[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
EXAMINING WAYS THE SOCIAL SECURITY ADMINISTRATION CAN IMPROVE THE
DISABILITY REVIEW PROCESS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON ENERGY POLICY,
HEALTH CARE AND ENTITLEMENTS
of the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
APRIL 9, 2014
__________
Serial No. 113-104
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.fdsys.gov
http://www.house.gov/reform
----------
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
DARRELL E. ISSA, California, Chairman
JOHN L. MICA, Florida ELIJAH E. CUMMINGS, Maryland,
MICHAEL R. TURNER, Ohio Ranking Minority Member
JOHN J. DUNCAN, JR., Tennessee CAROLYN B. MALONEY, New York
PATRICK T. McHENRY, North Carolina ELEANOR HOLMES NORTON, District of
JIM JORDAN, Ohio Columbia
JASON CHAFFETZ, Utah JOHN F. TIERNEY, Massachusetts
TIM WALBERG, Michigan WM. LACY CLAY, Missouri
JAMES LANKFORD, Oklahoma STEPHEN F. LYNCH, Massachusetts
JUSTIN AMASH, Michigan JIM COOPER, Tennessee
PAUL A. GOSAR, Arizona GERALD E. CONNOLLY, Virginia
PATRICK MEEHAN, Pennsylvania JACKIE SPEIER, California
SCOTT DesJARLAIS, Tennessee MATTHEW A. CARTWRIGHT,
TREY GOWDY, South Carolina Pennsylvania
BLAKE FARENTHOLD, Texas TAMMY DUCKWORTH, Illinois
DOC HASTINGS, Washington ROBIN L. KELLY, Illinois
CYNTHIA M. LUMMIS, Wyoming DANNY K. DAVIS, Illinois
ROB WOODALL, Georgia PETER WELCH, Vermont
THOMAS MASSIE, Kentucky TONY CARDENAS, California
DOUG COLLINS, Georgia STEVEN A. HORSFORD, Nevada
MARK MEADOWS, North Carolina MICHELLE LUJAN GRISHAM, New Mexico
KERRY L. BENTIVOLIO, Michigan Vacancy
RON DeSANTIS, Florida
Lawrence J. Brady, Staff Director
John D. Cuaderes, Deputy Staff Director
Stephen Castor, General Counsel
Linda A. Good, Chief Clerk
David Rapallo, Minority Staff Director
Subcommittee on Energy Policy, Health Care and Entitlements
JAMES LANKFORD, Oklahoma, Chairman
PATRICK T. McHENRY, North Carolina JACKIE SPEIER, California, Ranking
PAUL GOSAR, Arizona Minority Member
JIM JORDAN, Ohio ELEANOR HOLMES NORTON, District of
JASON CHAFFETZ, Utah Columbia
TIM WALBERG, Michigan JIM COOPER, Tennessee
PATRICK MEEHAN, Pennsylvania MATTHEW CARTWRIGHT, Pennsylvania
SCOTT DesJARLAIS, Tennessee TAMMY DUCKWORTH, Illinois
BLAKE FARENTHOLD, Texas DANNY K. DAVIS, Illinois
DOC HASTINGS, Washington TONY CARDENAS, California
ROB WOODALL, Georgia STEVEN A. HORSFORD, Nevada
THOMAS MASSIE, Kentucky MICHELLE LUJAN GRISHAM, New Mexico
C O N T E N T S
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Page
Hearing held on April 9, 2014.................................... 1
WITNESSES
Mr. Daniel Bertoni, Director, Education, Workforce and Income
Security, U.S. Government Accountability Office
Oral Statement............................................... 6
Written Statement............................................ 8
Ms. Jennifer Nottingham, President, National Association of
Disability Examiners
Oral Statement............................................... 23
Written Statement............................................ 25
Ms. Marianna Lacanfora, Acting Deputy Commissioner, Retirement
and Disability Policy, Social Security Administration
Oral Statement............................................... 36
Written Statement............................................ 38
Ms. Jennifer Shaw Lockhart, State Director, Sooner Success, The
University of Oklahoma Health Sciences Center
Oral Statement............................................... 47
Written Statement............................................ 50
Mr. Patrick P. O'Carroll, Jr., Inspector General, Social Security
Administration
Oral Statement............................................... 68
Written Statement............................................ 70
APPENDIX
Entered into record by Chairman Lankford: Letter to Carolyn
Colvin, SSA Acting Commissioner from Chairman Lankford &
Ranking Member Speier.......................................... 114
EXAMINING WAYS THE SOCIAL SECURITY ADMINISTRATION CAN IMPROVE THE
DISABILITY REVIEW PROCESS
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Wednesday, April 9, 2014,
House of Representatives,
Subcommittee on Energy Policy, Health Care &
Entitlements,
Committee on Oversight and Government Reform,
Washington, D.C.
The subcommittee met, pursuant to call, at 1:37 p.m., in
Room 2154, Rayburn House Office Building, Hon. James Lankford
[chairman of the subcommittee] presiding.
Present: Representatives Lankford, Walberg, Massie, Speier,
Cartwright, Duckworth, Lujan Grisham, Horsford, Cummings, and
Woodall.
Staff Present: Melissa Beaumont, Majority Assistant Clerk;
Brian Blase, Majority Senior Professional Staff Member; Will L.
Boyington, Majority Deputy Press Secretary; John Cuaderes,
Majority Deputy Staff Director; Adam P. Fromm, Majority
Director of Member Services and Committee Operations; Linda
Good, Majority Chief Clerk; Mitchell S. Kominsky, Majority
Counsel; Mark D. Marin, Majority Deputy Staff Director for
Oversight; Emily Martin, Majority Counsel; Ashok M. Pinto,
Majority Chief Counsel, Investigations; Jessica Seale, Majority
Digital Director; Katy Summerlin, Majority Press Assistant;
Sharon Meredith Utz, Majority Professional Staff Member; Jaron
Bourke, Minority Director of Administration; Courtney Cochran,
Minority Press Secretary; Devon Hill, Minority Research
Assistant; Suzanne Owen, Minority Senior Policy Advisor; and
Brian Quinn, Minority Counsel.
Mr. Lankford. Good afternoon. The committee will come to
order.
I would like to begin this hearing by stating the Oversight
Committee mission statement.
We exist to secure two fundamental principles: first, that
Americans have the right to know what Washington takes from
them is well spent; second, Americans deserve an efficient,
effective Government that works for them. Our duty on the
Oversight and Government Reform Committee is to protect these
rights.
Our solemn responsibility is to hold Government accountable
to taxpayers, because taxpayers have the right to know what
they will get from their Government. We will work tirelessly in
partnership with citizen watchdogs to deliver the facts to the
American people and bring genuine reform to the Federal
bureaucracy. This is the mission of the Oversight and
Government Reform Committee.
I will do a quick opening statement.
The Social Security Administration oversees two large
Federal disability programs: the Social Security Disability
Insurance Program and the Supplemental Security Income Program.
Both have grown rapidly over the last 25 years. The growth is
unsustainable. It also poses a threat to the truly disabled,
who are often pushed to the back of the line and face large
benefit cuts in the future.
In the vast majority of cases, a decision to allow benefits
is an irrevocable commitment of taxpayer funds since favorable
decisions are not usually appealed. Unfortunately, the growth
in these programs has limited some people from reaching their
full potential, and in many cases a program that was intended
to fight poverty is perpetuating poverty.
According to a 2010 paper published jointly by the liberal
Center for American Progress and the left-of-center Brookings
Institution said SSDI is ineffective in assisting workers with
disabilities to reach their employment potential or to maintain
economic self-sufficiency. Instead, the program provides a
strong incentive to applicants and beneficiaries to remain
permanently out of the labor force.
I welcome the testimony of Jennifer Lockhart today--thank
you for being here--a fellow Oklahoman, who has both personal
and professional experience assisting children and young adults
with both physical and intellectual disabilities. Ms. Lockhart
will provide perspective today on how the Federal disabilities
programs, while seemingly very well intentioned, can have
devastating consequences on individuals and communities if not
handled correctly. Tragically, many children are languishing on
SSI programs, rather than being encouraged to pursue vocational
and educational opportunities.
In June of last year, the subcommittee heard testimony from
two former and two current Social Security administrative law
judges. One of the themes of the testimony was the agency's
plan to reduce the backlog of initial claims, resulting in AJLs
inappropriately putting people onto these programs. We also
learned that the agency policy allows claimants and their
attorneys to submit biased and incomplete evidence.
While we have serious questions for the agency about its
policies and management of these programs, I thank the agency
for providing timely information to the committee requests.
Agency personnel have conducted numerous briefings and
transcribed interviews with the committee. During one of these
interviews, Regional Chief Administrative Law Judge Jasper Bead
testified that it raises a red flag for a judge when they allow
75 to 80 percent of their decisions. It is stunning that
between 2005 and 2012 more than 930,000 individuals were
approved for benefits by an ALJ who approved more than 80
percent of the claimants for benefits. During the same time
period, more than 350,000 people were awarded disability by an
ALJ with an allowance rate in excess of 90 percent.
I appreciate, by the way, the bipartisan manner which the
subcommittee has been able to approach this oversight. Ranking
Member Speier and I both recognize there are significant
problems with these programs and that reform is needed. I thank
her very much for the work and the partnership in this issue.
Yesterday, Ms. Speier and I sent Acting Commissioner Colvin
a letter outlining 11 common sense recommendations for the
agency in order to improve the integrity of the disability
determination process. One of the recommendations is for the
agency to conduct timely continuing disability reviews. The
agency is currently out of compliance with its legal
requirement to conduct timely CDRs and has allowed a backlog of
1.3 million CDRs to develop.
As Ms. Speier and I explained in our letter, an increase in
CDRs must be coupled with a change to the medical improvement
standard, because this standard does not allow the agency to
remove claimants who were wrongfully awarded benefits in the
first place. Under the current standard, the claimant's record
must show that the claimant made significant medical
improvement in order to end benefits. If the claimant was not
disabled and wrongly received benefits initially, the standard
of review will not remove them.
Today the agency must address this question: Are the vast
majority of people who the agency expects to improve failing to
do so or is it just extremely difficult for the agency to cease
benefits? The question highlights a significant problem that
needs to be addressed and needs to be addressed quickly.
Today's testimony will show that the state of disability
determination offices that conduct CDRs suffer from a lack of
clear guidance about the medical improvement standards.
It will also reveal GAO made recommendations to the agency
to correct problems with the CDR process, and made that
recommendation years ago, yet the agency has failed to
implement fully the GAO's recommendations to address these
problems. It is in the works, but we have to be able to get it
finished. Failure is not an option at this point. The agency
must take steps to improve the disability review process and
modify the review standards so that only individuals with
genuine disabilities and who are unable to work continue to get
benefits from these programs.
This is a program designed to protect those most
vulnerable. Through our inattention, if we don't protect the
most vulnerable, it is our gross error, and this committee
intends to stay on top of that.
With that, I recognize the ranking member, Ms. Speier.
Ms. Speier. Mr. Chairman, thank you.
At the outset, let me say this. There aren't a lot of
cameras in this room today, but this is precisely the kind of
work that the Oversight and Government Reform Committee should
be doing; in a bipartisan fashion, in a constructive fashion,
with a number of experts who are here who are, in many
respects, civil servants doing remarkable work. And I think we
both know that part of our effort in making sure that this
system is improved upon is making sure they have the resources
to do the job.
So I want to thank you, at the outset, for your commitment
and the great work that you have shown, and the way we have
collaborated and worked together and had meetings outside of
hearings to try and come up with some solutions to this
situation.
The committee has been conducting oversight of the Federal
disabilities program at the Social Security Administration.
Just yesterday, as the chairman pointed out, together we sent a
bipartisan letter to Social Security laying out a number of
reforms and recommendations we believe the agency can implement
to enhance the efficiency and effectiveness of disability
adjudications and improve the integrity of Federal disability
programs.
Now, I believe that and I said that, but I also recognize
part of what we are asking for is going to require more
resources in order to do it well.
Social Security disability and supplemental security income
are important lifelines for millions of Americans with
disabilities. Recent estimates project disability insurance
benefits of about $145 billion to approximately 11 million SSDI
beneficiaries and $59 billion to almost 8.5 million SSI
recipients.
In previous testimony before this committee, Social
Security Administration recited a motto repeated at the agency:
The right check to the right person at the right time. Making
sure that only those who meet the eligibility guidelines
receive benefits is important so the American public can have
confidence in their Government's efficient and effective
operation.
The primary tool at SSA's disposal is the CDRs, the
Continuing Disability Reviews. These reviews are critical to
the integrity of the Social Security disability program. CDRs
are a highly cost-effective measure, saving the Federal
Government, on average, $9 for every $1 spent on CDRs. So it
makes all the sense in the world that we invest in providing
the resources so that more CDRs can be done so that we can be
confident in knowing that those who are receiving SSDI and SSI
are receiving it appropriately.
SSA's most recent report on CDRs estimates present value
savings of $5.4 billion in lifetime program benefits. These
numbers speak for themselves as to why CDRs are so critical.
Unfortunately, as the chairman mentioned, there is a backlog of
1.3 million uncompleted CDRs. This is just unacceptable. We all
get an F for not properly funding you and for not reducing that
backlog in an appropriate fashion. We have had a backlog at the
Veterans Administration on disability claims and we have thrown
a whole lot of money at that agency to get them to reduce that
backlog, and I am afraid we are going to have to do it here,
but I think it is going to be cost-effective in the long run.
An IG's report found that 79 percent of childhood CDRs were
not conducted in a timely fashion. Additionally, GAO has found
thousands of cases of child recipients who were expected to
medically improve within 18 months, exceeded their scheduled
review date by as much as six years or more. You know, this is
unacceptable as well.
Another IG found that even when a CDR is conducted and
determines benefits are no longer medically justified, those
benefits are not always terminated in a timely manner. That
results in an estimated $83.6 million in improper payments.
That is unacceptable.
President Kennedy once said we can do better, and I really
do believe we can. But so must Congress. Annual appropriations
of funds for CDRs have fallen short of the levels authorized in
the last few years, and that is unacceptable. This is not the
first time Congress has allowed a backlog of CDRs to develop.
Again, we have to take some responsibility here. In the 1980s,
the mid-1990s, Congress also failed to provide adequate funds.
Finally, in 1996, Congress acted by increasing funds for CDRs.
The backlog was eliminated by 2002, but, again, it took six
years to do it, even with the resources being put in place.
We should once again recognize the importance of CDRs and
this year finally provide the agency with the funds it needs.
CDRs help protect taxpayer funds and the public's interest.
Congress must dependably provide adequate funds so that
backlogs and the improper payments that result from them never
return.
Today we will also hear from a representative of disability
examiners who are well positioned to help detect and prevent
fraud at the initial determination level and while conducting
CDRs. It is important that disability examiners have the
training and resources to perform their jobs effectively. It is
also important that we support the work and achievements of the
inspector general on initiatives like CDIs that allow
coordination and collaboration on efforts to prevent, detect,
and investigate fraud in Federal disability programs.
Mr. Chairman, it is a pleasure to work with you on this
issue, and I look forward to the testimony.
Mr. Lankford. Members will have seven days to submit
opening statements for the record.
We will now recognize the panel.
Mr. Daniel Bertoni is the Director of Education, Workforce
and Income Security at the U.S. Government Accountability
Officer.
Ms. Jennifer Nottingham is the President of the National
Association of Disability Examiners and a supervisor within the
Ohio Disability Determination Service. We will have DDS thrown
around a lot today.
Ms. Marianna LaCanfora is the Acting Deputy Commissioner
for Retirement and Disability Policy at the Social Security
Administration.
Ms. Jennifer Shaw Lockhart is the State Director for Sooner
SUCCESS at the University of Oklahoma Health Sciences Center, a
fellow Oklahoman.
Mr. Patrick O'Carroll is the Inspector General for the
Social Security Administration.
Pursuant to committee rules, all witnesses are sworn in
before they testify. If you would please stand and raise your
right hand.
Do you solemnly swear or affirm the testimony you are about
to give will be the truth, the whole truth, and nothing but the
truth, so help you, God?
[Witnesses respond in the affirmative.]
Mr. Lankford. Thank you. You may be seated.
Let the record reflect that all the witnesses answered in
the affirmative.
We will have time for discussion and questions after your
opening statements. We have assigned five minutes for each of
your opening statements.
Mr. Bertoni, you are first up.
WITNESS STATEMENTS
STATEMENT OF DANIEL BERTONI
Mr. Bertoni. Thank you. Chairman Lankford, Ranking Member
Speier, members of the subcommittee, good afternoon. I am
pleased to discuss our work on the Social Security
Administration's efforts to assess DI and SSI program
recipients' continued eligibility for benefits.
Last year, SSA provided nearly $200 billion in benefits to
about 11 million DI and 8 million SSI recipients. Both the
numbers of recipients as well as program costs have grown in
recent years, and are poised to grow further due to economic
and population changes.
To ensure that only eligible individuals receive disability
benefits, accurate determinations at the time of application
and follow-up reviews after benefits are granted provide an
important check on growth and are key to ensuring program
integrity.
Federal law requires that SSA conduct periodic Continuing
Disability Reviews, or CDRs, of recipients and requires SSA to
find substantial evidence of medical improvement before ceasing
benefits, known as the medical improvement standard. My remarks
today are based on our prior work and discuss SSA's efforts to
assess recipients' continued benefit eligibility and aspects of
the review standard that affect these efforts.
In summary, SSA reported in January 2014 that it is behind
schedule in conducting CDRs and has a backlog of 1.3 million
reviews. The agency is also conducting fewer CDRs in general.
From fiscal year 2000 to 2011, adult CDRs fell from over
580,000 to 100,000, and child CDRs dropped from over 150,000 to
45,000.
For those children with mental impairments, CDRs declined
80 percent, from 84,000 to just 16,000. Thus, in 2012, we
reported that over 400,000 child SSI cases with mental
impairments were overdue a CDR, with more than 24,000 overdue
by six years or more, including thousands who were deemed
likely to medically improve.
When CDRs are not conducted as scheduled, especially for
those children whose conditions are likely to improve, improper
payments may occur. And although child benefits are more likely
to be ceased after review, SSA has historically placed a higher
priority on conducting adult CDRs, which generally result in a
cessation rate of around 12 percent.
Of the child CDRs SSA does conduct, we found that the
average benefit cessation rate was 32 percent; and for those
with mental impairments, such as personality disorder and
speech and language delay, cessation rates were 39 and 38
percent, respectively.
In our report, we recommended that SSA work smarter to
better target its limited resources and eliminate the backlog
of child CDRs, with a specific focus on those likely to
medically improve. SSA generally agreed with our
recommendation, but cited resource limitations and competing
workloads as a barrier going forward.
Beyond the issue of SSA CDR prioritization, factors
associated with the medical improvement standard pose a
challenge to assessing recipients. During CDRs, individuals
that SSA determines to have improved medically may have their
benefits ceased. However, we reported in 2006 that only 1.4
percent of recipients who left the rolls did so because they
had medically improved.
We also noted several factors that hindered us the ability
to make this determination, including the limitations in SSA's
guidance for determining what level of improvement would
constitute a cessation and how to apply key exceptions;
inadequate documentation of prior disability decisions,
especially for cases decided at the appeals level; and the
judgmental nature of the process, especially for those cases
involving psychological impairments.
In our report, we noted that these factors had implications
for the consistency and fairness of decision-making and
recommended that SSA clarify its policies for assessing medical
improvement. Since then, SSA has taken some steps that may help
address the issue, but has not fully implemented our
recommendations. Thus, its guidance is likely to continue to be
problematic for staff in their efforts to make sound and
consistent decisions.
Mr. Chairman, this concludes my statement. I am happy to
answer any questions that you or other members of the
subcommittee may have. Thank you.
[Prepared statement of Mr. Bertoni follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Lankford. Thank you.
Ms. Nottingham.
STATEMENT OF JENNIFER NOTTINGHAM
Ms. Nottingham. Chairman Lankford, Ranking Member Speier,
and other members of the committee, thank you for inviting NADE
to share the perspective of the frontline disability
determination employee. After several years of high attrition
rates and hiring freezes, combined with an increased number of
people applying for disability, the DDS's caseload grew,
particularly CDRs. With this year's budget, SSA was able to
hire a DDS staff and is dramatically increasing the number of
CDRs sent for review.
NADE believes it is critical to invest and train for all
staff. Employees at all levels of the disability adjudication
process should receive more training opportunities and updates.
This includes disability hearing officers and ALJs. It would be
counterproductive to remind examiners of a policy, only to have
it be not known by a hearing officer or ALJ.
Medical improvement review standards shifts the burden of
proof from the claimant to the DDS. SSA has a strict definition
of disability, and to be found disabled the individual must
prove that they meet the criteria. However, at the CDR the
definition is removed. The medical improvement review standard
policy dictates that benefit continue unless the beneficiary's
disabling condition has shown to have demonstrated medical
improvement related to the ability to work. This standard is
very stringent and, as a result, few claims are actually
ceased. It is important to note that, through appeals, a DDS
cessation may end up being continued by the disability hearing
officer or ALJ.
In processing a CDR claim, the DDSs are required to compare
a beneficiary's current condition to their condition at the
time of the most recent medical decision. Because of MIRS, the
DDS cannot fix what may be perceived as a mistake or wrong
decision, as the DDS is not allowed to substitute judgment.
There are many times during the processing of a CDR claim where
the disability examiner would not currently find the
beneficiary disabled, but must continue benefits because
medical improvement has not been demonstrated. If an individual
is allowed and had minimal or normal findings at the Comparison
Point Decision, as long as they still have similar findings,
they will be continued.
There are exceptions to MIRS; most notably the fraud and
error exception. These exceptions only apply in a small portion
of CDRs. The error exception policy states that it cannot be
used to substitute judgment, and it can only be used when a
previous claim shows evidence that there was a clear objective
error. An example would be a decision based off of records for
the wrong patient. So even though the CDR examiner may consider
the previous decision wrong, it is very difficult to prove an
error, particularly if there is minimal rationale. The
exceptions are underutilized and additional training is needed;
however, the exception would still only apply to a small
portion of CDRs.
There has been significant attention on the allowance rate
of ALJs. It is likely that fraud or error would not be found in
most cases. The difference in the high allowance rate is more
likely due to a difference in subjective conclusions or
decisions based on limited information. Where this is often
seen is in the assessment of credibility and the weight of
medical source statements. The totality of the evidence needs
to be considered. Factors such as objective medical evidence,
medical history, consistency of the record, and activities of
daily living should be considered when assessing the
credibility and medical source opinions. If a statement is not
well supported or inconsistent with the record, it should be
given less weight. The credibility and medical source opinions
can have a large impact on the outcome of a claim. They are
subjective conclusions and the DDS is directed to not
substitute judgment.
In the adjudicative process, if a conclusion is not
supported, poorly documented, or inconsistent with the
available evidence, this would not be considered an error that
can be cited, and if there is no clear objective error found,
then MIRS directs us to determine if benefits continue. NADE
recommends changing the CDR process and would support a
discussion on a de novo decision at CDR.
It is important to make sure the correct decision is made
initially and only appropriate claims are allowed. NADE
applauds SSA's recent focus on policy and medical training with
ALJs. Many examiners complain of ALJ decisions where the
medical source statements are not supported with evidence, yet
given great weight. NADE feels it would be beneficial if the
DDSs were able to be represented at the ALJ to help ensure
policy compliance where display examiners receive more
training.
More review and oversight may be needed at all levels of
the adjudication process. Currently, there is minimal review of
ALJ in disability hearing officer decisions. Although most
claims are now electronic, there are still paper claims and
some end up lost. CDRs with lost folders end up being continued
most often. If the DDS cannot reconstruct the prior decision in
order to make a comparison, it will be continued. Steps should
be taken to decrease the number of paper claims processed and
to prevent lost folders.
NADE continues to support the expansion of CDI units to
help combat fraud. More emphasis on referrals to CDIU of CDR
claims may be needed, along with additional fraud or similar
fault training. At CDR, many beneficiaries do not have
treatment, despite many having access to treatment. That means
the examiner rely upon a decision from a consultative
examination that they are only seen one time. It is hard to
make a decision without longitudinal evidence, and it is
discouraging to see beneficiaries that don't take advantage of
medical treatment to improve their condition.
That is all I have. Thank you for allowing me the
opportunity to share NADE's views on CDRs.
[Prepared statement of Ms. Nottingham follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Lankford. Thank you.
Ms. LaCanfora.
STATEMENT OF MARIANNA LACANFORA
Ms. LaCanfora. Chairman Lankford, Ranking Member Speier,
members of the subcommittee, thank you for this opportunity to
continue the conversation on Social Security's disability
programs. My name is Marianna LaCanfora and I am the agency's
Acting Deputy Commissioner for Retirement and Disability
Policy.
Today, my testimony focuses on medical continuing
disability reviews, or CDRs. These program integrity reviews,
which cover both the Disability Insurance and Supplemental
Security Income disability programs ensure that only those
beneficiaries who remain disabled continue to receive benefits.
While CDRs are essential, it bears acknowledging that they are
only one of many critical workloads that millions of Americans
depend on us to complete each year. Absent sufficient funding,
we must make difficult tradeoffs as we balance our service and
stewardship responsibilities.
I would like to highlight a few important points regarding
our CDRs. First, we have proven that our CDRs are an excellent
investment and, when we receive adequate resources, we deliver.
For example, we received a seven year commitment of special
funding from Congress in fiscal year 1996 so that we could
eliminate our backlog of CDRs. By the time the funding had
expired, in 2002, we had eliminated the backlog and saved about
$36 billion in taxpayer money.
The second point I would like to make about our CDRs is
that we strictly adhere to legal requirements and we
consistently achieve high quality. Our adherence to the medical
improvement review standard perhaps best illustrates this
point. Congress enacted the medical improvement review standard
in 1984 to address widespread concern that disability
adjudicators were substituting their judgment to overturn the
judgment of a prior adjudicator.
In 1984, the law remedied this by generally requiring that
we terminate benefits only if a beneficiary's condition
medically improves and that improvement is related to the
ability to work. This standard has remained unchanged for 30
years. We continuously train our adjudicators on its correct
application and our quality review of CDRs shows a high rate of
decisional accuracy, 97.2 percent last year.
My third point is that absent adequate funding, we are
forced to make difficult tradeoffs and prioritize CDRs. We
focus our limited funding on the CDRs most likely to produce
the highest return on investment or the highest amount of
taxpayer savings. Our highest priority CDRs are age 18 re-
determinations and low birth weight baby cases because they are
statutorily required. We prioritize other CDRs using a
statistical model that gathers data from our records to
identify a high likelihood of medical improvement and a high
return on investment. We complete of these cases as our funding
permits.
We began using our model in 1993 and we have been
continuously validating and updating it in collaboration with
the best outside experts. The model allows us to conduct some
CDRs in an expedited manner, without the need for expensive
medical development when the likelihood of cessation is remote.
Despite our efforts to keep pace with the CDR workload,
chronic under-funding has led to a backlog of 1.3 million
cases. We did not receive the full funding for CDRs authorized
by the Budget Control Act in each of the last two years, but I
am pleased to say we did receive the full amount this year, and
thank you to the committee. With the additional funding, we
plan to complete 510 full medical CDRs this year, and we will
also hire and train more employees. The President's budget for
fiscal year 2015 also requests the full BCA level for Social
Security. With this funding we plan to complete 888,000 full
medical CDRs.
Starting in fiscal year 2016, the President's budget
proposes a dedicated dependable source of mandatory funding for
our agency to conduct CDRs. The mandatory funding will enable
us to eliminate the CDR backlog. We need your support of the
President's budget to ensure that only those beneficiaries who
remain disabled continue to receive benefits. Timely,
sustained, and adequate funding is the single most important
way to eliminate the CDR backlog.
Thank you, and I am happy to answer any questions you may
have.
[Prepared statement of Ms. LaCanfora follows:]
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Mr. Lankford. Ms. Lockhart.
STATEMENT OF JENNIFER SHAW LOCKHART
Ms. Lockhart. Thank you, Mr. Chairman and thank you, Ms.
Speier. Thank you all for your time today.
On behalf of Sooner SUCCESS and every individual with
disabilities, I am here today. I am here today to speak with
you about the state of our existing system. I am here to tell
you it does not work and I am here to tell you why.
You might ask what positions me to speak out so strongly
about what I believe to be one the most undignified supports we
have in our great Country. I have seen it firsthand and I have
lived it. From the moment my family adopted four children with
special needs over 30 years ago to the moment I stand here
today, I have witnessed it up close and personal.
First let me tell you about Sooner SUCCESS. Sooner SUCCESS
was piloted over 10 years ago by Dr. Mark Walraich. At the
time, Dr. Walraich left Vanderbilt University for the
University of Oklahoma to fill the chief of developmental
behavior pediatrics Shaun Walters Endowed Chair, also known as
the University of Oklahoma Child Study Center. Dr. Walraich,
realizing the same struggles he found at Vanderbilt, developed
Sooner SUCCESS.
Sooner SUCCESS was developed on a complex adaptive systems
approach, CAS, allowing local coalitions to address their
unique needs. We believe Sooner SUCCESS, exactly through this
advancing and inclusive comprehensive unified system, does
this. We do it within their community. Sooner SUCCESS embeds
multiple levels of service delivery seamlessly so families can
address both immediate and long-term goals and adaptive
approaches.
Through this approach we are not only able to analyze the
multiple systems, but educational, health, and social families
struggle to navigate, but also mobilize the system as warranted
within the community when needed through adaptive agents. This
is where our local coalitions and county coordinators are
tremendous assets. Change is inevitable, so we must organize
the system in a way, adapting to change, but also educate
providers, caregivers, self-advocates, and families and
patients to understand an ever-evolving system instead of
multiple independent, static structures or agencies.
Anecdotally speaking, we believe this model works. We see
this observation in articles such as the recently published
Newsweek article titled The Health Gap: The Worst Place in
America for Mental Health, Child Poverty, and College
Attendance Mapped. The article ranked counties in each State.
Of the top 10 counties in Oklahoma, 5 are Sooner SUCCESS
counties and part of the original program 10 years ago.
Last year alone, in 2013, Sooner SUCCESS made over 31,000
community linkages in our 13 pilot counties. Our 13 counties
consist of Tulsa and Oklahoma City, Oklahoma's two most
populated cities, and 11 rural communities. Within these
demographics, we are able to serve close to half of Oklahoma's
children with disabilities ages newborn to 21.
We often serve transitional years 18 to 24 as well. With
that said, you could say we have a pulse on the grassroots
level, the view from the balcony, as to what our communities
look like; each very different, with very unique needs. We are
your eyes and ears on the ground. What does the view from the
balcony look like? A victim of unintended consequences our
system designed to assist individuals with disabilities is
paralyzed by multiple levels of dysfunction.
For the sake of understanding why, we will understand
Sooner SUCCESS. Sooner SUCCESS based on this system, is able to
see--and I am going to skip through here because I want you to
hear this. This is the problem: system complexity; weak ties
and poor alignment among professionals and organizations; a
lack of funding; incentives to support collaborative work; a
bureaucratic environment based on command approach and control
management.
Further, I quote from recent publication in the
International Journal of Integrated Care: Lack of system change
towards integration is that we have failed to treat the system
as a complex adaptive system. The data suggests that future
integration initiatives must be anchored in this perspective
and focus on building the system's capacity to self-evolve. We
conclude that integrating care for disabilities requires
policies and management practices that promote system
awareness, relationship building, and information sharing, and
that recognized change as an evolving learning process rather
than a series of programmatic steps.
What does this mean on the system level and what does it
have to do with our issues here today?
Permission to continue further.
Mr. Lankford. I give you unanimous consent to do another
minute.
Ms. Lockhart. I am sorry?
Mr. Lankford. You want to close, then we will come back for
questions, or do you need another minute?
Ms. Lockhart. I need another minute, please.
Mr. Lankford. Go for it.
Ms. Lockhart. Thank you, sir.
It means that unless the system fluid and adaptive, we
leave it vulnerable. Those vulnerabilities expose themselves
through certain outcomes, mostly gaps in service, system
exploitation, duplicative services, and fragmentation or
dissonance in services. Those vulnerabilities also tell us what
often numbers cannot, what the system looks like from real-life
application.
So in real world terms what does that look like? In the
words of our Oklahoma County coordinator, proud Democrat and
mother of a child with Downs Syndrome, I am tired of seeing
those who need help unable to get it because people who don't
need it are using the system. We see it every day.
From Donald Baily of South Carolina--I sent this to him; I
wanted to be sure he was okay--I am testifying at a hearing
next week in DC presenting testimony regarding disability
reform. In my testimony, I hope to be discussing the higher Ed
piece and referencing work with the College Transition
Connection in South Carolina. Is this okay? Donald's reply--and
I will tell you why this is important--good for you. Of course
you can. Tell all. Thanks.
Donald is a former trustee with the University of South
Carolina, father of a son with autism, founder of the South
Carolina College Transition Connection, a consortium of five
universities in South Carolina providing higher Ed options for
individuals with intellectual developmental disabilities.
Donald and his wife, along with other parents, created the CTC
because they wanted something more for his son than sitting at
home after he aged out of the system.
I have chosen Donald and Lori, and could provide you with
many more parent provider statements as to the barriers in the
system. The bottom line is due to the many gaps we have created
a pervasive problem in which we have left not only the system
vulnerable, but the individuals we are to be helping. We see
children with impairments labeled disabled. We see parents and
adolescents remain underemployed so they may sustain their
benefits. We see thousands on a wait list in Oklahoma who
receive no service because they are waiting for assistance.
Aside from service gaps, we see something more concerning,
deeply concerning. We see people with disabilities unknowingly
segregated from their communities because the transition from
the school support service stops often when the individual ages
out of the system. Services stop; the sports system is gone
instantly; and because transition services are programs rather
than processes, we see individuals who should be out in their
communities go from an active community life, that being their
school, to nothing almost overnight.
In observation, we are able to see a gap where most young
adults with disabilities should be transitioning into the
community. Why weren't they in their community all along?
[Prepared statement of Ms. Lockhart follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Lankford. Ms. Lockhart, we are going to move on. When
we come back, we are going to pummel you with questions here in
just a minute as well, so I want to make sure we have time for
everybody, too.
Ms. Lockhart. Thank you, sir. Yes, sir.
Mr. Lankford. Mr. O'Carroll.
STATEMENT OF PATRICK P. O'CARROLL, JR.
Mr. O'Carroll. Good afternoon, Chairman Lankford, Ranking
Member Speier, and members of the subcommittee. Thank you for
inviting me to be here today.
A 42-year-old man was living out a childhood dream: he was
the lead singer of his own hard rock band and he also owned a
popular cafe. For almost 20 years his band had toured the
Country and performed at large music festivals. He talked up
his band's success on social media, touting performances for
millions of fans and worldwide sales of thousands of albums and
t-shirts; even been interviewed for local newspaper articles
and TV interviews. And during this entire time he was receiving
Social Security Disability for mood disorders.
Last year, during a continuing disability review, or a CDR,
a disability examiner referred the man's case to one of our
cooperative disability investigations, or CDI, units. The man's
musical exploits made the examiner suspicious that he might not
be eligible for benefits because he was more capable than he
claimed. The CDI investigation confirmed that the man was able
to work and perform activities contrary to his disability. With
this information, SSA ceased the man's benefits in January.
I share this example because it combines the value of two
of our most effective integrity tools: CDRs and the CDI
program. CDI efforts usually focus on initial claims, but
disability examiners can also refer questionable in-pay cases
to a CDI unit for investigation, as in this case. It is one of
the many reasons we are pleased that the acting commissioner
has agreed to expand CDI by up to seven units by the end of
2015.
Of course, CDRs on their own have proven to be effective
guards against improper payments in the disability programs. My
office has long urged SSA to conduct more CDRs every year. We
also consistently encourage Congress to fund these critical
reviews. With the return on investment of $9 saved for every
dollar invested in CDRs, appropriating funds to conduct these
reviews is sound fiscal policy. However, after dedicated
funding ended in 2002, CDRs declined by over 75 percent,
creating a significant backlog.
Although SSA has been conducting more CDRs since 2009, the
backlog still stood at $1.3 million last year. As a result, SSA
continues to make payments that could be avoided. For example,
according to past audit work, up to $1.1 billion in disability
payments could have been avoided in 2011 alone if CDRs had been
performed when due.
Similarly, re-determinations can prevent improper payments
in the SSI program. These non-medical reviews will yield an
anticipated 5 to 1 return this year. From 2003 to 2008, re-
determinations decreased by 60 percent. Our audit work found
that $3.3 billion in SSI payments could have been avoided in
just two years if more reviews were completed.
I am encouraged that SSA has completed more eligibility
reviews in recent years. For this year, the agency has stated
that it plans to complete 510,000 medical CDRs and almost 2.5
million re-determinations. We are currently evaluating SSA's
progress in completing these reviews and we plan to issue a
report later this year.
We have long focused our audit efforts on CDRs and re-
determinations because there are such sound reasons for funding
and conducting them as scheduled. For example, in a recent
audit we found that SSA hadn't conducted 79 percent of
childhood CDRs or 10 percent of age 18 re-determinations within
the time frames required by law. The cost over four years was
$1.4 billion. Payments made because of delayed reviews are
troubling because they are largely avoidable. We recognize that
SSA is a difficult task in processing and increasing number of
new claims, but the agency must continue to seek ways to
balance customer service with stewardship responsibilities.
Through our audit and investigative work, we keep working
with SSA and Congress to protect these critical programs.
Thank you again for the invitation to testify, and I would
be happy to answer any questions.
[Prepared statement of Mr. O'Carroll follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Lankford. Thank you to all of our witnesses.
I will begin our questions.
Ms. Lockhart, I have a question. Your statement about
undignified supports and then your statement of multiple levels
of dysfunction.
Ms. Lockhart. Yes, sir.
Mr. Lankford. You tried to walk through some of those as
well, but one of the key issues--you started to talk at the
very tail end--I know I had to cut you off a little bit on your
testimony. You started talking about the impact of families and
individuals in communities and out of communities. What it
seemed like you were saying is when these individuals are put
into this, they are actually pulled out of society and they are
separated out.
The question I have for you is what do you think the goal
of the disability program should be?
Ms. Lockhart. The goal should be to provide a route back
into their community. The overarching goal should be that
people with disabilities have an independent life. Also, define
what disability is. Impairment does not necessarily mean
disability.
Mr. Lankford. Okay. Now, hold on for just a moment on that
one. You are right, impairment is not disability. The challenge
of this is that once you get into the system, if you have an
impairment and they define it as you are not able to do
substantial gainful work, employment, then you may be impaired,
but you are now tagged as disabled and you are actually
prevented from employment. Is that what you are experiencing?
Ms. Lockhart. Right.
Mr. Lankford. So what does that look like?
Ms. Lockhart. We have situations where either the children
aren't getting services that would help them move forward or
children that in our professional position might be impaired,
but not disabled. We have experienced families that the parents
at times will--what is the word I want to use?--sometimes stall
the process.
Mr. Lankford. You mean stall the process of re-engagement
in society?
Ms. Lockhart. Right. Right. So we see both. But we are
saying that to those that do have disabilities, sir, we don't
have a mechanism that is sure and sound that provides them a
way into the community. We are still, for the first time,
really understanding. And I know that we have programs, but
what we see is we see the families on the system level here, so
imagine two rails, and then we see commerce, private sector
over here. And really what we need to see is they converge. So
to say we want our disabilities to have jobs, people with jobs
be paid fairly, those kinds of things, and be an integral part
of our community, we have to prepare this side over here as
well.
Mr. Lankford. Okay.
Mr. O'Carroll, you made a comment about increasing the CDRs
and watching out for the reviews and such. Based on what Ms.
Nottingham was saying, it is not just a matter of increasing
the number of CDRs, it is actually the effectiveness of the
CDRs. So what are you experiencing with the actual review when
the review occurs?
Can I put this up on the screen as well?
[Slide.]
Mr. Lankford. There is a stat that we have been able to
locate here. Social Security Administration provided this. This
is from 2003 to 2013, so it goes back a decade for us, asking
the question of when CDRs actually occur, what happens at that
point. Once they have been evaluated, when they go into the
system, evaluated, are they expected to recover from this or be
out of the system possible or not expected.
So here is the number of reviews, the number of removals,
and what we found interesting is over the decade there the
people that were expected to at some point leave the system,
there is only 18 percent of them that actually do. What is
interesting to me is those that were not expected, 7 percent of
the folks that were not expected leaving. It is really not that
far apart, an 11 percent difference between the two.
So what we see is people that are even expected to be out
of the system really don't leave the system. It sounds like, to
go back to what Ms. Nottingham was saying, there is an issue
with not just doing CDRs, but the effectiveness of CDRs based
on even the initial expectation.
Mr. O'Carroll. Yes, Mr. Chairman. On that, I guess from
some of the work that we have done, a lot of the expectations
that they are having aren't found as we are finding here. One
of those issues that is part of this hearing is talking about
medical improvement on it and the issues with medical
improvement. And with medical improvement, if you were found
disabled, by the next time you come back to a DDS on it, unless
you have improved from what you were found the last time, you
are going to be found still disabled.
And we are finding that if you use the standard that you
use when you first come in, which would be different than the
medical improvement, it would be an initial application, there
would be a lot more findings in terms of a person improving.
And what we found on that, we just did a report on it, we are
waiting for comments back from the agency, but we found in that
case about 4 percent of the people that were found disabled
would not be found disabled if you used the initial disability
application formula instead of the improvement formula.
Mr. Lankford. I am sorry, I am just about out of time. Can
you say that last part again?
Mr. O'Carroll. The last one I said is it is about 4 percent
of the people that we looked at that were found disabled would
not have been found disabled had they come in on an initial
application. So, in other words, what they are saying is that
what they purport with was below the level of what they would
have been put on disability, but since they were already on
disability, they couldn't be taken off it.
Mr. Lankford. Okay.
Mr. O'Carroll. So we are seeing that 4 percent. To be
truthful, it could be a much higher percentage. There is a
problem, though, with the record-keeping that SSA was doing on
it, and we find it could go as high as 12 percent, because
there about 8 percent of the cases that we looked at were
incorrectly cited. So, as an example, they said they were
thrown off or they were taken off for a medical improvement,
but when we read the file on it, we found it was really because
they had returned to work.
Mr. Lankford. Okay.
Mr. O'Carroll. So we are asking for more accuracy on that
so we can get a better standard. But that is an example of what
you were saying here.
Mr. Lankford. Thank you.
Ms. Speier.
Ms. Speier. Mr. Chairman, thank you, and thank you to all
of our witnesses.
The presentation that was made by the inspector general of
this rock band that suggested they had lots of social media,
you were able to access it on social media, Ms. LaCanfora, does
the Social Security Administration have the authority to
consult social media accounts when conducting CDRs?
Ms. LaCanfora. Our adjudicators do not consult social
media. And let me explain why, if I may. We understand the
committee's interest in this issue, and we are certainly open
to more discussions and discussions with the IG, but let me be
clear about one thing. Right now, our adjudicators refer 22,000
cases per year to the inspector general that they find to be
suspicious. Our adjudicators are trained in fraud detection and
they look at medical evidence, they look at the allegations of
the individual, they weigh all of the evidence and they detect
anomalies, and they do it very well.
Ms. Speier. I have very limited time, so you just have to
answer the question. Right now they do not, is that correct?
Ms. LaCanfora. That is correct.
Ms. Speier. Do they have the authority to and they just
don't?
Ms. LaCanfora. We do not allow them to look at social
media.
Ms. Speier. Do you, within the Social Security
Administration, have the authority to require them to look at
social media?
Ms. LaCanfora. Yes.
Ms. Speier. All right, so we don't need legislation to do
that.
Ms. LaCanfora. Correct.
Ms. Speier. All right, so this is a decision that you made.
Ms. LaCanfora. Correct.
Ms. Speier. All right. I would disagree with that decision
because I think that social media is a very fair and
appropriate way of doing a CDR. So that is just one area that
we need to pursue a little bit more.
Inspector General, your office found that DI beneficiaries
and SSI recipients improperly receive payments after medical
cessation determinations, costing taxpayers $83.6 million. Does
the Social Security Administration have a clawback provision
for collecting improper payments?
Mr. O'Carroll. Yes, they do, in two ways. One is that they
can declare an overpayment and then of any benefits that are
going in the future on it, they will take the penalty out of
that. Then the other tool that we use is civil monetary
penalties. So when we find that a person has lied, and if they
aren't on benefits and we can't attach the benefits to get the
overpayment from them, we will then charge them with a civil
monetary penalty and get benefits back that way.
Ms. Speier. So does that clawback actually take place,
then? And you are in charge of the clawback, not----
Mr. O'Carroll. No. Unfortunately, all we do is, if it is in
a court and the court has a judgment that the person has to pay
it back, it is up to the Justice Department to collect it. And
in the other ones where overpayment is assessed by SSA, they
monitor it and collect it, we don't.
Ms. Speier. All right, so it is unclear whether or not we
do any clawback. On the one hand, if someone is getting
payments that shouldn't be getting them and it is our fault
because it is a clerical error, I would not necessarily be
supportive of a clawback.
Mr. O'Carroll. Agreed.
Ms. Speier. But if it was adjudicated, they know they are
not supposed to be getting payments, they continue to get
payments, then I think there is a reason to clawback; and you
are saying they have the authority and it is unclear whether or
not they use it.
Mr. O'Carroll. Yes.
Ms. Speier. All right. The IG report recommended that the
Social Security Administration enhance its automated
termination system following medical cessation decisions and
the Social Security Administration agreed to that
recommendation.
So my question to you, Ms. LaCanfora, is when will that
recommendation be implemented?
Ms. LaCanfora. That recommendation has already been
implemented. We discussed this at our hearing in November, if
you might recall. We have made two systems changes to ensure
automated cessation, so that there is no time delay between the
decision at the DDS and the actual cessation. We have one more
piece of that to implement, which we are going to do this
fiscal year, to make sure that there is no gap at the hearings
level. In addition to those systems changes, we are also going
to continue to have a safety net in place where we do periodic
runs to make sure no cases fall through the cracks. We fully
support the idea that the cessations need to be made timely.
Ms. Speier. So to you, inspector, does that then cover all
the potential terminations that don't take place that should
take place?
Mr. O'Carroll. Yes. In fact, our recommendation was that
systems enhancements be made so that it is automated and that
it will be caught, and that is being implemented right now. So
we haven't audited it, we haven't declared it a success, but at
least they are in the right direction.
Ms. Speier. All right, very good.
Mr. Chairman, I am going to actually give you back 15
seconds in the hopes that we will be able to have a longer
second round.
Mr. Lankford. We will. We will.
Mr. Walberg.
Mr. Walberg. Thank you, Mr. Chairman, and thanks to the
panel for being here.
Mr. Bertoni, as I understand, every two years a high-risk
list is established of agencies and programs. Can you explain
how the GAO designates a program to be high-risk?
Mr. Bertoni. Sure. There is typically two criteria. The
first criteria is whether they have significant management
operational issues or problems that expose it to fraud, waste,
and abuse, program integrity issues, mismanagement. The second
part is organizations may need urgent transformation in many
ways.
Mr. Walberg. As I understand it, Federal disability
programs have been designated as high-risk every time the list
was issued since 2003. Can you explain why?
Mr. Bertoni. On the first front, in terms of the management
and operational side, we continue to see issues with their
ability to get out in front of the backlogs, with their ability
to make timely and accurate payments. We still have a
significant overpayment situation. So even on that management
and operational front, where we have seen some progress in some
areas, it wouldn't be proper for us to remove it from the list.
On the other side, the area of transformation, we have said
for many years they need to take a more modern approach to
disability.
Mr. Walberg. More modern approach?
Mr. Bertoni. More modern approach to disability. Disability
today versus what it was 20 years ago, when we were a manual
labor economy versus a service and knowledge-based economy is
much different. Their criteria, their listings, their listings
of jobs in the national economy have not kept up to date with
the transitioning and what a disability looks like today, and
we have had numerous recommendations that they address that.
Mr. Walberg. Thus the illustration of the performing
artist, being able to work and successfully raise a lot of
funds.
Mr. Bertoni. Well, in that case, that is a significant
management and operational issue there, not having appropriate
tools to get out in front of that problem.
Mr. Walberg. Mr. O'Carroll, which reviews, of the multiple
reviews, adult CDRs for SSI, SSDI, childhood CDRs for SSI, age
18 re-determinations for SSI, which reviews are most cost-
effective?
Mr. O'Carroll. Mr. Walberg, probably the most cost-
effective one would be the work CDRs, and work CDRs are the
ones where we are showing wages are being posted against a
person who is supposedly not working because they are disabled.
Then, at that point, they would be brought in to SSA. But a
little bit of texture to the conversation is that work CDRs are
difficult to do; they are done by SSA, usually take a lot of
study in terms of seeing if somebody had gotten a bonus or
termination, another type of bonus like that. So, any way, they
are difficult to do, but they have a very high return on
investment.
The next one down would be the medical reviews, and the
medical reviews are, just as we said, because of the person
having a disability, getting better, they are probably the more
easily accepted and understood of the type of reviews that are
done; and they are done by DDSs, and that is where the DDSs are
doing those.
So, anyway, I guess the best one to say on it is the word
CDRs are the most effective.
Mr. Walberg. Mr. Bertoni and Mr. O'Carroll, how much
taxpayer money has been wasted because of SSA CDR backlog?
Mr. Bertoni. I can't speak to the dollar amounts. I can say
that we had over 400,000 cases that we identified in the SSI
kids realm that were well overdue for a CDR, and we didn't
project that to what that would be, but over time, a lifetime
of benefits, that is a significant amount of dollars.
Mr. Walberg. That was in the children's realm, you said?
Mr. Bertoni. Yes.
Mr. Walberg. Thank you.
Mr. O'Carroll?
Mr. O'Carroll. We are anticipating that several billion
dollars are lost every year because of the backlog on the CDRs.
Mr. Walberg. Four hundred thousand cases, several billions
of dollars.
Ms. LaCanfora, why did the agency allow a huge backlog of
CDRs for children with conditions that tend to be temporary?
Ms. LaCanfora. Well, with all due respect, I return that
question in part back to the Congress. We have been
inadequately funded over a series of years and unable to
complete the number of CDRs that we need to complete. In fact,
we have had to make very difficult tradeoffs in which CDRs we
are going to do. And with respect to children, here is how we
prioritize: we look for the greatest savings to the taxpayer;
and the reality is the greatest savings to the taxpayer does
not lie with children, because their benefits tend to be lower
than adults. So we strictly look for savings to the taxpayer
when we prioritize.
Mr. Walberg. But the length of time is significantly more,
correct, with children?
Ms. LaCanfora. We take into consideration the fact that we
do review all children at age 18, so the average lifetime
savings is actually lower when you look at children.
Ms. Speier. Would the gentleman yield?
Mr. Walberg. I will yield.
Ms. Speier. Ms. LaCanfora, my understanding is the
difference between adult payments and child payments is about
$100 a month, isn't that true?
Ms. LaCanfora. I don't know off the top of my head what it
is, but children's payments can be significantly less than
adult payments. And, remember, the SSI program, there is all
kinds of rules for children like deeming. Children's benefits
are offset by income from the parents.
Ms. Speier. All right. I don't want to take any more time
of the gentleman. My understanding is that the actual payments
are about $100 in difference.
Mr. Walberg. In difference. Correct.
I yield back.
Mr. Lankford. Ms. Duckworth.
Ms. Duckworth. Thank you, Mr. Chairman.
Ms. LaCanfora, I would like to continue on the CDRs. My
understanding is that the Federal Government saves about $10
for every dollar spent on CDRs. Is that correct?
Ms. LaCanfora. It is about one to nine, but close.
Ms. Duckworth. One to nine? And I wanted to sort of touch
on this history. You mentioned the fact that we had adequately,
at one point, funded CDRs and you were able to catch up. In
your opinion, what is your recommendation in terms of funding?
You just said that you are not being adequately funded. Are you
asking, recommending a similar funding to get rid of this
particular backlog of, what is it, $1.3 million over a multi-
year period? What is your recommendation as an expert in the
field?
Ms. LaCanfora. Yes. Absolutely, the bottom line is you get
what you pay for when it comes to CDRs. In fiscal year 2014 we
received the Budget Control Act funding level, $1.197 billion,
which will allow us to do 510 medical continuing disability
reviews. If, in fiscal year 2015, we get the BCA level, we will
be able to do 888,000 CDRs, and we are asking for $1.396
billion to do that. Subsequent to 2015, the President's budget
has a proposal for mandatory sustained funding separate from
our administrative budget so that we can continue the momentum
and eliminate the CDR backlog.
Ms. Duckworth. So what you are saying is you need to get
help covering the next two years to make a big dent in getting
caught up in the backlog, and after that you have the mandatory
that kicks in and then you will be able to work towards getting
rid of the backlog and maintain parity with the new cases
coming in? Am I saying that correctly?
Ms. LaCanfora. Yes. Yes.
Ms. Duckworth. Okay, thank you.
Ms. LaCanfora. And that is our objective.
Ms. Duckworth. Mr. O'Carroll, you wanted to say something?
Mr. O'Carroll. Yes, Ms. Duckworth. Just to give a little
context on that, what we are finding with that $1.3 million
that is in the backlog on it, just doing the 510 on it won't
touch the backlog at all. And under the current funding level,
what we took a look at is in the next five years is four of the
five plans on it will not reduce the backlog.
So what we are finding is that, at least from our studies
on it, they are going to have to be doing up in about the
900,000 level to be able to have a significant impact on that
backlog. So that is the biggest issue. They are keeping
current, but they are not getting the backlog down, and that is
where the more funding and more direction is needed.
Ms. Duckworth. Are there any other reasons why a backlog
has developed, other than inadequate funding, in your opinion?
Mr. O'Carroll. No, because we can pretty much show from all
the work that we have done is when SSA dedicates the resources
to doing it and the dedication is coming from their funding,
that they will reduce that backlog back. That is what we were
talking about in the early 2000s, was when the money was there
they did reduce the backlog.
Then after that, when the funding wasn't there, the backlog
kept growing, and then what would happen is they would be doing
less and less each year, so the backlog kept growing. In fact,
last year, even with funding on it, it went from $1.2 to $1.3
million as the backlog of it. So it goes to show even with the
current funding on it it is difficult for them to be getting
any progress on the backlog.
Ms. Duckworth. I just have a little time left. Inspector
General, can you touch a little bit on CDIs and on how the CDI
units have become effective in rooting out fraud and preventing
disability overpayments? How do the CDI complement CDRs?
Mr. O'Carroll. The CDI program is, I guess, one of our most
effective anti-fraud programs going on; it is a group of
between us and the SSA that we do it. And one of the things you
were saying, how it ties in with the CDR is that we work very
closely, because we have two DDS employees assigned to the CDI
unit, and as the DDS is noticing anything suspicious either in
an initial application or when somebody is brought in for a CDR
and they need more information on it, they will refer it to the
CDI unit. The CDI unit then will be using all the different
tools that they have, between records to find out whether
persons have licenses or other types of information that is
contrary to the disability; social media; surveillances, and
all those ones. So that usually there if there is a question on
a CDR, the CDI unit can help.
Ms. Duckworth. Thank you.
I yield back the remainder of my time.
Mr. Lankford. Mr. Cartwright.
Mr. Cartwright. Thank you, Mr. Chairman, and I thank the
chairman and the ranking member for bringing this important
hearing, and certainly all of our witnesses for appearing here
today to shed light on this important subject.
The public trust in this Country really depends on the
Social Security Administration's efforts and success at
ensuring that people are not getting Social Security Disability
payments who don't qualify for them and also that everybody who
does qualify for Social Security and should be getting Social
Security Disability is getting it. And I thank you for
appearing here today.
Ms. LaCanfora, I have a question for you. Your testimony
lays out some of the steps SSA has taken to improve program
integrity and to help ensure CDRs are done right and that their
outcomes are based on consistent application of policy. These
efforts demonstrate an organizational priority on improving the
quality of CDRs, the efficiency of the process, and fair
treatment of the beneficiaries. In fact, the truth is SSA's
efforts have resulted in a very high CDR decisional accuracy
rate. Am I correct in that?
Ms. LaCanfora. You are correct.
Mr. Cartwright. Okay. In prior testimony, SSA Deputy
Commissioner Sklar stated, ``The aging of baby-boomers, the
economic downturns, additional workloads, and tight budgets
increase our challenges to deliver.'' Isn't it true that
actuaries have known for years that the number of people
eligible to receive Social Security Disability was going to
grow? Is that true?
Ms. LaCanfora. Yes.
Mr. Cartwright. And how did they know that?
Ms. LaCanfora. Not only the actuaries, but the Social
Security trustees, as well as the Congress have known for a
very long time that the program was not sustainable.
Mr. Cartwright. It was as plain as the nose on your face,
wasn't it?
Ms. LaCanfora. Safe to say.
Mr. Cartwright. Does SSA have the funds necessary to ramp
up its program integrity efforts in view of the greater need
created by this anticipated growth in SSD claims?
Ms. LaCanfora. We are very pleased with the fiscal year
2014 budget; it is the first time that we have received the
money authorized in the Budget Control Act. It will put us on a
trajectory that will allow us to eliminate the CDR backlog,
yes.
Mr. Cartwright. Does SSA have sufficient legal authority to
protect the integrity of the disability program?
Ms. LaCanfora. Yes.
Mr. Cartwright. Okay, so we don't have to legislate new
law; it is just about money, isn't it?
Ms. LaCanfora. That is the single biggest determining
factor, yes.
Mr. Cartwright. All right. Well, I thank you for that.
I think our witnesses have made clear that SSA has to have
sufficient resources, and I appreciated your comments,
Inspector General O'Carroll, about the return on investment, as
I think you put it. We got an ROI of nine to one if we properly
fund your efforts, and I think that the CDR proper funding is a
subset of the entire question of proper funding of the SSA,
again, to make sure not only that people who are getting
disability checks are supposed to be getting them, and that is
the work of the CDRs, but also that the people who should be
getting disability checks and aren't getting them, that the
process is sped up for those people, that justice is done for
those people, and that the public trust in SSA is maintained
and restored so that we clean up the backlogs not only in the
CDR system, but also for the claimants to begin with.
I thank you again for appearing today and I yield back to
the chairman.
Mr. Lankford. Thank you, Mr. Cartwright. I do agree that
the CDR time--by the way, we are going to start a second round
here to be able to jump in and we will have a more open
conversation as we go through.
CDRs are incredibly significant in this, but I go back
again to Ms. Nottingham, and I want to be able to mention this
to you and want to be able to pull something out. It seems to
be that it is not just the quantity of CDRs, it is the quality
of what they are able to actually accomplish with it.
I want to go back to your comments earlier about the
definition for medical improvement. Both what is coming out
from the ALJs and what you see, the quality of that product,
that work product that is coming and the determination of does
this person actually have medical improvement, how is that
working? Because with 18 percent of the people that were
expected to be removed actually removed, those are CDRs that
actually occurred, were paid for, and I am quite confident that
many of them that were expected to be removed shouldn't be
removed yet, they still qualify. But 18 percent seems like a
very low number to me, and it goes back to your comment
earlier, trying to deal with the definition of medically
disabled. Can you help me with this?
Ms. Nottingham. Most cases wouldn't get a medically
improvement expected diary for when it should come back to CDR.
Conditions, there are some that really are unknown that tend to
get that, like certain cancers, where it really depends upon
the result of the treatment, so we might give a shorter diary
for that. I think that we tend to see an expected diary given
from an ALJ, and I think, from what I have seen, or believe
that there might be in a belief that the person will return to
their own; they will get treatment, improve, and just return to
work on their own. And that is just not what happens.
Ms. Speier. By returning to work, is it returning to the
same kind of work they were doing before or just being able to
work in some job?
Ms. Nottingham. That is not something that we would look
at.
Ms. Speier. No, but I was just wondering in terms of the
definition.
Ms. Nottingham. Oh. Depending upon their age and education,
the vote grids is where that comes into play. We first look and
see if they can return to their work as it was described or as
it was performed in the general economy and if not, then is
there other work out there, and that is where we take into
consideration age and education.
Mr. Lankford. Are you talking about at the CDR or are you
talking about at the initial evaluation?
Ms. Nottingham. The initial. The vocational grids and those
factors only come into play on a CDR if we have already found
that medical improvement has occurred; otherwise, we wouldn't
look at that at all.
Mr. Lankford. Okay, that is my preference on the question
when we are coming back. Let me see if we can broaden this out.
When you are doing the disability determination, you have
it on a State level. Do you have access to social media? Are
you doing some of your own investigations or are you dealing
with just all the documents that are in front of you? Do you
have authority to be able to do any of your own investigation
as well?
Ms. Nottingham. We would basically mainly look at medical
records. We might get information from a third party if we have
permission from the claimant to contact other people. Sometimes
we might contact a former employer, but it is hard to actually
get that information. The CDIUs have access to social media,
the examiners do not have access.
Mr. Lankford. Okay, wait. Run that passed me again. Who
doesn't have access?
Ms. Nottingham. Adjudicators or examiners would not, only
CDIU.
Mr. Lankford. Okay, so a typical case. But the CDI, that is
not normal on that.
Ms. Nottingham. Right.
Mr. Lankford. That is a smaller number and only in certain
regions, correct?
Ms. Nottingham. Yes, only 22 office or States.
Mr. Lankford. Okay, so in a typical disability
determination you are taking only basically the documents that
are in front of you. If you are going to contact a next door
neighbor or if you are going to contact an employer, you have
to actually get permission typically from the person that you
are looking at the forms from.
Ms. Nottingham. Yes. Usually when they file an application
there is a place for them to list a contact person. Sometimes
they don't have anyone or don't list anyone; generally they do.
And we also use that just to follow up with them in case we
lose contact with them. So if it is on there, then we already
have permission to contact them, so we wouldn't necessarily ask
during the middle of development.
Mr. Lankford. Okay, what I am trying to figure out is there
is really no investigation; you are taking the documents, the
one-sided--and this is going to sound more caustic than it
should--the biased documents, because everyone has a natural
bias; they are applying for disabilities, they are going to
make sure they write it, prepare it, or they have counsel that
is helping them prepare it to make sure they get all the right
words on there to be able to detail out here is what needs to
be. That is really all you have to evaluate by.
Ms. Nottingham. We are very limited in what we can get.
That is why I mentioned the point about having only a
consultative examination when someone doesn't have treatment.
It is best when we have records for years because the
consistency helps make sure we are making the right decision if
there is a consistent history of how they have been doing. But
when we only have an exam or one-time exam, it really leaves
the decision a little bit more questionable.
Ms. Speier. Can we have Ms. Nottingham go through her
recommendations that were in her statement that I don't think
you actually got to, did you, or you kind of rushed through?
Ms. Nottingham. One of the things that we would like to
look at the MIRS policy, the medical improvement review
standard, in general.
Ms. Speier. Right.
Ms. Nottingham. Because we do see that very few people get
off the rolls through this process.
Ms. Speier. And you would attribute that to the MIRS
process.
Ms. Nottingham. Yes.
Ms. Speier. So how would you have us change that?
Ms. Nottingham. When the diaries do have a new decision to
see if they are disabled at that point, following the initial
rolls.
Ms. Speier. So that is your reference to de novo review, is
that what you are suggesting?
Ms. Nottingham. Yes.
Ms. Speier. So it basically would allow you to open up the
entire case to look at, as opposed to just looking at
documents. So you could, for instance, look at social media.
Ms. Nottingham. By policy we are not allowed to look at
social media.
Ms. Speier. I have a hard time with that.
Ms. Nottingham. I do have some concerns with social media.
Ms. Speier. All right, tell me what they are.
Ms. Nottingham. Just that it could be of some benefit, but
someone posting on their social media, we would have to make
sure you can confirm that that was actually them, and also a
picture of them working on a truck or something like that could
have been years prior to their actual injury. So it is a piece
of information that could be useful, especially when you are
looking into fraud or similar fault, but it is only one piece
of information.
Ms. Speier. All right, Inspector, how would you comment to
that?
Mr. O'Carroll. Thanks for asking. I have to say of course
we have concerns what would happen if they rolled out social
media to all SSA employees, and I think that is a management
issue with SSA.
But what we think in terms of the social media, and I used
that in my example here, we have used it on other examples, we
think it is a good tool. And as it happens now, we call it in
the investigative world it is a clue. And you take a look at
that clue, you take a look at other clues, and it is part of a
big picture, not the picture itself.
So one of the suggestions that I have been coming up with
is with SSA we now have an national anti-fraud committee, which
is co-chaired by myself and the CFO of the organization, and
one of the subcommittees under it I would like us to do a pilot
program when we start taking a look at giving different SSA
employees access to social media and give it a pilot and see
how it works out. So that is one of the things that I am taking
to the national anti-fraud, is to see if we can start doing
that.
Ms. Speier. You know, I just am sitting here thinking if 60
Minutes did a piece and showed all of the potential abuse, and
then it was then turned on us and what are you doing about it,
and we are basically saying, well, we don't allow people to
look at social media. I think we would be laughed at.
Mr. O'Carroll. I agree. That is why I am saying it is a
good tool and it is something that SSA should start piloting
and see. But it is one of those things that, in fairness to
them, probably some caution needs to be done in doing it; is
not something of the snap of the fingers. But I think it is
something to move into the 21st century, that it has to be
considered.
Mr. Lankford. It doesn't solve everything, we understand
that, but it is a tool. As you mentioned, it is a clue; it is
something that could be out there. It just provides an
opportunity for a question. Even if there was the opportunity
to be able to say notice this, tell me about this. Just to be
able to initiate the conversation. By the way, notice that you
also have on your social media that you hire out to also mow
lawns. That would be something that you would ask a question
about at some point.
I want to go back to this MIRS process. We need to drill
down on this more. There is a difference between their initial
evaluation and then what happens when we have a CDR. Talk to us
about the differences here between the two.
Ms. Nottingham. In my testimony, I mentioned that the
definition of disability is removed from the CDR process.
Mr. Lankford. Right.
Ms. Nottingham. The initial claim process, we are looking
at their conditions and making assessment of their functioning,
and then applying the vocational grids and finding out, then,
if they meet the criteria for disability. We don't consider
that at all in a CDR with the MIRS, if there is no indication
of significant medical improvement.
Mr. Lankford. Okay, so help me understand. When you are
dealing with this and you have to evaluate medical improvement,
what is the grid that you are working through on that one?
There is the grid that is the prior one. How do you make a
decision of medical improvement? Because you really have two
issues here, the medical improvement and then can they engage
in substantial gainful activity. Or is this at this point, once
we have left it, gainful activity is not there, it is just
medical improvement?
Ms. Nottingham. You have to consider medical improvement.
If we can't establish that there is medical improvement, we
would not go on to the vocational aspects.
Ms. Speier. But the problem there is that if it was
questionable in the initial evaluation, but they got benefits
anyway, then you are perpetuating what may have been a bad
decision to begin with, correct?
Ms. Nottingham. Correct. That happens regularly.
Mr. Lankford. When you say regularly, are you talking 4
percent or are you talking 40 percent? I know this is going to
be your ballpark guess. We get that. So we are not going to
hold you to an absolute statistical number. Your experience.
Ms. Nottingham. My experience, and the experience of many
examiners, would perceive it to be higher than 4 percent. I
would think maybe something 20 percent is a ballpark.
Mr. Lankford. That should have never been on in the first
place.
Ms. Speier. Mr. O'Carroll, what do you say?
Mr. O'Carroll. As I said, on that one there, when we did
the study on it, we found 4 percent for sure, and then we found
8 percent that was questionable because of the information. So
anywhere from 4 to 12 is us.
Mr. Lankford. Okay.
I am sorry to interrupt. Keep going on that, then.
Ms. Nottingham. It becomes difficult because a lot of
subjective conclusions are made in the disability process, and
we can't substitute judgment, so if we can't establish an
actual true error was made, we end up continuing, and we look
at, then, if there is medical improvement.
So someone who is allowed for very minimal impairments,
their functioning wasn't really limited but they were granted
disability benefits because of maybe the statements they made.
The statements should have been supported by the evidence and
consistent with everything else, but even though that wasn't
given appropriate weight and they maybe just based the decision
solely on the statement of the claimant, or maybe even one of
their doctors, that would be substitution of judgment is how I
understand the policy, so we would then use the MIRS to find
out if there is medical improvement, it would not be an error.
Mr. Lankford. But we are still back to the same spot. How
are you defining medical improvement? You are not substituting
judgment, but there is some judgment in this.
Ms. Nottingham. Yes, the medical improvement is going to be
subjective. We look at the signs, symptoms, and laboratory
findings. Some conditions have a lot more objective findings,
particularly physical.
Mr. Lankford. Okay, so help us with an example. Give us an
example of something working through.
Ms. Nottingham. A back impairment is something that is very
common, and we usually look at things. They have x-rays, so
that is a very objective test, or other imaging, and then we
look at things like their muscle strength, their range of
motion, and any neurological injuries. So we would look at
that, and if they still continue to have decreased range of
motion and some normal strength or decreased strength, if those
are consistent with what we saw before, then we would say that
that is not medical improvement.
How much medical improvement is where a lot of the
subjectivity and differences may come in. I would think,
though, that most--I have seen people who try to use very
little improvement, something like a range of motion that was
limited to 60 degrees and then they have 90 degrees range of
motion, something minor like that, they would try to use that
as an argument, and then we get overturned. Those would not
fight through appeal.
Ms. Speier. So, Mr. Chairman, I have a question here. You
are attorneys or you are judges, correct?
Ms. Nottingham. No.
Ms. Speier. What are you? I mean what are the examiners.
Ms. Nottingham. The DDS examiners are State employees and
the qualifications range from State to State. Most require a
bachelor's degree of some sort, and we have extensive training
in medical policy.
Ms. Speier. Okay, but no medical training per se, I mean,
you are not professionally physicians or health care
professionals.
Ms. Nottingham. Correct. Most people would not have a
medical background.
Ms. Speier. So you came up through the ranks with a
bachelor's degree and then, through training, became examiners,
is that correct?
Ms. Nottingham. Correct. We usually have quite extensive
training, at least of 10 to 12 weeks of pure training, and then
we ease people into a caseload with extensive review. In my
State we have a one-year probation for an examiner.
Ms. Speier. But here is my concern. In a workers comp
system, in an interesting sort of way, this is like a workers
comp system. In a workers comp system, it is a system that is
very different from this system, but there is a physician that
evaluates the claim and then the continuation of the benefits
depends on that physician review and by a second physician
review that may be from the employer.
Ms. Nottingham. We do have doctors that review things,
review the decisions, the medical assessment in most States.
Ms. Speier. What States don't?
Ms. Nottingham. There are single decision-maker States and
there are some decisions that do require like any denial for
psychological impairment would require a doctor. They are the
prototype States and the 10 additional.
Ms. Speier. They are the which States?
Ms. Nottingham. I don't know. There was a prototype that
started about 16 years ago, and we are still running on a
prototype for those 10 States, and there were an additional 10
States that receive single decision-maker authority.
Ms. Speier. Oh, prototype. A permanent pilot.
Mr. Lankford. Yes, that is a pretty long pilot project.
Ms. Nottingham. Yes, exactly. I can name a few States, but
I don't have that information.
Ms. Speier. Can you just name them?
Ms. Nottingham. Michigan, Missouri, North Carolina.
Mr. Lankford. Anyone else can jump in on this if you know
what some of the States are as well.
Ms. LaCanfora. I don't know the States off the top of my
head, but I do want to say I think we are getting into a very
confused area on this issue. If the question is do the
examiners have access to medical consultants, we have hundreds
of medical consultants on contract, and they review cases.
There are certain cases where we do not have a medical review,
but we are pretty specific about where that is. For example, we
have cases called compassionate allowances; they are very
specific impairments where the objective medical evidence will
prove a finding of a severe disability. In those cases we don't
require medical consultation.
It is a little bit of a complicated area I think that we
are getting into, but disability examiners generally have
access to medical professionals.
Mr. Cartwright. Mr. Chairman, may I jump in for a moment?
Mr. Lankford. Sure. Jump in.
Mr. Cartwright. Now, we have heard testimony today about
the backlog of CDRs being $1.3 million, is that right? So we
are talking about 1.3 million people who are receiving SSD or,
in some cases, SSI who have gone passed their scheduled date
for review, which makes them part of a backlog, is that it? I
see heads nodding.
So one thing that I am wondering about is whether this is a
backlog that is disproportionate to the CDR process in SSD.
Specifically what I am wondering is the people who have
originally applied for SSD, somebody has had a horrible illness
which has left him or her, rendered them unable to work, at
least that is what they think and that is what they claim, so
they put in for Social Security Disability. And I have heard
talk that there are backlogs for those applicants as well.
Anyone disagree with that? Seeing no nodding heads there.
Does anybody have an idea of what the number of the people
is who are in that backlog, the people who are waiting for
overdue Social Security Disability initial determinations in
this Country?
Ms. LaCanfora. I don't have that number off the top of my
head, but let me try to answer your question this way. I think
you hit upon a very important point. We have seen extreme
service degradation in the past few years that ranges far
beyond the realm of program integrity or medical CDRs. We are
closing our field offices an hour early every day and on
Wednesdays we close at noon simply because we do not have the
resources to handle all the work coming in the door. We have
lost 11,000 employees in the past few years. Our wait times
have gone up across the board.
Mr. Cartwright. So that is exactly what I was getting at,
Ms. LaCanfora, and thank you for your candor there, because
when you talk about severe degradation, it doesn't just apply
to the CDR process; it applies across the board at SSA, doesn't
it?
Ms. LaCanfora. Absolutely.
Mr. Cartwright. Thank you.
I yield back.
Ms. LaCanfora. May I also just give you the data that you
wanted regarding the benefits of individuals on whom we perform
CDRs? The average benefit payment for an SSI child is $545 a
month; the average benefit payment for an adult getting SSDI is
$1,146 a month. Thus, the reason I said that the payoff is much
greater for adults on disability.
Mr. Lankford. Okay, I am going to go to Ms. Lujan Grisham
in just a moment here, but when we talk about the benefits, the
administrative costs, and the backlog, and all that is
happening is accelerating, is some of the issue just the number
of people that are trying to enter the system? We are dealing
with fairly static numbers. When you look at the last five
years, the numbers have been fairly static for what is actually
coming in in administrative costs for SSA.
Ms. LaCanfora. Our workloads have consistently increased,
while our staffing levels have consistently decreased.
Mr. Lankford. You have a tremendous number of new people
that are coming in, your funding levels are not going up, so
part of our issue is the number of applicants that are coming
into the system. So part of our question is why have we seen
this giant jump in the number of applicants get in the system?
Ms. LaCanfora. Well, I think as we discussed before, this
is not news. The Social Security actuary, the board of
trustees, the Congress has been well aware, and this has been
predicted for many, many years. The reason for the growth in
the disability programs, and we have research done by
economists on our Web site which corroborates the findings of
our actuary, demographic changes have resulted in an increase
in the number of people on disability, specifically the aging
of the baby-boomers, individuals entering into their
disability-prone years, and women entering the workforce and
gaining insured status under the program. Those demographic
changes are the reason for the increase in the growth in our
programs.
Mr. Lankford. But that is not going to show an increase in
why we have more children in the program, aging and all those
things, that dynamic. We have this dramatic increase as well in
SSI.
Ms. LaCanfora. There is a very good CBO report that is out
that talks about the increase in the growth in the childhood
program, and it talks about a variety of factors that are also
demographic. First, there is more widespread acknowledgment and
diagnosis of medical conditions among children. We don't create
the diagnosis at Social Security, we follow the medicine. There
has also been an increase in the number of children living in
poverty. And you have to remember that SSI is a needs-based
program. So as more children live in poverty, more applications
come in for SSI.
Mr. Bertoni. If I can just jump in here. There is a big gap
between the growth in physical impairments versus mental
impairments. If you look at physical impairments in the SSI
program, the line goes like this. If you look at mental
impairments, the line goes like. So we don't know what explains
that, but we do know that on the mental impairment side, when
those cases are decided, at least in the case of speech and
language delay, 80 percent of those cases are decided on the
functional criteria, which is very subjective. So it is not a
listing, it is not a grid; it is a functional criteria.
Ms. Speier. So let's drill down on that, because a whole
group from Social Security came in and met with me on ADHD.
Speech and language is one of those conditions that does
improve as the child advances, and you are saying that you are
seeing a dramatic increase in that particular area.
Mr. Bertoni. Absolutely. It is one of the top three
impairments where there are increases. Speech and language
delays has increased significantly, and it is considered by
many to be a transient impairment, where you can grow out of it
with maturity. And the allowance rates are very high, so I
think it is evident that these children have that condition.
But the cessation rates are very high down the road when they
finally do these, MIRS notwithstanding; 38 percent cessation
rate. So it tells me that these folks, these children are
likely growing out of this condition, but SSA is not reviewing
the cases.
Ms. Speier. Okay. So, to that point, you would say, Ms.
LaCanfora, that they don't reap the same benefits, so you don't
focus on those cases. But it would seem, based on the GAO's
study, that that is the one area where there is dramatic
improvement; whereas, in many medical conditions of adults,
there isn't improvement. Certainly in these mental, for the
most part, disabilities there is dramatic; I know ADHD is one
of them. So why wouldn't we, then, focus more attention on
those cases, as the GAO is suggesting?
Ms. LaCanfora. So the math here is very simple. We could.
We could do more childhood CDRs. But if we did more childhood
CDRs, we would do fewer of something else. And then my
colleague, Mr. Bertoni, would be here with a different report
citing the much greater loss to the taxpayers in revenue by not
doing that other group of CDRs.
Ms. Speier. No, he is going to disagree with you, and I
think I will as well. Go ahead, Mr. Bertoni.
Mr. Bertoni. I think we acknowledge that there are resource
issues and there are tradeoffs to be made. Managers manage;
managers to the pain. We have put on the record at least three
impairments that have cessation rates in excess of 30 percent;
ADHD at 25 percent, some personality disorders 39, and then, of
course, the speech and language delay. For SSA to come here at
some later date to say we understand that, we may have a
problem, we are going to take some piece of the DI money, given
the return on investment, and perhaps do a limited 10-year look
at these cases to perhaps cease the ones that need to be
ceased, we would not have a problem with that; that is managing
to your resources.
Mr. Lankford. Ms. Lujan Grisham, just to let you know, we
are in a second round on this, so anywhere you want to jump in,
you are welcome to be able to jump in with any set of
questions. So take off.
Ms. Lujan Grisham. Thank you all for being here. This is a
subject that, in both a positive and not so positive way, are
very near and dear to my heart. First, my sister, who has been
gone many, many years, unfortunately, had a significant
disability, both physical and developmental back when special
education was brand new. So just in terms of getting any
resources for a family tough. And I know all too well what it
is like even today, decades later, what it is like to get
disability services, whether it is a Medicaid through a waiver,
whether it is SSI, whether it is SSDA. Whatever that resource
component is, it is very difficult still to get it, attain it,
hold it, and then make it last for the things that you need.
And I also worked in the field of aging and long-term care
and DD, adults with disabilities, world for 30 years. I also
come from a State who, unfortunately, as has been highlighted
now in every major news media, has the worst public health
outcomes of any State in the Country, largely related certainly
to socioeconomic issues.
But just look at our fetal alcohol syndrome issues and look
at our higher than national averages, which are way too high,
for autism. So when you are looking at the number of kids that
are spiking, we are also seeing a whole new host of significant
increases, and I think a lot of it is better diagnostics, but I
think probably we will find, and that is beyond my pay grade,
some researcher is going to find very clearly what is going on,
I hope, so that we can do something about it.
The balance here, and I appreciate this committee's hearing
today and the comments of my colleagues, when we are wasting
billions of dollars by doing overpayments and not doing an
effective administrative service, because I worry about the 220
average days for somebody to get a disability determination. I
am concerned about the growing waiting list on the other side.
And I do respect that you have to manage to your resources, but
I worry that in the context of this hearing we are going right
back to where we go; it is all of one and none of the other.
I think that there can be much more accountability in all
of these offices. And maybe I am on a diatribe with no
question, I am so sorry, Mr. Chairman--that is what happens on
the second round, I guess--that I expect this Administration,
probably more than most, to do it. But managing to your
resources isn't going to change that we need to, I am going to
call it a level of care in some of the claims determinations
review.
But the last time I heard, when you have Down Syndrome,
that doesn't change, that diagnosis; you keep it. So the notion
that you get better; you can improve some functional
limitations, but I always am offended when there is a sense
that people can get dramatically better. And that is not to
say, by any stretch of the imagination, that I don't expect
accountability where there can be, because it is finite. We
have a growing number of people and we want to do the best by
the number of people we have.
So if I can maybe boil this down to a question, what can we
do to balance those two issues more than just we need more
resources in Social Security? I would be one of those there, I
would be one of those who is there. But I also want you to be
accountable with those resources and expect that you do
everything in your power. How do you start, today, catching up
in a way that recognizes that I don't want this to be on the
backs of beneficiaries and I don't think--I heard Ms. Lockhart
earlier. I may disagree with your characterization about how
people with disabilities come to you and what those situations
are.
How do we right-size those so that we are aggressive on the
management side, we don't create more discrimination and a more
difficult process for people to attain the benefits that they
are entitled to, which are intended to provide dignity,
respect, independence, a savings on the long-term care side
somewhere else, and an opportunity for people to reenter the
workforce and to do the things that we want them to have every
opportunity to do?
Give me as many quick ideas as you can about right-sizing.
Nobody can.
Ms. LaCanfora. I will start out. You mentioned the funding
issue, and I know you are well aware of that, but with respect
to the discussion of prioritizing CDRs, we wouldn't have to
prioritize CDRs if we had adequate funding. We wouldn't have to
prioritize them at all because we would be doing all of them.
Now, with respect to what else we can do, we fully
acknowledge that we have to evolve the policies in the
disability programs to keep pace with medicine, technology, the
world of work. We also have to focus on consistency and
objectivity in the decision-making process. And we discussed at
the last hearing and in our intervening meeting all of the host
of things that we are doing at Social Security in that area,
and we are working with experts across the Nation; the
Institute of Medicine, the National Institutes of Health, ACIS,
the Bureau of Labor Statistics. We have a whole variety of
initiatives underway to make sure that, in fact, our policies
are evolving and reflecting today's economy and today's world
of medicine.
Ms. Lujan Grisham. If the chairman will let me, Mr.
Bertoni, do you have any? Because I worry about that imbalance,
which tends to occur every time, all or none.
Mr. Bertoni. Sure. And I think you mentioned Downs
Syndrome. That was not an impairment we focused on. We look at
the broad spectrum of impairments, and we just flagged three
that looked to be impairments that could yield a return on
investment in terms of recovery. So we have given them that
information, acknowledge that there are resource tradeoffs, but
again, within that pot of money, I think they can work more
efficiently. Should that money come down the road, we would
hope that they would continue to prioritize to the areas that
would continue to give them a return on investment. That is
unclear whether they would going forward.
Mr. Lankford. I want to recognize the ranking member of the
full committee, Mr. Cummings. I saw you came in and I want to
be able to recognize you for time. And this is a second round,
so it is open microphone, so you have all the time that you
need on it.
Mr. Cummings. Thank you very much. I want to thank the
committee, Mr. Chairman, and the ranking member, for
highlighting the need to conduct timely CDRs to help make sure
disability programs are serving the truly disabled. When I
served in the Maryland legislature for some 14 years, I was the
chairman of the committee that oversaw Social Security for the
State of Maryland, so this is of great interest to me.
Now, Ms. LaCanfora, would you agree that CDRs are a highly
cost-effective program and an effective way that ensures that
disability benefits are going to only those individuals who
continue, continue to be eligible?
Ms. LaCanfora. Absolutely.
Mr. Cummings. And so when a CDR finds that an individual is
no longer eligible for benefits, does that mean that the
original eligibility determination was in error?
Ms. LaCanfora. No. In fact, more often than not, it is due
to the fact that the person has medically improved.
Mr. Cummings. And that is what we would hope for, is it
not?
Ms. LaCanfora. Correct.
Mr. Cummings. I mean, that is a great result. In other
words, instead of somebody being disabled for years and getting
benefits, when they have improved, then that helps the person,
I guess that gets them back to work or whatever, so that helps
all the way around.
Ms. LaCanfora. That is right.
Mr. Cummings. Does a CDR decision to cease benefits because
an individual is no longer disabled mean that there was fraud?
Does it?
Ms. LaCanfora. No, absolutely not.
Mr. Cummings. And how often is fraud found, though?
Ms. LaCanfora. Well, this is a question that I think we
have debated quite a lot in prior hearings. The only real data
that we have on fraud in our disability program is a study that
was done by our inspector general in 2006 that cited less than
one percent of fraud in the program.
Mr. Cummings. So when a CDR is done and fraud is suspected,
what happens then?
Ms. LaCanfora. We refer that case to the inspector general.
And as I said earlier, we refer 22,000 cases each year to the
inspector general, and those instances of suspicion arise when
our examiners look at the facts of the case, the assertions of
the individual claimant against all of the records that they
have, and they detect some sort of anomaly or gap in the
evidence. So 22,000 times a year we refer those cases to the
inspector general for further investigation.
Mr. Cummings. And you said that is about 1 percent?
Ms. LaCanfora. The 1 percent is a little bit different.
What I am saying is you asked how much fraud is in the program.
Mr. Cummings. Yes.
Ms. LaCanfora. And the best indicator we have is a study
that was done in 2006 by the inspector general citing less than
1 percent fraud.
Mr. Cummings. Well, let's go back. I am trying to get to
the CDRs. What percentage of the CDR cases--you may not have
this information, and let me know--of the CDR cases is fraud
suspected and then you pass them on? You follow what I am
saying? In other words, the CDR is conducted, it appears that
there is a problem that is connected with fraud. I am asking
you do you have any idea what percentage of the CDRs that are
conducted result in suspected fraud. Does that make sense?
Ms. LaCanfora. It does make sense, and Mr. O'Carroll can
chime in.
Mr. Cummings. Somebody can answer. If you can't answer,
somebody else can.
Ms. Speier. Actually, Mr. Ranking Member, I think one of
the points of the CDR, of the CDRs that aren't done because of
the backlog, they have established that it is $2 billion--was
that the figure you used, Mr. O'Carroll?--of money that would
come back to the system as a result.
Ms. LaCanfora. But those cases are not an indication of
fraud.
Mr. Cummings. Okay.
Ms. Speier. Not fraud, but they no longer have the medical
disability.
Mr. Cummings. All right.
Mr. O'Carroll. There are 22,000 that are referred to us by
SSA. A small portion, Mr. Cummings, is going to be from the
CDRs and fraud related to that, and that is sort of the subset
that goes to our CDI units. We figure of the 22,000 referrals
that SSA sends to us, about one-third of them are going to the
CDI units. So that is where there is suspicion in a DDS
referred to our CDI units. So about one-third of our referrals
are in relation to suspicions or concerns in disability.
Mr. Cummings. You know, I am sure you all are familiar with
that 60 Minutes show that came on not long ago. It seemed like
there were--they talked about these attorney mills. And I am an
attorney, so I just want you to know, but do you see a lot of
that? Yes, sir.
Mr. O'Carroll. As you said, with that series on it, there
were a number of news articles on it, The Wall Street Journal
covered it. It was in a number of things. It is one of our
biggest concerns, what we call facilitator fraud, and that is
where you have sort of the mills that are going, where there
are going to be people do introductions to people saying that
they will get them on disability; they will be using
unscrupulous medical providers; there will be facilitators for
it. It has been in the news quite a bit.
And, yes, we are concentrating on that very heavily. We are
doing it in, I guess, three regions now; we have units that are
just out there taking a look at facilitator fraud. They are
very difficult investigations to do because usually you are
using undercover agents to be inserted in to be able to show
what was happening. We film it, we videotape it, we do all
that, but it usually takes a couple years, where you establish
an identity for a person to go in as an undercover on it.
So, yes, we are exploring that extremely a lot.
Ms. Speier. But, Mr. O'Carroll, in a prior meeting that we
had, didn't you indicate that there were thousands of these
cases in Puerto Rico and so many hundreds of them in New York
and so many more in West Virginia?
Mr. O'Carroll. Yes.
Ms. Speier. Could you just give that number?
Mr. O'Carroll. The two examples that I used that were
really specific was Puerto Rico. It is hundreds at this time,
but there is also suspicion of over 1,000. And in New York City
there was a large amount on that one, too, where facilitators
were going to people as they retired from Government and said
to them, we will get you on benefits. So we have a couple of
those and we have others going in the other regions that I
talked about.
Mr. Cummings. Now, Ms. LaCanfora, it has been suggested
that the medical improvements standards, going back to the
CDRs, does not allow the removal of beneficiaries who were
wrongly awarded benefits in the first place. Is it true that
under the existing review standards, if a clear and
indisputable error in the initial disability determination was
found during a CDR, the examiner can cease benefits?
Ms. LaCanfora. That is correct.
Mr. Cummings. So Social Security actuaries projected the
disability insurance trust fund is only years away from being
unable to fully finance disability insurance benefits. I would
like to just as a few questions about that. If the agency
performed every CDR required in a timely manner, would the
savings in spending make a small, medium, or large dent in the
shortfall in the trust fund?
Ms. LaCanfora. It would be small.
Mr. Cummings. How small?
Ms. LaCanfora. Not being an actuary, I am a little
concerned about commenting on it, but I think it would not
significantly extend the life of the DI trust fund.
Ms. Speier. [Remarks made off microphone.]
Mr. Cummings. Okay, I am just asking a question.
Ms. LaCanfora. But it would not extend the life of the
trust fund.
Mr. Cummings. I am just asking questions. Thank you.
So go ahead, what were you saying?
Ms. LaCanfora. Just that if we did all of the CDRs,
certainly that is desirable, that is what we all want to do.
With adequate funding we will do it. But in terms of extending
the life of the disability trust fund, it would not have a
significant impact.
Mr. Cummings. Well, going to Ms. Speier's point, we are
talking about billions of dollars? I see everybody shaking your
heads.
Ms. LaCanfora. Yes. Yes.
Mr. Cummings. Okay. But you are saying that it wouldn't,
you see that as small.
Ms. LaCanfora. I don't see it--okay, let me put it into
perspective. I think was said before, but for every $9 that we
save the taxpayers, we have to invest, on average, $1. So it is
clearly an excellent investment to do continuing disability
reviews; they are essential, they should be fully funded
without question.
Mr. Cummings. I agree.
Ms. LaCanfora. But your question was to what extent would
doing all of them extend the 2016 date of reserve depletion
which is currently projected, and my answer is that doing the
rest of the CDRs isn't going to have a dramatic impact on that
date.
Mr. Cummings. So what is a meaningful way, do you think, to
address the shortfall?
Ms. LaCanfora. The shortfall is not new; there have been
shortfalls in our trust funds at least a half dozen times since
the inception of the programs, and the Congress has a couple of
options. They can do payroll tax redistribution and there are a
couple of legislative mechanisms through which to do that.
Mr. Cummings. And Congress has acted before?
Ms. LaCanfora. Yes.
Mr. Cummings. All right, thank you very much.
Mr. Lankford. Was that for disability insurance
specification you are talking about the redistribution?
Ms. LaCanfora. It has been done for both trust funds.
Mr. Lankford. Short of that, what else can we do? Because
one of the things that Ranking Member Speier and I, when we
sent the letter, we were trying to detail 11 different items
that can be done that are not just about efficiency and
dollars; they are about people in this process, going back to
what Ms. Lockhart was talking about before. These are lives and
people that we hope to be able to transition back into
productive lives for the sake of their children and the sake of
the community as a whole and what they bring to society. So
there are multiple issues here. What are other things, besides
just redistributing payroll taxes, to be able to stabilize this
and be able to bring down some of the cost areas?
Ms. LaCanfora. So I think that there is not a connection
between any of the items in your letter or any of the things we
are working on at Social Security and the reserve depletion
that is projected in 2016. In other words, all of those things
that we are working on are wonderful ideas and we need to keep
our eye on the prize and evolve the policy and the program to
be more efficient and effective. You all have some good ideas
as well, but those things are not going to extend the life of
the DI trust fund. You would need to fundamentally, through
legislation, completely change the nature of the program.
But I want to go back to something I said earlier, which is
the policy and the process and the management of the agency is
not the cause of the reserve depletion. The cause of the
reserve depletion is demographics; baby-boomers aging, women
entering the workforce.
Mr. Lankford. I understand. I only partially accept that
just from some of the other things. We talked last time about
the Federal Reserve in San Francisco and the report, I am sure
you are very familiar with that. They also tracked those same
issues, about women, age, all those things, but they came out
with a 44 percent of unexplainable increase beyond just
demographics.
So it wasn't just, hey, this is a pure demographic issue;
they identified, of the additional people in the system, 44
percent of them no one can identify. This shouldn't be there.
That is a fairly high number of individuals to enter into the
system unexplainable. We have talked about the high number of
people that are actually applying that create this backlog not
only of CDRs, but there is a backlog of actually getting into
the system because so many people are hitting the system. They
go through the two different DDS reports and they just
automatically go to the ALJs. So there is a press in the
backlog of the ALJs that SSA has worked on to try to fast-track
and get people in the system and have the ALJs deal with this.
So we have issues on every side of this. We have 44 percent
of the people unexplainable while they are pressing into the
system; we have a fast-track system of actually getting people
through the ALJ system; we have CDRs that are occurring that we
are getting 18 percent turnaround rate of what we are
expecting, and we are dealing with the definitions of it. There
are issues on each side of this that have to be addressed. Some
of these are legislative, we get that. That is one of the
questions that we are asking, what is it legislatively do you
need.
But we do feel like there is a need administratively that
does make a difference in billions of dollars. If it takes us
from 2016 to 2017, that is a gain. What are we doing to be able
to get ahead of this? It is just unacceptable to get to 2016
and for Congress to wake up and go, gosh, we have a problem.
When do we all see it?
Ms. Speier. Well, and let me also say that regardless of
whether it is a lot of money or not a lot of money, the system
has to have integrity; and people who are receiving benefits
should be eligible to receive benefits, and those that are
ineligible or grow out of eligibility should not receive
benefits. And we should have a system that works for that end.
I am curious about, if we could go back to Ms. Nottingham's
statement and her recommendations. I would just like to
understand some of the ones you referenced. You said electronic
claim exceptions should be eliminated to prevent any future
claims from being processed in a paper format. Makes a lot of
sense. Are claims still being processed in a paper format?
Ms. Nottingham. There are still some exceptions. It is very
few, but it happens still to this day.
Ms. Speier. Well, by very few, then why is that a
recommendation if it is de minimis. Is it de minimis?
Ms. Nottingham. Well, the claims that are currently
processed that are paper may be de minimis. The problem is that
just more paper folders in general. When they come up for CDRs,
some of them are still paper, so the fewer that we have coming
in as paper, when they become CDRs, the few we all have that
are lost. We see at CDR maybe a small percentage, but one or
two percent of claims that are lost is still a large amount.
Ms. Speier. So you also said the lost folder policy should
not apply to cases of fraud or similar fault. What is the lost
folder policy?
Ms. Nottingham. In the CDR, if the prior decision folder is
lost, we have to try to reconstruct the file, and if we are
unable to do that, then we just continue benefits. Prior to
reconstruction, we actually try to see if they meet the
criteria currently, but generally we don't have anything to
compare because it becomes really hard to reconstruct the prior
file.
Ms. Speier. So that is our fault for losing the file.
Ms. Nottingham. Correct.
Ms. Speier. So what percentage of cases are lost folders?
Ms. Nottingham. My belief, what I see is that it might be
more than SSA has fully accounted for or been able to track, I
should say, and I think it is probably like 1 or 2 percent,
still.
Ms. Speier. Okay, so those are small, although, even though
they are small, they could be a significant number. I
understand that.
Revisions to the fraud or similar fault policies are
needed. Can you kind of expand on that and what kinds of
changes should be made there?
Ms. Nottingham. There is very minimal policy at this point
in time addressing that. Claims are very complex and it is hard
to prove fraud or similar fault, particularly on CDRs. With
CDRs, we have to prove that there was fraud or similar fault at
the prior decision as well, so I don't actually handle those
types of claims, though.
Ms. Speier. Okay, I understand that. Mr. Bertoni was
nodding his head. Maybe you can give us some----
Mr. Bertoni. I just think when you start talking about the
issue of fraud, fraud is a very high bar. To get to fraud, you
had to suspect something, you had to develop a case, and then
you had to actually get a conviction for fraud, typically. Then
there is your fraud figure. But is there waste? Is there abuse
in the program? Absolutely. A person who gets on the rolls five
years ago, recovers, but doesn't have a CDR for the next three
years, you finally call that person in, they are deemed not to
be medically eligible anymore, they have three years of
overpayments. Was that fraud? Probably not; you probably
couldn't go there and prove that. But was it potential waste
and abuse in the program? Absolutely. So you have to look at
this in a broader context, and it is very costly.
Ms. Speier. So ADHD, can I have your opinion on how we are
handling ADHD cases?
Mr. Bertoni. I think similar to the speech and language
delay. We have, again, an impairment that could possibly,
according to many experts, improve. We know that there is a
high approval rate, a high cessation rate, and it doesn't
appear to be on the radar screen of the agency. I think there
is, again, opportunity to look at these impairments and do some
targeted reviews, again, within the current resource structure.
And believe me, with additional resources head on into this
area, but right now I would guess that the numbers of backlog
claims in that $1.3 million are disproportionate to the SSI
population. So I think there is opportunity here to look at
that population.
What is the benefit? The taxpayers certainly benefit. The
child benefits because they get early intervention, early
services, they get mainstreamed back into a regular school
environment and back into perhaps a more productive future.
Ms. Speier. So here is my one concern here with ADHD. Most
of the recipients are poor families, probably single parents.
From my discussions with the experts at Social Security, many
of these people aren't eligible for SSDI, the parents, so the
SSI is the one benefit that can come to a family that has no
resources. So I understand that.
But what happens, evidently, is that at age 18 there is a
review done. If it is determined that you still have ADHD, then
that benefit continues into adulthood, which does not make
sense. I mean, I have a lot of experience with ADHD on a
personal level, so we need to do something about that point.
Mr. Bertoni. Almost half of those re-determinations end up
going into the adult disability population. So the cessation
rate, although it is high, upper fifties, you would surmise
that those who are deemed eligible, are still disabled at that
time, are going to go into that next phase of disability.
Ms. Nottingham. What I see for ADHD claims that come back
with age 18 for review, we then use the adult standards, so we
are not using the medical improvement standard at that point,
at the age 18 re-determination. A lot of those we are not able
to find disabled at that point in time.
Ms. Speier. I am sorry, what?
Ms. Nottingham. We are usually not able to find someone who
was allowed for ADHD as a child; we usually don't find them
disabled as an adult, because we are using a new criteria.
Ms. Speier. I think the numbers are actually pretty high,
if I remember correctly, the percentage that continue to be.
The percentage of children who have ADHD who then continue to
have SSI after 18 is not a small percentage.
Ms. LaCanfora. Ms. Nottingham is correct, and so is Mr.
Bertoni. We actually cease 50 percent of all of the
beneficiaries. Specific to ADHD, I don't know off the top of my
head, but childhood beneficiaries at age 18 get the de novo
review, to use Ms. Nottingham's term. We are not using the
medical improvement review standard at that point. By law, the
age 18 re-determinations look at the claim fresh and we apply
the adult disability standards and we process an initial claim
at that point, not looking at whether they have improved. That
is not a requirement.
Ms. Speier. But if they still have difficulty focusing,
they still have ADHD, and so their benefits can continue.
Ms. LaCanfora. The medical standards are, obviously, a lot
more complicated than that, and what we look at is, despite
treatment intervention, medication, and so forth, the
individual still has significant impairments in multiple
domains of function. So it is a little bit more complicated,
but generally those are the more severe cases.
I would also add that there are 74 million children in the
United States. Less than 2 percent of them get SSI. They are
the poorest children in the Nation, and 32 percent of the
children getting SSI, despite the receipt of SSI, are still
living in poverty. Without SSI, it would be more like 60
percent living in poverty.
Mr. Lankford. Mr. Horsford, just to give you a head's up,
you have been here before, this is a second round, so you can
jump in at any point.
But I do want to be able to ask Ms. Nottingham you had on
your statement, to finish up with Ms. Speier was talking about
your statement, there is to be a consideration of the
possibility of requiring treatment for conditions that may
improve. The challenge of this is if there is a disability that
is treatable, that is manageable, and we go to ADHD or other
things, whether it may be hearing loss or they have hearing
aids, whatever it may be, a disability that is treatable and
manageable, how is that then evaluated for long-term
disability? Is there the possibility, going back to Ms.
Lockhart's earlier statement here, how do we get folks back
into the community if they have a disability, it is being
managed, they are capable of getting back in the workforce? Do
we?
Ms. Nottingham. I think this is an area where there is
possibly room for improvement. We have some conditions where
the policies are very--maybe the listings address it. Hearing
is one thing. When we measure their hearing, it is with best
correction. Or vision as well. There are some conditions like
seizures are ones that we are very specific that if they are
not following prescribed treatment, then we would not allow
them, because most times seizures are treatable.
There is an exception for following prescribed treatment,
it is good cause; and usually that is--one of them is access to
medical care. So you might have a condition, depression,
anxiety, ADHD, some of these conditions that could very well be
improved with treatment, but they don't have access to it, so
the hope is when they get benefits that they could get
treatment and get better; however, at CDR many claims we see do
not actually have any treatment.
The failure to follow prescribed treatment is something
that, from my experience, is not really used much at CDRs, and
I am wondering if that is a possibility where we consider that
more.
Mr. Lankford. Okay, slow down. Say that last statement one
more time.
Ms. Nottingham. The failure to follow prescribed treatment
policy is not something that is really considered at CDR. I
don't know if that is the direct policy on that, whether we
should be or not, but in practice it is not really followed and
I am thinking that is a possibility of where we can be looking
into that more.
Mr. Lankford. Okay, so I want to lean into this. If a
person could improve, be in the community, be employable if
they maintain medication or treatment, or whatever it may be,
and they choose not to, you are saying that is not considered?
Hey, this person still should be listed as disabled because
they are not taking the treatment that has been prescribed for
them?
Ms. Nottingham. It depends on the condition. There are some
that you don't know, with treatment, how they would do. Some
are much more likely, like I mentioned seizure disorders, if
people get treatment on that, they get better and, if not, then
they should be found disabled. So we would find someone to not
be found to be disabled because they are failing to follow
prescribed treatment. However, some conditions it is harder to
tell how they would respond to treatment, like depression or
anxiety. But there is little guidance on that at this point in
time on CDRs and when that would apply, outside of a few
conditions.
Ms. LaCanfora. If I might just add one point, and that is
we do take into consideration a person's compliance with
treatment and we do have tools to cease benefits or disallow
benefits if a person does not comply with treatment, but
understand that for medical impairments the failure to follow a
prescribed treatment is often part of the mental impairment; it
is not just that the person is trying to be obstinate, it is
that they have a serious mental condition, whether it be
schizophrenia or something else, that creates an intense, let's
say, fear of the medication or fear of the side effects that
the medication creates. So it is a difficult determination and
we would be happy to work with NADE and anybody else to clarify
it or provide training on it, if that would be helpful.
Mr. Lankford. And I am not necessarily talking about the
mental illnesses and such. This is a physical thing. If they
have a physical disability and they choose not to take
medication just because they don't feel a requirement to and
say, it doesn't matter to me one way or the other. That is a
more serious thing not only for the taxpayer, but also for that
individual and their families, obviously, and somehow we have
to have a way to be able to incentivize, saying re-engage in
culture.
Again, I come back to what Ms. Lockhart was saying. It is a
very big issue to isolate people and to be able to separate
them out, and we basically discourage them from future work,
because if they are able to work, we want them to be able to
re-engage in culture and be able to get back to work. But if
benefits and all those things suddenly go away, there is no
sliding scale, there is no possibility to be able to drift off
this even when there was a pilot, even; how do we help people
that are capable of doing that actually being able to re-
engage. So that is something I think we have to take a look at,
at how we actually can do that. Is that something you need a
legislative fix on or is that something you have administrative
authority? Can we pilot something or how do we help to be able
to transition out?
Ms. Lockhart, are you trying to say something on that as
well?
Ms. Lockhart. Yes. On the compliance, I just want to add to
that real quickly. We are currently working with our Department
of Health, for example, with patients with sickle cell anemia.
The biggest problem with barrier of care we have is compliance.
It is simply getting the patients to get to the doctor and
follow the protocol they are given. It is not always a
psychological issue as much as it a socioeconomic or cultural
issue. So we work with them on education to help them follow
those protocols.
ADHD, our chief rights on the international level, the
standards for that, I am not sure he would always agree it is a
disability, so I would welcome you to contact him at any time
to follow up on that.
Currently, Oklahoma has 19,475 children in the aid category
that are receiving some sort of disability aid. My concern, as
we are talking about all of this, is not are they getting
disability or not, but what happens to them. Where are they
going and what is their future? And within these programs the
bigger picture. That would be my question.
Ms. LaCanfora. If I might jump in on the bigger picture,
which goes back to your question about creating self-
sufficiency and having people re-engage in the community and be
productive members of society, we believe at Social Security,
as Ranking Member Speier said, that we need to pay the right
check to the right person at the right time. That is the law
and we work hard to do that well. But we also believe that part
of our mission is evolving policy and practice to support
people to become self-sufficient and to re-engage.
And I think at the last hearing I may have mentioned we
have a research budget and we use that money to test new
policies and demonstrations, and right now we have a couple
right along the lines of what you are suggestion. PROMISE is
the Promoting Readiness of Minors in Social Security Program.
It is an interagency effort to grant money to States around the
Country. There are 11 States participating. And the idea is to
create community-based incentives very similar to what Ms.
Lockhart is doing, and to figure out what community supports
will work to help children, in particular, re-engage and become
productive potential working members of society as they age.
Ms. Speier. Let me just add that for a number of years I
worked with the developmentally disabled community in my
county, where what we were doing was placing adult
developmentally disabled in positions, in local grocery stores,
at drug stores, in law firms, doing meaningful work, getting a
paycheck, turning tax receivers into taxpayers was one of the
lines that was used by this nonprofit, with great success. And
they were developmentally disabled. So I would hope that, as we
look at ways to just enhance the program and create greater
self-sufficiency, that we would look at some of the models that
exist around the Country. I mean, it is not like we are
reinventing the wheel here.
But certainly this PROMISE program, if you have youngsters
who have speech delays or ADHD, I think it would be really
important, when they are still minors, to get them working,
getting them placed in jobs in the communities so that if in
fact 50 percent of them are ceasing that benefit at age 18,
that there is somewhere for them to go in terms of being valued
members of society in terms of employment.
Ms. LaCanfora. Absolutely. And the PROMISE program does
include employment support, placement, benefit counseling, and
all of those integrated supports that Ms. Lockhart was
referring to. That is the point of the program. And it is not
the first time that we have engaged on that front. We have
completed the Youth Transition Demonstration, which targeted
youth between the age of 14 and 25, and did generally the same
thing; we provided community-based supports in many different
locations and it proved effective.
Ms. Speier. Well, I guess my point is I think it should be
something that we do automatically with most of these
youngsters, not just as pilot programs. Because if they are
successful, let's fold it into the existing----
Ms. LaCanfora. Absolutely. Our demonstrations are intended
to inform the dialogue and provide the Congress with some food
for thought as you consider legislative changes to the program.
Mr. Lankford. It is not going to be a 16-year prototype,
though, is it?
Ms. LaCanfora. No.
Mr. Lankford. We would like to see some progress on.
Ms. LaCanfora. We have actually completed the Youth
Transition Demonstration. The findings are publicly available
and there are some really interesting things that we found.
Community-based programs do work. PROMISE is going to, I
believe, further corroborate that evidence.
Mr. Lankford. Great. Let me ask about the vocational grid.
We have talked about this before. I was six, I think, when it
was finalized. How are we doing on the vocational grid?
Ms. LaCanfora. We are doing well. I think there are two
pieces to this. The first is the update of the occupational
information system. That is the dictionary of jobs that you
mentioned has not been updated in a long time. We have
partnered with the Bureau of Labor Statistics. We are cooking
along.
Mr. Lankford. Our date for that to be completed?
Ms. LaCanfora. Our date is 2016, when we believe we will
have something useful.
Mr. Lankford. Still on track.
Ms. LaCanfora. We are on track, absolutely. The grids is a
slightly different, yet very much related issue. You know, and
we discussed it at the last hearing, we attempted rulemaking on
the grids in the past and we were shut down, essentially, and
the reason for that is that we did not have an evidence base
behind the proposal that we made to increase the age limits in
the grid; and when we got questions about the disproportionate
effects to minorities and other questions, we didn't have the
science to back it up. We learned from that experience; we are
not going to make that mistake again.
So we are, as I described to you before, in the process of
building our evidence base to support logical changes to the
grid, and we are well under way. We are working with the
Disability Research Consortium and the Library of Congress. We
are engaging them in a literature review to look at how other
disability systems, both internationally and in the private
sector, use age, education, and work in their systems so that
we can learn from that and shape our own policy.
Mr. Lankford. The date for that?
Ms. LaCanfora. The initial phase of literature review from
the Disability Research Consortium, we expect their report in a
couple of months.
Mr. Lankford. Okay. Is that something that will be
available to us as well to be able to review?
Ms. LaCanfora. Yes.
Mr. Lankford. How publicly available is that?
Ms. LaCanfora. We can share. We can share the findings with
the committee.
Mr. Lankford. So we are talking July-ish, somewhere through
there?
Ms. LaCanfora. Yes. Now, understand that is the first phase
of our exploration.
Mr. Lankford. I understand. That is getting the science out
there to be able to review it. Then the next part of it, after
that is done, then it is a matter of starting to make the
recommendations.
Ms. LaCanfora. Exactly.
Mr. Lankford. You hope to get all this together by 2016,
but the vocational grid and the other recommendations, get them
to complete proposal?
Ms. LaCanfora. That would be ideal, yes. It really depends
on what we find in the exploration. Remember that the law
requires us to consider age, education, and work as part of the
determination. How we do that needs to evolve over time, as
people work longer and so forth. But it is a very complicated
analysis. So we are in the fact-finding stage.
Mr. Lankford. Okay, let me ask another question we have
talked about before, and that is the high rate of reversal
judges for the ALJs, whether it be Judge Daltry or any number
of others there. You have CDR funds that have been allotted.
You have said you are setting aside some of those for the high
priority cases. Are those some of the high priority cases that
you are actually targeting, some of these high reversal ALJs?
Ms. LaCanfora. Yes.
Mr. Lankford. Okay. How is that coming so far?
Ms. LaCanfora. So we have been looking at this from a legal
standpoint, because you know we try hard to respect judicial
independence of our ALJs, so there are some legal parameters
that we need to work within, and we have been working hard to
kind of figure out a path forward. But we believe that we are
going to get to where this committee wants us to be and where
we need to be by looking at the cases that have the potential
of being out of policy compliance.
In other words, we know what cases are problematic from a
policy standpoint, and we are going to target those cases; and
in doing so we will get to a lot of the decisions that were
problematic and made by those judges that were outliers or that
were high allowance rate judges. And we will take those cases
and put them to the front of the CDR pipeline. So we will do
CDRs.
Mr. Lankford. So give me a date on that. When does that
begin?
Ms. LaCanfora. We are going to start that now.
Mr. Lankford. Okay, that is ongoing now. One other quick
question on the medical improvement definition GAO. You have
some thoughts on this as well, Mr. Bertoni, I understand, of
how we handle this.
Mr. Bertoni. Well, in our report essentially there was much
confusion about how to apply some of the provisions in terms of
the exceptions; how much improvement in medical capacity was
sufficient to determine or make a judgment of cessation. It
just wasn't clear. There was a lot of confusion. We surveyed
every DDS director and a number of examiners, had a 95 percent
response rate, I believe, and there was a lot of confusion as
to how to apply those two critical provisions. And we asked the
agency to go in and put some more granularity around those
instructions. It hasn't occurred, and we still think it needs
to.
Mr. Lankford. How does that happen?
Mr. Bertoni. That is in SSA's ball court, ball whatever,
field.
Mr. Lankford. Ms. LaCanfora, it is on your desk. How does
that happen?
Ms. LaCanfora. So it has happened. We have done training on
the medical improvement review standard and the exceptions.
However, as I mentioned before, we have lost 11,000 people. The
lack of funding has resulted in high turnover in the DDSs, so
training is not a one-time thing; we need to do continual
training. We have been reviewing cases where the medical
improvement review standard was utilized and we are looking at
where we need to provide new improved training and clarity, and
we will do that. And we are happy to work with NADE to do that.
Mr. Lankford. And the goal here, again, is to get people
back out to work. We are all on this dais we are all unanimous.
There needs to be a safety net for the most vulnerable. But if
there is an expected return to work, how do we help transition
people back out to work and be evaluated? When they are in a
vulnerable moment that our society comes alongside of them, but
also incentivizes that there is an end-date for people that are
expected to have returned, so how do we help you in that
process.
So the medical improvement, and this definition becomes
very helpful to us to know that it is not a matter you are 100
percent back, you are not going to be 100 percent back.
Everyone lives with aches and pains. My ranking member lives
with aches and pains all the time from past injuries. She is
doing extremely well. So there are other people I have talked
about before in my own family, in a wheelchair, all sorts of
different medical issues that do extremely well vocationally.
How do we help incentivize that and to be able to encourage
people to re-engage with culture, again going back to what Ms.
Lockhart asked.
So I am not saying we have to determine that today. I am
saying from this panel we want to see a way that medical
improvement is clear and that they see improvement not back to
100 percent, but see improvement where they can re-engage again
for the sake of their families and our economy.
Mr. Bertoni. Mr. Chairman, earlier you talked about the
initial decision and not being able to overturn a case on the
initial decision. It is really the last decision. In many
cases, in our work, it was the ALJ decision that the DDSs were
revising in CDR, and the information just wasn't there to
determine medical improvements.
So I really think the agency needs to look at reconciling
the tools that they have at the initial level, and I think they
are doing some things there to standardize and to get enough
information in the record, where you can revisit and determine
medical improvement. I think there are real issues at the ALJ
level, where that tool just doesn't exist yet. I know they are
thinking about it, but I think something needs to happen there.
Ms. Speier. I am not following you. What tool are you
talking about at the ALJ level?
Mr. Bertoni. I don't believe there is at this point. At
least at the DDS level we have eCAT, which provides a platform
for the examiners to more thoroughly document their rationale
for the decision. And if you had to revisit that in a CDR,
perhaps you would have more information to document medical
improvement.
At the hearings level, at least in our work, most of the
concern was that when the DDS revisited that case in a CDR that
was decided at the hearings level, the information was not
there; there wasn't enough information to document medical
improvement; and the agency, I think, needs to look to
additional tools that the ALJs can use to document more
thoroughly that rationale. When you are under pressure to
process claims, 700 a month, it is real easy to fly through
these claims with limited rationale; and in the event of a CDR
there is not enough there for the DDS representative to make a
decision.
Ms. Speier. So are you saying that the ALJ, because they
don't have enough information, tends to continue the benefit,
but doesn't document it enough? Is that what you are saying?
Mr. Bertoni. I would say in our case, in our review, the
concern was that when the DDS examiner received the CDR for
review, and the last person who touched it was an ALJ, that
decision, that justification did not have sufficient
information for them to determine medical improvement. So there
could be an opportunity to provide additional tools at the ALJ
level so that decision is more thoroughly documented, the
rationale is there for the DDS examiner, should there be a CDR,
to make a determination of medical improvement.
Ms. Speier. And the ALJ typically has attorneys write their
decisions, correct?
Mr. Bertoni. I will defer to the agency on that. I know
that happens; I don't know to what extent.
Ms. LaCanfora. That is true. There are four support staff
to every ALJ. I do want to agree with Mr. Bertoni, though, in
terms of the importance of documentation. He mentioned eCAT,
which is the electronic case analysis tool. It is basically a
tool that the DDSs use to thoroughly document the rationale for
their decisions. We love that took because it inspires policy
compliance consistency across the board. We are implementing a
version of that with the ALJs, we call it the electronic bench
book, but it is essentially the same thing. Think of it as sort
of a tool that pads you through the decision and makes you
document your rationale.
Mr. Lankford. When?
Ms. LaCanfora. I have to get back to you on that one. I
have to ask Mr. Sklar what his plan is.
Mr. Lankford. But we are thinking in the next year, the
next five years? What are you thinking? Give me a ballpark.
Ms. LaCanfora. Probably somewhere in between for a full
rollout.
Mr. Horsford. Mr. Chairman? Mr. Chairman, I want to break
in here because I want to ask about the continuing disability
reviews, which was the primary purpose for the hearing today,
and talk about this annual report on continuing disability
reviews report that was done by the SSA that found that the
Government saved approximately $5.4 billion in fiscal year 2011
alone as a result of completed continuing disability reviews. I
think, from what I understand, part of this problem is a huge
backlog and a lack of staff resources at the front end of the
process where the initial determinations are made, is that
correct?
Ms. LaCanfora. Yes.
Mr. Horsford. So what are the current barriers, then, to
conducting more medical CDRs?
Ms. LaCanfora. We need adequate, sustained, and predictable
funding; and that is the number one way to get current on
medical CDRs. The only way.
Mr. Horsford. So the chairman and the ranking member sent
an 11-page letter yesterday regarding recommendations for
improvements to the disability program. What were some of the
examples of how SSA is already addressing some of those
concerns?
Ms. LaCanfora. Well, the committee suggested, for example,
that we ensure that claimant representatives give us all of the
evidence at their disposal, and we have actually already done
that. We have a notice of proposed rulemaking out for comment
right now; it went out on February 20th. The comment period is
open, so we are already there.
Mr. Horsford. And what is the estimated number of positions
that you need based on the current backlog that is in place?
Ms. LaCanfora. I will give you a dollar amount. In fiscal
year 2014, we were given the Budget Control Act level of
funding, $1.197 billion, to do program integrity work. In
fiscal year 2015 we need from the Congress $1.396 billion for
program integrity. Subsequent to fiscal year 2015, the
President's budget has a proposal for mandatory sustained
funding for program integrity, and we hope that the Congress
will support it. That is what we need to get the job done and
to eliminate this backlog of medical CDRs.
Mr. Horsford. So despite the fact that every dollar that is
spent on CDRs saved the Federal Government $9, that lack of
funding, in large part, is what is contributing to this 1.3
million backlogs of CDRs.
Ms. LaCanfora. That is the reason.
Mr. Horsford. So, Mr. Chairman, I would just ask that we
enter this report into the record. I agree that there are a
number of different policy and operational recommendations that
need to be implemented, but I also think that the main thing we
need to do as Congress is to properly fund and resource where
there is the greatest return on investment, and that is through
the CDRs. That is the front-end part of the process.
I know we had an extensive hearing about the ALJs and
whatever discretion that they have, and that is an important
discussion, but I just feel like the meat of the problem is at
the front-end, and it is really about a lack of resources to a
program that we know, when you fund it, it works and it
provides the types of medical reviews that are necessary.
So I yield back.
Ms. Speier. Ms. LaCanfora, the inspector general had put up
that one photo of the rock band star who obviously was provided
benefits inappropriately. Have you clawed back that money?
Ms. LaCanfora. I don't know that specific case. I will say
that we identified that case and referred it to the inspector
general.
Ms. Speier. All right. Would you just inform us as to
whether or not you have attempted to claw back that money?
Ms. LaCanfora. Sure.
Ms. Speier. All right.
And then to you, inspector general and to you, Mr. Bertoni,
you have spent a lot of time in this issue area, and I would
like to just know from each of you recommendations you would
make to us for improvements to the system beyond what you have
provided. And I guess to you, Mr. Bertoni, if there is another
issue area that you think we should be requesting you to look
at at the GAO, we would be happy to make that request of you to
kind of make the system work more effectively.
Mr. Bertoni. Well, I think we have done a lot of work on
the front-end of the process, looking at the initial claims
process, SSA's processes for moving claims through the system.
I think there are opportunities to gain some efficiencies
there. I understand the resource issues, I certainly do, but
again I think there are opportunities for efficiencies there to
be able to process claims more quickly and smoothly.
I think there is opportunity in the area of quality
assurance to make sure that if we are in an environment where
we have a backlog situation, we are telling people to process a
lot of claims, that we also keep our eye on the quality
assurance piece so that these are not only quickly processed,
but accurately processed. And ultimately I think follow-on
work, I would be interested in doing a top-to-bottom review of
the medical continuing disability review process, the CDR
process, some of the assumptions, some of the formulas, things
that are being used to drive these reviews. I think that would
be great work.
Ms. Speier. Mr. O'Carroll?
Mr. O'Carroll. Just a couple things, and I guess this is a
good time to say it. I think one of the common tones or themes
throughout this hearing has been what we talk about all the
time. There is a balance between stewardship and service, and
one of the things I guess that has come out, and I was looking
at my numbers as we were sitting here, is that there is about--
we are talking about the 1.3 backlog on CDRs, million backlog
on it, and there is about that same, if not more, backlog for
initial claims going into SSA. So the agency has to make that
balance out between stewardship and the service part of it.
Our job is to keep reminding them about the fraud, waste,
and abuse side of it. And I think one of the other themes from
this thing has been if we prevent the fraud, one prevention is
best. Let's get the money before it goes out the door and
prevent it. That is the reason why the CDI units have been so
effective. And along that same line, with the CDI units, we
bank now about $10 billion in savings by using the CDI units,
and going back to what Mr. Cummings was talking about in terms
of the trust fund on it, that might equate to $10 billion, it
would be about an extension of a month into the trust fund,
which is a big deal. So my feeling is that these anti-fraud
initiatives are major money savers for the trust fund and it is
something that are very successful and we can show it.
So, anyway, one other thought on the funding part that we
were talking about, too, was that we suggested a number of
times, we put it every year when we go to OMB for our budget
presentation, we put it in each time with our appropriators, is
an integrity fund for SSA. And with that integrity fund is with
the $3 billion-plus that are recovered every year in terms of
overpayments, if SSA could have access to some of that money.
What we have suggested is 25 percent of that money, and use
that for the anti-fraud initiatives like CDRs and other things
that would fund it; it wouldn't need any additional funding for
it.
One of the other things we would like is if the IG could
get a percentage of that, we can use that for expansion of the
CDI program and be better able to address the 22,000 disability
referrals we get from SSA every year. In terms of our resources
that we have, we are doing about 10,000 cases from the
resources that we are getting, and we could do a lot more if we
had more resources, and I think an integrity fund, instead of
coming and asking for a bigger appropriation, would be very
helpful.
Mr. Lankford. What is the source of the integrity funding?
Mr. O'Carroll. Integrity fund would be the recovered
dollars that are coming from the recovery of overpayments. So
SSA is banking $3.26, I think, in overpayments every year that
are recovered, so instead of that going back into the trust
fund or into the general fund, which some of the money goes
back to, redirect that back into anti-fraud initiatives.
Mr. Lankford. Okay. I have one last question, unless you
have additional things, and that is this issue that you
referred to the bench data system that is trying to line up,
the eCAT and then there was the other one.
Ms. LaCanfora. The electronic bench book.
Mr. Lankford. The electronic bench book. Until that is up
to speed, we are still going to have an issue with ALJs that
have final basically document that we can't track all the
reasons for and all the policy documents for. So when we come
back to do CDRs, it is not written in such a way that we can
really evaluate medical improvement.
Ms. LaCanfora. Let me say that we have no indication that
that is a widespread problem. Certainly we want the ALJs to do
extensive documentation, and the electronic bench book will
help that, but under current policy and process they are doing
that today; and there are always going to be cases where we
don't do as good a job as others, but I don't have an
indication that that is a systemic problem.
Mr. Lankford. Okay. Anyone else experience that? Ms.
Nottingham?
Ms. Nottingham. I would disagree with that. The most common
complaint I hear from other examiners about ALJs is that the
allowances are not well documented. I can tell you that the
denial decisions that they do usually are well documented, but
the allowances, it is very hard for us to make a finding of
medical improvement when we don't really know what they were
allowed for. It is sometimes difficult to really see what their
rationalization was when there is--you know, their
rationalization on the decision on a denial might be 9 or 10
pages long; whereas, an allowance is generally like 1 or 2
pages.
Mr. Lankford. Tough to be able to tell on that, then, 1 or
2 pages. So when we are dealing with that, how do we process
this in the meantime? We have something coming in the future
with the bench book. How do we deal with medical improvement
until we get that in place?
Ms. LaCanfora. Let us get back to you on the bench book,
because I don't want to speak prematurely, but I believe we are
already well into the rollout of the electronic bench book.
Mr. Lankford. Okay.
Okay, final questions or thoughts? Anyone else have final
questions or thoughts as well?
Long day. Thanks for allowing us to be able to pummel you
with questions. We want to help in this process and I
appreciate what everybody is doing to be able to serve some of
the most vulnerable in our society. So thank you.
With that, we are adjourned.
[Whereupon, at 4:10 p.m., the subcommittee was adjourned.]
APPENDIX
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Material Submitted for the Hearing Record
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