
SSA should improve its controls to ensure that non-medical development (such
as verification of income or date of birth) of claims selected for QDD is expedited
so that beneficiaries are paid quickly after the Agency determines they are
disabled. SSA field office staff were instructed to complete all non-medical
development as soon as QDD claims are transferred to the DDS for the medical
decision. Of the 667 cases selected for QDD processing, 16 claimants (or 2.4
percent) were determined to be disabled but had not been paid at the time of
our review. These claimants had been waiting up to 5 months after the DDS found
them disabled for the Agency to finish the non-medical development and initiate
payments. Of these 16 claims:
6 were SSI claims that could have been paid as soon as the DDS made its medical decision;
8 were DI claims that could have been paid because the waiting period had already passed when the DDS allowed the claim; and
2 were DI claims for which the waiting period ended soon after the DDS allowed the claim (in October 2006 and January 2007 respectively).
We referred these cases to the SSA Regional Office on January 18, 2007, and the Agency took immediate action to expedite their completion. Specifically, the day after we referred the cases to the Agency, the Boston Regional Office began preparing instructions for all field offices on identifying and monitoring QDD cases and completing non-medical development quickly. SSA issued interim procedures on February 13, 2007 and formal procedures on March 15, 2007 to make sure payments for QDD claims are not delayed in any Agency component.
SSA SHOULD REFINE THE QDD SELECTION PROCESS
As QDD is expanded beyond the Boston region, the number of cases, workload issues and resources may be a concern for the Agency. SSA should refine the QDD selection process based on the results of the pilot to focus resources on expediting benefits to the greatest number of claimants possible who can immediately receive benefits.
Of the 667 cases selected for QDD processing, 249 (or 37 percent) were claims for SSI benefits-whether SSI only or concurrent DI/SSI. SSI eligibility provides cash assistance and immediate access to medical coverage (generally through Medicaid in most States) to needy individuals who are disabled, blind or aged.
The remaining 418 cases selected for QDD were DI claims only. The Social Security
Act states that a DI beneficiary is eligible to receive payments after serving
a waiting period of 5 consecutive calendar months throughout which he or she
has been under a disability (i.e., 5 full months after the date SSA establishes
as the onset of his disability). DI eligibility generally provides access to
medical coverage through Medicare after the beneficiary serves a waiting period
of 24 months.
Table 5 shows the length of time the 418 DI claimants were in their waiting period on the day their claims were selected for QDD-based on the date they alleged their disability began. Of these 418 claimants, 136 (about 32.5 percent) were early in their waiting period when DDS received their claims. If these 136 claims had not been selected for QDD and had been adjudicated within SSA's average processing time, these claimants would have been allowed by the first date they were eligible to receive benefits. Additionally, the Agency could have used those QDD resources to expedite cases for SSI claimants or DI claimants at the end of or beyond their waiting period.
Table 5: Waiting Period When Case Selected for QDD
Waiting Period Number of Cases Percent
Waiting Period Not Begun Yet 14 3.4%
In 1st Month of Waiting Period 47 11.2%
In 2nd Month of Waiting Period 39 9.3%
In 3rd Month of Waiting Period 36 8.6%
Subtotal 136 32.5%
In 4th Month of Waiting Period 42 10.0%
In 5th Month of Waiting Period 27 6.5%
Waiting Period Completed 213 51.0%
Subtotal 282 67.5%
TOTAL 418 100%
CONCLUSION AND RECOMMENDATIONS
Although SSA is in the early stages of implementing the QDD process, claims selected for QDD processing were completed sooner than those claims completed through SSA's normal (non-QDD) process. However, as SSA expands QDD beyond the Boston region in the coming years, workload issues and resources may be a concern. The Agency should fine-tune the QDD process and the predictive model used to select QDD cases based on the results of the cases processed during the pilot in Boston.
Therefore, we recommend SSA:
1. Ensure that non-medical aspects of QDD claims processing are expedited.
2. Consider refining the QDD selection process in the future-prior to rolling it out to another region-to focus on SSI claims and DI claims at the end of or beyond the statutorily required waiting period.
AGENCY COMMENTS AND OIG RESPONSE
SSA agreed with Recommendation 1 but did not concur with Recommendation 2 due to the cost of systems reprogramming. (See Appendix D for SSA's comments.)
We understand that the Agency has limited resources and, according to the Agency, it would be costly to reprogram the QDD predictive model at this time. However, SSA should consider making the changes necessary to implement our recommendation when future programming changes are made. We believe individuals who will immediately benefit from expediting processing (those with SSI claims and DI claims at the end of or beyond the statutorily required waiting period) should receive priority over individuals who might benefit from receiving an allowance determination prior to their eligibility for benefits.
Patrick P. O'Carroll, Jr.
APPENDIX A - Acronyms
APPENDIX B - Disability Service Improvement
APPENDIX C - Scope and Methodology
APPENDIX D - Agency Comments
APPENDIX E - OIG Contacts and Staff Acknowledgments
ALJ Administrative Law Judge
CFR Code of Federal Regulations
DDS Disability Determination Services
DI Disability Insurance
DSI Disability Service Improvement
FedRO Federal Reviewing Official
NH New Hampshire
POMS Program Operations Manual System
PPO Program Policy Online
QDD Quick Disability Determinations
RI Rhode Island
SSA Social Security Administration
SSI Supplemental Security Income
U.S.C. United States Code
Disability Service Improvement
The Commissioner of the Social Security Administration (SSA) began working on improvements to the Agency's disability determination process in 2001 after a discussion with the President. On September 25, 2003, the Commissioner presented a new approach to disability determination to the Congress. The final regulations for the Disability Service Improvement (DSI) process were published March 31, 2006.
The final DSI regulations provide for:
A quick disability determination process for those who are obviously disabled. Favorable decisions would be made in such cases within 20 days after the claim is received by the State disability determination agency.
A new Medical-Vocational Expert System to enhance the expertise needed to make accurate and timely decisions-composed of a Medical-Vocational Expert Unit and a national network of medical, psychological and vocational experts who meet qualification standards established by the Commissioner.
A new position-the Federal Reviewing Official (FedRO)-that will review State agency determinations upon the request of the claimant. This will eliminate the reconsideration step of the current appeals process.
Retention of the right to request a de novo hearing and decision from an Administrative Law Judge (ALJ) if the claimant disagrees with the decision of the FedRO.
Closing the record after the ALJ issues a decision, with provision for certain good cause exceptions to this rule.
A new body-the Decision Review Board-to review and correct decisional errors and ensure consistent adjudication at all levels of the disability determination process. The current Appeals Council will be phased out.
The Agency's goals for DSI are to:
Make the right decision as early in the process as possible;
Provide for consistent decision-making nationally and at all adjudicative steps;
Improve documentation through clearly articulated determinations and decisions;
Ensure that decisions are legally sustainable and follow SSA's policy; and
Strengthen quality review mechanisms at all adjudicative steps.
DSI applies to disability claims filed beginning August 1, 2006 for residents of the Boston region (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut). After full implementation in the Boston region, SSA plans to monitor the changes and collect management information before implementing DSI in a second region.
Scope and Methodology
To accomplish our objective, we:
Reviewed applicable sections of the Social Security Act and Social Security Administration (SSA) regulations, rules, policies, and procedures.
Reviewed the Commissioner's testimony before the Subcommittee on Social Security of the House Committee on Ways and Means on June 15, 2006 on the Disability Service Improvement (DSI) process.
Reviewed the Disability Determination Services (DDS) Performance Management Report showing the average time from DDS receipt of a case to the DDS clearance.
Obtained a file of all 667 claims selected for Quick Disability Determination (QDD) processing between August 1, 2006 and October 31, 2006.
1. For each of the cases selected for QDD processing, we:
a) Reviewed SSA's systems, including the Disability Determination Services Query, the Master Beneficiary Record, the Supplemental Security Record, the Disability Control File, and the electronic disability folder.
b) Calculated the number of days it took the Agency to complete the medical determination (including quality reviews) after the claim was selected for QDD processing.
c) Calculated the number of days it took the Agency to complete all actions to initiate payments-for claimants who were medically allowed-after the claim was selected for QDD processing.
2. For each of the 418 claims for DI benefits only, we obtained the alleged onset date at time of application and the claim was selected for QDD processing. From these dates, we determined how far into the waiting period each case was when it was selected for QDD. Additionally, we determined-for the 397 DI only claims that were medically allowed-whether the disability onset date established by SSA differed from the date alleged by the claimant.
Obtained a file of all claims designated as DSI cases between August 1, 2006 and October 31, 2006. After removing duplicate Social Security numbers and the 667 cases selected for QDD processing, there were 26,981 claims not selected for QDD. From this file, we isolated the 7,307 claims that were medically allowed as of February 1, 2007. For each of these 7,307 cases, we:
1. Reviewed SSA's systems, including the Disability Determination Services Query, the Master Beneficiary Record, the Supplemental Security Record, the Disability Control File, and the electronic disability folder.
2. Calculated the number of days it took the State Agency to complete the medical determination after the claim was transferred to the DDS.
We conducted our audit between January and February 2007 in Boston, Massachusetts.
The entities audited were the Office of Disability Programs under the Deputy
Commissioner for Disability and Income Security Programs and the Office of Disability
Determinations under the Deputy Commissioner for Operations. We conducted our
audit in accordance with generally accepted government auditing standards.
Date: May 8, 2007
To: Patrick P. O'Carroll, Jr.
From: David V. Foster /s/
Chief of Staff
Subject: Office of the Inspector General (OIG) Draft Report, "Quick Disability Determinations" (A-01-07-17035)-INFORMATION
We appreciate OIG's efforts in conducting this review. Our comments on the draft report content and recommendations are attached.
Please let me know if we can be of further assistance. Staff inquiries may be directed to Ms. Candace Skurnik, Director, Audit Management and Liaison Staff, at extension 54636.
COMMENTS ON THE OFFICE OF THE INSPECTOR GENERAL (OIG) DRAFT REPORT, "QUICK DISABILITY DETERMINATIONS" (A-01-07-17035)
Thank you for the opportunity to review and comment on the draft report. Our responses to the specific recommendations are provided below.
The Social Security Administration (SSA) should ensure that non-medical aspects of Quick Disability Determinations (QDD) claims processing are expedited.
We agree. As with any new process, we need to continually reinforce the initial training. So, as noted in the draft report (page 6, first full paragraph), "SSA issued interim procedures on February 13, 2007 and formal procedures on March 15, 2007 to make sure payments for QDD claims are not delayed in any Agency component."
In addition, the Boston region has developed a Workload Action Control system to make it easier to identify and take timely action on these cases. It appears to be working well to solve the issue raised.
SSA should consider refining the QDD selection process in the future, prior to rolling it out to another region, to focus on Supplemental Security Income claims and Disability claims at the end of, or beyond, the statutorily required waiting period.
We disagree. We have seriously considered this recommendation, and for the reasons stated below, we will not implement it at this time:
The predictive model is run through the Electronic Disability Collect System, not the Modernized Supplemental Security Income Claims System or the Modernized Claims System. Accordingly, it cannot tell whether a case is Title II or Title XVI or if a waiting period applies. To change this would require costly systems reprogramming.
The onset date, which determines when the 5-month waiting period begins, is an allegation at the beginning of the process. It isn't until the actual disability determination is done that the exact onset date is determined. Until then, we cannot know where the claimant is in terms of satisfying the 5-month waiting period.
There are public policy benefits to making a determination as early in the process as possible, regardless of cash benefit status. Examples include: resolving claimant anxiety; having an SSA determination for purposes of other public or private benefits; and, allowing individuals to notify private entities, such as landlords, loan companies, and health insurance providers, that they will have an income in the near future, thus possibly avoiding eviction or postponing collection activities.
OIG Contacts and Staff Acknowledgments
Judith Oliveira, Director, Boston Audit Division, (617) 565-1765
David Mazzola, Audit Manager, (617) 565-1807
In addition to those named above:
Phillip Hanvy, Senior Program Analyst
For additional copies of this report, please visit our web site at www.socialsecurity.gov/oig or contact the Office of the Inspector General's Public Affairs Specialist at (410) 965-3218. Refer to Common Identification Number A-01-07-17035.
Overview of the Office of the Inspector General
The Office of the Inspector General (OIG) is comprised of our Office of Investigations (OI), Office of Audit (OA), Office of the Chief Counsel to the Inspector General (OCCIG), and Office of Resource Management (ORM). To ensure compliance with policies and procedures, internal controls, and professional standards, we also have a comprehensive Professional Responsibility and Quality Assurance program.
Office of Audit
OA conducts and/or supervises financial and performance audits of the Social Security Administration's (SSA) programs and operations and makes recommendations to ensure program objectives are achieved effectively and efficiently. Financial audits assess whether SSA's financial statements fairly present SSA's financial position, results of operations, and cash flow. Performance audits review the economy, efficiency, and effectiveness of SSA's programs and operations. OA also conducts short-term management and program evaluations and projects on issues of concern to SSA, Congress, and the general public.
Office of Investigations
OI conducts and coordinates investigative activity related to fraud, waste, abuse, and mismanagement in SSA programs and operations. This includes wrongdoing by applicants, beneficiaries, contractors, third parties, or SSA employees performing their official duties. This office serves as OIG liaison to the Department of Justice on all matters relating to the investigations of SSA programs and personnel. OI also conducts joint investigations with other Federal, State, and local law enforcement agencies.
Office of the Chief Counsel to the Inspector General
OCCIG provides independent legal advice and counsel to the IG on various matters, including statutes, regulations, legislation, and policy directives. OCCIG also advises the IG on investigative procedures and techniques, as well as on legal implications and conclusions to be drawn from audit and investigative material. Finally, OCCIG administers the Civil Monetary Penalty program.
Office of Resource Management
ORM supports OIG by providing information resource management and systems security. ORM also coordinates OIG's budget, procurement, telecommunications, facilities, and human resources. In addition, ORM is the focal point for OIG's strategic planning function and the development and implementation of performance measures required by the Government Performance and Results Act of 1993.