Claims at  all levels for which the claimant is determined to be eligible for DI or SSI,  also called favorable claims, are forwarded to other SSA offices for  payment. Referral processes can vary by DDS. Once a case is referred to the SSA OIG, that office determines whether it  will investigate the case.with other federal, state, and local agencies. Despite Anti-Fraud Policies and Procedures, SSA Remains Vulnerable to Potential Physician-Assisted Fraud

		Staff Reported Difficulty Identifying Potential Fraud and Lack Sufficient Incentives and Training

SSA relies heavily on front-line staff in DDS offices—those who are  responsible for reviewing medical evidence—to detect and prevent   The employees in the five DDS  potential physician-assisted fraud.offices we visited, however, said that they are not well-positioned to  identify signs of potential fraud, such as similar medical evidence across  multiple claims. Instead of systematically using data systems or analytics to  detect patterns of potential fraud, SSA’s guidance instructs front-line staff  to identify suspicious patterns of medical evidence—such as boilerplate  or similar language from the same physician across multiple claims—as  well as other factors that may indicate potential fraud. However, SSA  regional officials, DDS management, and front-line staff said that it is  difficult to detect these patterns because staff may review claims  originating anywhere in the state or across a large geographic area,  leaving it in part to chance that staff would see evidence from a single  physician on more than one claim. However, staff in three of the five DDSs we  visited said they may not always report potentially fraudulent information  to the OIG if there is already sufficient evidence to make a denial because  of the additional time required to process the fraud referral. Lack of Training on How to Identify or Report Potential Fraud

Staff from four of the five DDSs we visited stated that the anti-fraud  training they received was infrequent, insufficient, and that additional  training was needed. For instance, SSA does not require  DDSs to routinely and uniformly record the names and addresses of  physicians who submit medical evidence on behalf of claimants. SSA Has Launched Several Initiatives to Better Detect Fraud but Faces a Number of Implementation Challenges

		SSA Is Developing a Fraud Analytics Model, but Lacks an Implementation Plan

Recognizing that it must do more to systematically detect potential fraud,  SSA is in the early stages of exploring the use of computerized tools to  enhance its efforts. In the first stage, SSA developed its initial computer model and  identified existing sources of data within the agency. In its early efforts, SSA has so far followed some key practices. Disability Fraud Prevention Units: SSA established a centralized  fraud prevention unit based in New York City to identify instances of  potential fraud and look for trends nationwide. However, the  agency could be exposing itself to risk by using medical evidence from  physicians who are sanctioned by either federal or state governments. To address potential disincentives for staff to detect and prevent  physician-assisted fraud, SSA should review the standards used to  assess DDS performance; and develop and distribute promising  practices to incentivize staff to better balance the goal of processing  claims promptly with the equally important goal of identifying and  reporting evidence of potential fraud. 5. SSA agreed with the remainder of our recommendations and provided  additional information about the actions it has taken in the past year to  enhance its fraud detection and prevention efforts and steps they will take  going forward. Appendix I: Objectives, Scope, and Methodology

In conducting our review of potential physician-assisted fraud in the  Social Security Administration’s (SSA) disability programs, our objectives  were to examine (1) SSA’s policies and procedures for detecting and  deterring physician assisted fraud, and (2) the steps SSA is taking to  improve its ability to detect physician-assisted fraud. We reviewed  relevant federal laws and regulations, as well as SSA program  documentation including policies, procedures, training manuals, and  performance plans, as well as reports and testimonies from SSA and the  Office of the Inspector General (OIG) on fraud detection and prevention  efforts. These organizations included:
American Academy of Disability Evaluating Physicians (a professional  organization serving physicians involved in disability management and  evaluations)
Coalition Against Insurance Fraud (an anti-fraud alliance that includes  public and private insurers)
Centers for Medicare and Medicaid Services
Department of Health and Human Services, Office of Inspector
Elder Research Inc. (a consulting company focused on predictive  analytics and data mining)
The Recovery Accountability and Transparency Board
Unum (a private insurer that uses predictive analytics to identify  potential fraud)

	Analysis of Medical Provider Data

We conducted data matching using information from California and Illinois  to help determine the extent to which sanctioned medical providers  submitted evidence in disability decisions.
Why GAO Did This Study

SSA relies on medical evidence to determine whether the millions of new claimants each year qualify for disability benefits. This evidence—and those who provide it—have been the subject of intense scrutiny as questions have been raised about the potential for fraud schemes that include falsified medical evaluations. GAO was asked to study physician-assisted fraud in SSA's disability programs.
GAO reviewed (1) how well SSA's policies and procedures are designed and implemented to detect and prevent physician-assisted fraud, and (2) the steps SSA is taking to improve its ability to prevent physician-assisted fraud. GAO reviewed relevant federal laws and regulations, visited 5 of the 54 DDS offices that were selected to obtain geographic and office structure variation, and analyzed DDS data to identify whether federally sanctioned physicians (as of the end of January 2014) may have submitted evidence on behalf of claimants. GAO also interviewed SSA officials, as well as private disability insurers and others knowledgeable about SSA's programs to identify key practices for fraud prevention.

What GAO Found

The Social Security Administration (SSA) has policies and procedures in place for detecting and preventing fraud with regard to disability benefit claims. However, GAO identified a number of areas that could leave the agency vulnerable to physician-assisted fraud and other fraudulent claims:
SSA relies heavily on front-line staff in the offices of its disability determination services (DDS)—which have responsibility for reviewing medical evidence—to detect and prevent potential fraud. However, staff said it is difficult to detect suspicious patterns across claims, as directed by SSA policy, given the large number of claims and volume of medical information they review. Moreover, DDS offices generally assign claims randomly, so staff said it would only be by chance that they would review evidence from the same physician.
SSA and, in turn, DDS performance measures that focus on prompt processing can create a disincentive for front-line staff to report potential fraud because of the time it requires to develop a fraud referral. Four of the five DDS offices GAO visited count time that staff spend on documenting potential fraud and developing fraud referrals against their processing time. Some staff at these DDS offices said this creates a reluctance to report potential fraud.
The extent of anti-fraud training for staff varied among the five offices GAO visited and was often limited. SSA requires all DDSs to provide training to newly hired staff that includes general information on how to identify potential fraud, but does not require additional training. The five DDS offices GAO visited varied in whether staff received refresher training and its content—such as how to spot suspicious medical evidence from physicians—and staff at all levels said they needed more training on these issues.
SSA has not fully evaluated the risk associated with accepting medical evidence from physicians who are barred from participating in federal health programs. Although information from these physicians is not necessarily fraudulent, it could be associated with questionable disability determinations.
SSA has launched several initiatives to detect and prevent potential fraud, but their success is hampered by a lack of planning, data, and coordination. For instance, SSA is developing computer models that can draw from recent fraud cases to anticipate potentially fraudulent claims going forward. This effort has the potential to address vulnerabilities with existing fraud detection practices by, for example, helping to identify suspicious patterns of medical evidence. However, SSA has not yet articulated a plan for implementation, assigned responsibility for this initiative within the agency, or identified how the agency will obtain key pieces of data to identify physicians who are currently not tracked in existing claims' management systems. Furthermore, SSA is developing other initiatives, such as a centralized fraud prevention unit and analysis to detect patterns in disability appeals cases that could indicate fraud. However, these initiatives are still in the early stages of development and it is not clear how they will be coordinated or work with existing detection activities.

What GAO Recommends

GAO recommends SSA identify ways to remove potential disincentives for detecting and referring potential fraud, enhance its training efforts, evaluate the threat of physician-assisted fraud, and ensure that new and existing fraud efforts are coordinated. SSA agreed with four of our five recommendations, partially agreed with one, and noted plans to address all of them.