OFFICE OF
THE INSPECTOR GENERAL
SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals
Reversal of Disability Denial Decisions
Involving Investigative Information
from Cooperative Disability
Investigations Units
January 2006 A-07-05-15091
AUDIT REPORT
Mission
We improve SSA programs and operations and protect them against fraud, waste,
and abuse by conducting independent and objective audits, evaluations, and
investigations. We provide timely, useful, and reliable information and advice
to Administration officials, the Congress, and the public.
Authority
The Inspector General Act created independent audit and investigative units,
called the Office of Inspector General (OIG). The mission of the OIG, as spelled
out in the Act, is to:
... Conduct and supervise independent and objective audits and investigations
relating to agency programs and operations.
... Promote economy, effectiveness, and efficiency within the agency.
... Prevent and detect fraud, waste, and abuse in agency programs and operations.
... Review and make recommendations regarding existing and proposed legislation
and regulations relating to agency programs and operations.
... Keep the agency head and the Congress fully and currently informed of
problems in agency programs and operations.
To ensure objectivity, the IG Act empowers the IG with:
... Independence to determine what reviews to perform.
... Access to all information necessary for the reviews.
... Authority to publish findings and recommendations based on the reviews.
Vision
By conducting independent and objective audits, investigations, and evaluations,
we are agents of positive change striving for continuous improvement in the
Social Security Administration's programs, operations, and management and in our
own office.
SOCIAL SECURITY
MEMORANDUM
Date: January 20, 2006 Refer To:
To: The Commissioner
From: Inspector General
Subject: Office of Hearings and Appeals Reversal of Disability Denial Decisions
Involving Investigative Information from Cooperative Disability Investigations
Units
(A-07-05-15091)
OBJECTIVE
The objective of this audit was to identify circumstances that may have resulted
in the allowance of benefits at the hearings level when a prior investigation
conducted by Cooperative Disability Investigations (CDI) Units may have
contributed to a denial.
BACKGROUND
The Social Security Administration (SSA) is responsible for implementing
policies for the development of disability claims under the Disability Insurance
(DI) and Supplemental Security Income (SSI) programs. Disability determinations
under both DI and SSI are performed by Disability Determination Services (DDS)
in each State, Puerto Rico and the District of Columbia in accordance with
Federal regulations.1 In carrying out its obligation, each DDS is responsible
for determining claimants’ disabilities and ensuring that adequate evidence is
available to support its determinations. If the DDS suspects possible fraud or
similar fault2 in a case, it is referred to a CDI unit if one exists in the
State.3, 4
1 20 C.F.R. §§ 404.1601 et seq. and 416.1001 et seq.
2 SSA, POMS, DI 23025.005 B.1.a,b provides that fraud exists when any person
knowingly, willfully and with intent to defraud makes or causes a false
statement to be made or conceals or misrepresents a fact that is material to
eligibility or payment amount. Similar fault exists under the same circumstances
except intent to defraud is not required.
3 The highest percent of CDI referrals are from DDSs; however, field offices and
the public can also make referrals.
4 If there is not a CDI unit in a State, the DDS will develop and determine
whether a finding of fraud or similar fault is appropriate. The DDS may need
field office assistance to help resolve the potential fraud or similar fault
issue.
Page 2 – The Commissioner
The SSA Offices of Operations and Disability Programs, and the Office of the
Inspector General (OIG) manage the CDI program. The CDI units’ mission is to
obtain evidence of material fact sufficient to resolve questions of fraud in
SSA’s disability programs.
There are currently 19 CDI units located in 17 states. These units are typically
comprised of OIG special agents, State or local law enforcement, SSA Office of
Operations personnel, and DDS personnel. During the period July 1999 through
July 2005, CDI investigative results were used to support over 8,000 DDS
decisions to deny SSA disability benefits. This allowed SSA to avoid improper
payments of approximately $492 million.5 See Appendix B for additional
background on the CDI units.
Los Angeles
CDI units report facts uncovered during the course of an investigation in a
standard report of investigation. The investigative report is provided to the
appropriate DDS for use in the determination of disability. The DDS reviews the
investigative report, gives careful consideration to the results of the
investigation, and considers other relevant evidence in the case folder. If the
investigative report is material to the decision, the DDS will make reference to
the report and a copy will be included in the case folder. After the DDS makes a
medical decision, the case folder is returned to the SSA field office as an
allowance and/or denial for processing.6
A claimant whose application is denied at the DDS, during the initial and
reconsideration steps of the administrative review process, may request a
hearing. The Office of Hearings and Appeals (OHA) is responsible for conducting
hearings and issuing decisions determining whether a person may receive
benefits. Hearings are held before an Administrative Law Judge (ALJ), who
considers the evidence that is in the file and any new evidence, provides an
opportunity for a hearing, applies the SSA disability standards, and issues a
new decision, which affirms or reverses the DDS decision. The OHA organization
consists of 10 regional offices, approximately 140 hearing offices, and over
1,150 ALJs.
5 SSA program savings are projected at a flat rate of $66,500 for initial claims
that are denied as a result of CDI investigations, using a formula jointly
developed by the OIG and the Office of Disability. When a CDI investigation
supports the cessation of an in-pay case, the SSA program savings are projected
by multiplying the actual monthly benefit times 60 months.
6 SSA, POMS, DI 23025.020 B.1.
Page 3 – The Commissioner
Not all cases where fraud is suspected are accepted for investigation.7
Likewise, not all claimants, who have their case denied by the DDS, choose to
appeal to OHA. See Appendix C for an overview of possible actions for a case
from the identification of potential fraud through the appeals process.
RESULTS OF REVIEW
During the period July 1999 through April 2004, CDI units conducted
investigations on 4,712 cases8 denied at the initial level or at a continuing
disability review (CDR) of which 907 cases were subsequently appealed to OHA.9
Of these cases, OHA reversed the decision for 526 cases or 58 percent, which
will result in the payment of approximately $33 million in benefits.10
Based on our review of case folders, ALJs may not have always been aware that a
CDI unit investigation was conducted and may not have always considered the
investigative report in making the disability decision. These circumstances may
have resulted in the allowance of benefits when a prior investigation by a CDI
unit contributed to a denial decision. Specifically, our review of case folders
for 100 ALJ decisions found:
• 97 case folders were not clearly marked to indicate an investigation was
conducted and that the investigative report was included in the case folder;
• 40 investigative reports were missing from case folders;
• 28 investigative reports were not included on the exhibit list used to
identify documents for consideration at the hearing; and
• 59 investigative reports were not discussed in the ALJ case decision write-up.
We also obtained comments from ALJs on CDI unit investigations. Overall, the
ALJs responded that the CDI units provided evidence beneficial to their
disability decisions. The ALJs also provided suggestions related to CDI unit
investigations that would make them even more beneficial to the OHA disability
decision process.
7 Cases referred to a CDI unit are accepted for investigation based upon the
type of claim, type of fraud, workload of the CDI unit, location of claimant,
and resources available.
8 This is not intended to represent all cases that were investigated by a CDI
unit for this time period because CDI units also conducted investigations on
cases that were allowed at the initial level and at a continuing disability
review.
9 Of the 907 cases denied by the DDS and subsequently appealed to OHA, 718 were
initial claims and 189 were CDRs. See Appendix B for additional information on
the scope and methodology of our review.
10 The $33 million that SSA will pay in benefits is based on the program savings
that were previously identified by CDI units for the 526 cases for which OHA
reversed the decision.
Page 4 – The Commissioner
RESULTS OF CASE FOLDER REVIEW
Case Folder Not Clearly Marked
For 97 of the 100 cases we reviewed, the outside of the paper folder did not
identify that a fraud investigation was conducted as required by the Hearings,
Appeals, and Litigation Law Manual (HALLEX).11 In addition, on the three
remaining paper folders, the indicator was on the outside of the folder;
however, it could not be easily identified because other documents were stapled
on top of the indicator. Without proper notification of an investigation on the
outside of the paper folder, ALJs may not have always been aware that a CDI unit
investigation was conducted.
HALLEX12 indicates that when a CDI investigation has been conducted the paper
folder is generally identified by a distinctively colored label or flag bearing
the Special Agent seal and/or the acronyms OIG CDI or OIG/CDI.13 Accordingly,
the distinctively colored label or flag should be on the outside of the paper
folder when it arrives at OHA. However, we could not identify what SSA component
was responsible for placing the flag on the folder after a CDI investigation was
conducted.
SSA stated that it never intended to mark the paper folder to indicate that an
investigation was conducted and also, each adjudicative level is responsible for
reviewing the case folder to determine the evidence to be evaluated. During the
course of our audit, OHA revised HALLEX14 and issued a memorandum15 to OHA staff
on how to identify the investigative report. Accordingly, we are making no
recommendation related to the absence of the label or flag on the paper folders.
11 Although an indicator was included in 5 of the 97 case folders, it was not
attached to the outside of the folder as required by HALLEX I-5-1-15, Attachment
1, Question 1. A red sheet of paper that identified an investigation had been
conducted was loosely inserted in the case folder. It appeared that the
indicator may have been stapled to the outside of the folder but had been
subsequently removed.
12 HALLEX provides guiding principles, procedural guidance, and information to
OHA staff. It also defines procedures for carrying out policy and provides
guidance for processing and adjudicating claims at the Hearing, Appeals Council
and Civil Actions levels.
13 HALLEX I-5-1-15, Attachment 1, Question 1, provides general background
information to OHA (updated 6/15/01).
14 HALLEX I-2-1-15 (updated 9/28/05).
15 OHA, Memorandum for Adjudicating Cases Involving Potential Fraud, Similar
Fault, and Abuse Issues – REMINDER, October 31, 2005.
Page 5 – The Commissioner
SSA is in the process of implementing electronic folders (EF), which will be the
repository that stores the claimant’s disability information. Therefore paper
folders will be replaced by the EFs in most cases.16 The Program Operations
Manual System (POMS)17 for the EFs do not mention placing an indicator or flag
in the EFs to indicate a CDI unit investigation occurred. 18 SSA informed us
that a specific flag is not available in the EF to identify a CDI unit
investigation occurred, but a Special Handling Flag – F (Alert/High Risk) could
be used. The flag would remain with the EF after the case is closed (See
Appendix D). We believe a flag to indicate that a CDI unit investigation
occurred would provide an additional level of assurance that the investigative
report will be considered. Accordingly, SSA should include detailed instructions
in POMS to permanently mark the EFs, including identification of the SSA
component responsible to place the indicator or flag on the folder.
Investigative Reports Missing From Case Folders
The investigative report was missing from 40 of the 100 case folders that we
reviewed.19, 20 Accordingly, we could not determine if the ALJ was aware that a
CDI unit investigation was conducted on these cases. The CDI unit forwards the
investigative report to the DDS with a transmittal and receipt form. Once the
DDS makes a determination, the transmittal form is sent back to the CDI unit,
indicating whether the
claim was allowed or denied, or in the case of a CDR, continued or ceased. The
receipt of the transmittal form from the DDS is the CDI unit’s verification that
the investigative report was received.
We were unable to determine why the investigative report was missing from the 40
case folders. Specifically, we do not know if the DDS failed to place the
investigative report in the case folder or if it was removed from the folder
during the DDS or OHA determination processes. For example, when the Hearing
Office staff receives a case folder, the proposed exhibits are selected,
arranged in proper order, and marked before the exhibit list is prepared.21
Therefore, the investigative report may have been removed from the folder during
this process.
16 Paper folders will continue to be used for cases such as CDRs, mainframe
exclusions, foreign claims, age 18 redeterminations, and reopenings.
17 POMS is used for issuing instructions within SSA.
18 SSA, POMS, DI 80701.070 B.
19 We obtained copies of the missing investigative report from the CDI units for
use in our analysis.
20 In addition, 57 of the 100 cases we reviewed did not have the investigative
report filed correctly in the case folder. SSA, POMS DI 70005.005 B.6, provides
that the investigative report should be filed on top of all documents in the
medical evidence section of the paper folder.
21 HALLEX I-2-1-20 (updated 9/28/05).
Page 6 – The Commissioner
For the Region VII case folders in our sample, we found all investigative
reports (See Chart 1).22 This may be the result of the St. Louis CDI unit
sending a memorandum to the DDS when the case is accepted for investigation and
again when the investigative report is sent to the DDS at the completion of the
investigation. This memorandum includes such information as marking the folder
with the CDI unit investigation indicator, as well as instructions on where to
place the investigative report in the folder. This is a best practice that other
CDI units may want to consider
using.2340604456505010069315446020406080100Percent of cases reviewed per region
IIIVVIVIIIXXRegionChart 1Investigative Report in Case FolderNoYes
Upon implementation of the EF, SSA plans to have the CDI unit place the
investigative report in the EF. Although the investigative report cannot be
deleted from the EF, DDS and OHA staff will have access that will allow them to
delete the link for the investigative report.24 Once the link is deleted,
subsequent users may not be aware that an investigative report existed.
Accordingly, restrictions should be placed on the EF to ensure the link to the
investigative report cannot be removed. Further, since paper folders will
continue to be used for CDRs, current policies should be strengthened to ensure
the investigative report is always included in the folder.
Investigative Report Not Identified on Exhibit List
The investigative report was not identified on the exhibit list for 28 of the
100 cases we reviewed. Furthermore, we were unable to determine if the
investigative report was identified on the exhibit list for 16 additional cases,
because the exhibit lists were not
22 Less than 5 cases were included in our sample from each of Regions I, III, V,
VIII, and Headquarters. Therefore, these cases were excluded from our analysis
because there was an insufficient number of cases in these regions to reach a
reasonable conclusion on filing investigative reports. The cases from these
regions were included in other analysis presented in this report.
23 According to CDI unit management, they are in the process of developing
procedures for all CDI units to use a similar memorandum.
24 Although the link is deleted, the investigative report will remain in the
document management architecture. However, the document management architecture
is not where EF users would normally expect to gain access to the investigative
report.
Page 7 – The Commissioner
included in the case folders and were unavailable from OHA.25 Accordingly, we
were unable to determine if the ALJ was aware of or considered the investigative
report in making decisions on these cases.
The hearing office staff prepares an exhibit list that identifies documents
pertinent and material to the case.26 The ALJ uses the exhibit list to determine
documents that will be admitted as evidence to issue a decision on the
claimant’s disability. In the EF an exhibit list tab is included for cases at
the hearing level. This tab mirrors the paper exhibit list that OHA currently
uses to identify pertinent and material documents for the hearing.
For the cases we reviewed, instructions did not exist on how to specifically
address the investigative report on the exhibit list.27 However, during the
course of our audit OHA revised HALLEX28 and issued a memorandum29 to OHA staff
instructing them to list the investigative report as a document on the exhibit
list. Accordingly, we are not making any recommendations related to the
identification of the investigative report on the exhibit list.
ALJ Did Not Discuss the Investigative Report in the Case Decision Write-up
In 59 of the 95 ALJ case decision write-ups we reviewed,30 the ALJ did not
discuss the investigative report.31 Accordingly, we were unable to determine if
the ALJ considered the investigative report in making the disability decisions
on these cases. When ALJs write decisions they are required to consider medical
opinions in the case record together with the rest of the relevant evidence
received.32 The ALJs should provide the rationale for the findings on the
relevant issues and the ultimate conclusion, which
25 HALLEX I-2-1-20 (updated 9/28/05) states in a fully favorable decision, the
exhibit list does not need to be prepared, however, exhibits such as
investigative reports still need to be selected, arranged, and marked within the
paper folder.
26 HALLEX I-2-1-15 (updated 9/28/05).
27 HALLEX I-2-1-15.A (last updated 8/3/04).
28 HALLEX I-2-1-15.E.6 (updated 9/28/05).
29 OHA, Memorandum for Adjudicating Cases Involving Potential Fraud, Similar
Fault, and Abuse Issues – REMINDER, October 31, 2005.
30 We could not review five of the ALJ case decision write-ups because they were
missing from the case folder and SSA was not able to provide them for our
analysis.
31 Results of our review found 36 ALJs mentioned the investigative report in
their decision, however, only 24 of the cases had the investigative report
included in the case folder at the time of our review. Although the
investigative report was missing from 40 case folders, it is possible that the
investigative report was included in the case folder at the time of the ALJ’s
review. Further, even though the exhibit list for 28 of these cases did not
identify the investigative report as evidence to be considered by the ALJ, they
may have identified the investigative report themselves.
32 20 C.F.R. §§ 404.1527(2)(b) and (c) and 416.927(2)(b) and (c).
Page 8 – The Commissioner
includes a discussion of the weight assigned to the various pieces of evidence
used to resolve conflicts in the documents presented in the claimant’s
disability case folder.33 CDI evidence is to be weighed with the other relevant
evidence and accorded no special weight simply because it came from a CDI
unit.34 Recent HALLEX instructions dated September 2, 2005, state that if SSA’s
OIG has conducted a formal investigation on a particular disability claim, the
OIG investigative report, as well as any supporting evidence documented in the
report, should be addressed in the ALJs decision.35
The investigative report can provide valuable information for a finding of fraud
or similar fault and should be addressed in the ALJ case decision write-up.
Accordingly, the Chief ALJ should formally remind the ALJs of the new
requirements to address the investigative report when writing their decisions.
ALJ COMMENTS
We surveyed 20 ALJs that each issued decisions on 10 or more cases in our
population. Sixteen ALJs responded.36, 37 The ALJs stated that overall the CDI
units provided evidence beneficial to their disability decisions. Examples of
comments from the ALJs included:
“The CDI unit’s report regarding the claimant’s activities of daily living and
the individual’s social interactions with others gives me a better perspective
of what the individual is actually doing compared to most of the self-serving
testimony I receive from the claimant and his family members at the hearing.”
“I have had good results with the CDI cases I have come into contact with during
the past several years. I appreciate the CDI unit’s efforts in striving to be
objective and not bias the case in any way other than to report the facts they
have discovered. I wish them continued funding and success in the future.”
33 HALLEX I-2-8-25.C.2.c (updated 10/16/03).
34 HALLEX I-5-1-15, Attachment 1, Question 33 (updated 6/15/01).
35 HALLEX I-2-8-25.C.2.c (updated 9/2/05).
36 The four ALJs that did not respond to our survey were located in Region IX.
Region IX was the region with the highest number of cases we reviewed (42 of
100) of which the ALJs allowed benefits for 18 cases.
37 ALJs provided numerous comments, however, the comments were not associated
specifically to the 100 cases we reviewed.
Page 9 – The Commissioner
The ALJs also provided suggestions on some areas of the investigation that would
make them even more beneficial to their disability decisions.38 Specifically:
• A longer period of surveillance tailored to the claimant’s alleged impairments
would provide more complete evidence on some cases.
• Only factual observations about the claimant’s abilities identified during the
investigation should be included in the investigative report. For example, when
the claimant is observed walking only one block, the investigative report should
not conclude the claimant can walk long distances.
• Specific details of the investigation, such as the length of time the claimant
was observed, the distance the claimant walked, or the size of objects lifted
should be reported in the investigative report.
• Standards applied to the CDI Unit’s observations should be placed in proper
perspective. For example, investigative reports that indicate the claimant’s
pace and gait were normal should provide a context for normal, such as pace and
gate were similar to other people walking near the claimant.
• Documents that support statements made in the investigative report should be
presented for consideration. For example, the investigative report states that
medical evidence submitted by the medical provider for a different claimant was
very similar to the medical evidence for the claimant under investigation, which
could indicate duplicative use of medical evidence. Therefore, the CDI unit
should provide the medical evidence from the other case to support their
statement.
In addition, the ALJs identified factors that influenced their use of the
investigative report, which might have led to allowance of benefits.
Specifically, the ALJs identified circumstances that caused the investigative
report to conflict with other evidence in the case folder. For example, evidence
submitted by medical or vocational experts conflicts with the results of the
investigation or the investigative report, which includes interviews with
third-parties that ALJs consider as hearsay. When circumstances result in the
investigative report conflicting with other evidence, the ALJ should not
disregard the results of the investigation. Rather, the ALJ should request the
CDI investigator to testify at the hearing to clarify the results of the
investigation39 or request third-parties to testify at the hearing.40 In
addition, the ALJ should request, in writing, from SSA or the
38 Our audit did not provide evidence to prove or negate the ALJs’ comments.
39 HALLEX I-5-1-15, Attachment 1, Question 34, states that ALJs may request CDI
Special Agents to testify at the hearing if the ALJ believes that an aspect of
an OIG submission requires exploration in oral testimony (updated 6/15/01).
40 HALLEX I-5-1-15, Attachment 1, Question 34, states that hearsay rules, such
as courts apply to determine the admissibility of evidence, do not apply in the
informal, nonadversarial hearings conducted by the ALJs of SSA. However, the ALJ
can request the appearance of a witness in any instance which full inquiry into
the issues will require testing of the evidence in oral questioning (updated
6/15/01).
Page 10 – The Commissioner
DDS that additional evidence be obtained by the CDI unit.41 In Fiscal Year (FY)
2004, CDI units conducted investigations on 2,231 cases that were denied at the
DDS. Based on historical data, we estimate that at least 32 percent of these
cases, or about 717, were appealed to OHA. However, during FY 2005 – the time
period during which OHA would have made decisions on a large number of the
estimated 717 cases – CDI unit investigators were asked to testify at OHA
hearings only 23 times and CDI units were asked to provide additional evidence
on only 16 cases.
Based on our population, OHA allowed 58 percent of the cases where a CDI unit
investigation was conducted. However, OHA rarely requested additional
information or testimony from the CDI units. Accordingly, we question whether
ALJs are exercising their ability to request additional information and secure
investigator/third party testimony.
Availability of Videos
The ALJs responded that surveillance videos and pictures were beneficial to make
the disability decision. For example, one ALJ made the following statement about
the surveillance video:
“When we have the video tape itself at the hearing, it is usually difficult for
the claimant to explain away. This allows the claimant and his representative to
comment on it and to use it in the record as actual evidence. Sometimes it is so
incriminating that the claimant does not even want to see it.”
Currently, surveillance videos are recorded on Hi 8, Digital 8, Mini digital
video disk (DVD), and DVD, which are stored at the CDI units.42 Most CDI units
provide copies of surveillance to the DDS and OHA in videotape format (VHS) on
tapes. Since the VHS tapes are bulky, a copy of the tape is not placed in the
paper folder. If the tape was located in the paper folder, the folder would be
hard to store and the tape could be lost or broken when stored or transported.
To request a copy of the surveillance video, the Hearing Office staff must send
a request to the CDI unit, and then wait to receive the video. Once requested,
videos are sent via overnight delivery, certified mail and/or hand carried to
OHA.
41 HALLEX I-5-1-15, Attachment 1, Question 24, states that the ALJ should
request a CDI unit to investigate an issue of fraud or similar fault if the case
presents an issue of fraud or similar fault (updated 6/15/01).
42 CDI units are transitioning to record surveillance videos on compact disks
(CD) and DVDs, as funds become available to purchase the technology. From our
review of the case folders, we found that the Tampa CDI Unit included the
surveillance on a DVD submitted with the investigative report. The St. Louis CDI
Unit recently started sending key segments of surveillance videos on CDs to the
DDS.
Page 11 – The Commissioner
We are concerned that ALJs may not request videos due to the time factor
involved in obtaining the videos and the urgency to reduce OHA’s case backlogs.
In fact, during FY 2005, surveillance videos were requested for only 26 cases.
This represents a small percentage of the cases sent to OHA annually by CDI
units where surveillance video was available.
A multimedia evidence section was incorporated into the architecture of the EF
for the purpose of integrating audio and video evidence into the folder.43 The
EF holds the promise of integrating all the evidence into one readily accessible
location. Further, the EF will reduce the time it takes to receive information,
eliminate the need to wait for and store the paper folder, and eliminate the
need to associate mail with paper folders.
SSA stated that including surveillance videos in the EF would result in system
slowdowns and deplete available memory. However, SSA did not have any
information to support its position and stated that no studies were conducted to
determine the impact of including surveillance video in the EF.
Inclusion of surveillance videos in the EF should not cause substantial system
slowdowns or deplete excessive system memory. In fact, there are a very limited
number of cases that have surveillance video. For example in FY 2005, there were
approximately 2,800 investigations conducted and about half had surveillance
recorded on video. However, even if all 2,800 investigations had surveillance
video, the impact on the EF from a slowdown or memory capacity perspective would
be very limited.44 Accordingly, SSA should not dismiss the benefits of including
surveillance videos in the EF. SSA should take advantage of the EF’s ability to
provide all levels of adjudication with a complete file of evidence including
surveillance videos. In doing so, ALJs will make greater use of surveillance
videos and SSA beneficiaries and trust funds will be advantaged by ensuring that
all available evidence is considered in making disability determinations.
43 SSA, POMS, DI 80701.020.A.
44 After numerous discussions between SSA and OIG, the OIG’s Office of
Investigations stated in April 2005 that it would not request CDI surveillance
be included in the EF. However, upon further analysis of the EF’s capabilities
with regards to storage of multimedia, the Office of Investigations supports the
inclusion of surveillance videos to ensure that all available evidence is
readily available for all adjudicative levels.
Page 12 – The Commissioner
CONCLUSION AND RECOMMENDATIONS
Procedures developed for the EF will assist in eliminating circumstances that
may have resulted in the allowance of benefits at the hearings level when a
prior investigation was conducted by CDI units, such as ensuring the
investigative report is filed in the EF. However, additional changes are still
needed to ensure the flag to identify that a CDI investigation was conducted is
placed on the EF, and the link to the investigative report is not removed. In
addition, procedures to file the investigative report need to be strengthened,
since a paper folder will still be used for some cases. Further, actions are
needed by OHA to ensure that the investigative report is considered in its
decision-making process. Lastly, OHA’s use of surveillance videos should
increase if available in the EF.
We recommend that SSA:
1. Provide instructions in POMS on what component is responsible to: (a) file
the investigative report in the paper folder and (b) flag the EF to identify
cases in which a CDI unit investigation was conducted.
2. Place restrictions on the EF to ensure the link to the investigative report
cannot be removed.
3. Request the Chief ALJ to remind ALJs of the September 2005 instructions to
document the use of the investigative report in the disability decision
write-up.
4. Request the Chief ALJ to encourage ALJs to request CDI unit investigators and
third parties to testify at hearings when clarification of the investigative
report is needed, particularly the testimony of third parties, which might
otherwise be construed as hearsay evidence.
5. Request the Chief ALJ to encourage ALJs to request from SSA and DDSs
additional evidence from CDI units when warranted by case circumstances.
6. Require surveillance videos to be included in the multimedia evidence section
of the EF.
Page 13 – The Commissioner
ddition, three case folders were missing only the
cision and
ttachments should be filed in the
ecision
.. If
ts
gency Comments
commenting on our draft report, SSA agreed with the intent of our
recommendations.
t
oes
or
OTHER MATTERS
For 34 of the 100 cases we reviewed, both the ALJ decision and the exhibit list
were missing from the folder.45, 46 In aexhibit list (See Chart 2). The ALJ de
a
Payment Documents/Dsection of the paper folder. 47 It is important that all
information related to the claimant’s disability be included in the case
folderinformation is excluded from the case folder the processing of disability
cases is slowed down due to the wait time to acquiredocuments from other
sources. Also, there is no assurance that the missing documencan be obtained
from other sources. OHA should ensure that the ALJ decision and exhibit list are
filed in the case folder. Chart 2 ALJ Case Decision Write-ups and Exhibit Lists
63% 3%34%IncludedDecision and Exhibit List MissingOnly Exhibit List Missing
A
In
However, it did not agree to immediately implement recommendations 2 and 6. In
response to recommendation 2, SSA stated that it would not be cost-effective at
thistime to place restrictions on the EF to ensure the link to the investigative
report cannobe removed. Specifically, business rules, requirements and software
modifications would be needed. With regards to recommendation 6, SSA stated that
technology dnot currently exist to allow inclusion of surveillance videos in the
EF. However, SSA stated that it is making strides in maintaining multimedia in
the EF. See Appendix E fthe full text of SSA’s comments.
45 We requested the missing ALJ case decision write-ups and exhibit lists from
SSA, however only 29 ALJ case decision write-ups and 21 exhibit lists were
provided for our analysis.
46 HALLEX I-2-1-20 (updated 9/28/05) states in fully favorable decisions, the
exhibit list does not need to be prepared, however, exhibits will still be
required to be selected, arranged, and marked in the paper folder.
47 SSA, POMS, DI 70025.001.E.5.b.
Page 14 – The Commissioner
OIG Response
Although the Agency stated that it disagreed with recommendations 2 and 6, SSA’s
comments to the recommendations indicate agreement with the intent of our
recommendations. Accordingly, we continue to believe SSA should take the
corrective actions when they become cost effective and technologically possible.
SSA should place restrictions on the EF to ensure the link to the investigative
report cannot be removed. This will prevent a user from improperly deleting the
link to the investigative report. Accordingly, this enhancement to the EF should
be prioritized with other EF modifications and implemented at the appropriate
time.
SSA should make surveillance videos available in the EF. By doing so, ALJs may
make greater use of surveillance videos and SSA beneficiaries and trust funds
will be advantaged by ensuring that all available evidence is considered in
making disability determinations. Accordingly, exploration of maintaining
multimedia in the EF should continue.
S
Patrick P. O’Carroll, Jr.
Appendices
APPENDIX A – Acronyms
APPENDIX B – Background, Scope and Methodology
APPENDIX C – Overview of Actions for a Case from the Identification of Potential
Fraud through the Appeals Process
APPENDIX D – Electronic Case Folder
APPENDIX E – Agency Comments
APPENDIX F – OIG Contacts and Staff Acknowledgments
Appendix A
Acronyms
ALJ
Administrative Law Judge
CD
Compact Disk
CDI
Cooperative Disability Investigations
CDR
Continuing Disability Review
C.F.R.
Code of Federal Regulations
DDS
Disability Determination Services
DI
Disability Insurance
DVD
Digital Video Disk
eDib
Electronic Disability
EF
Electronic Folder
FY
Fiscal Year
HALLEX
Hearings, Appeals, and Litigation Law Manual
NADE
National Association of Disability Examiners
OHA
Office of Hearings and Appeals
OIG
Office of the Inspector General
POMS
Program Operations Manual System
SSA
Social Security Administration
SSI
Supplemental Security Income
VHS
Videotape format
Appendix B
Background, Scope and Methodology
BACKGROUND
Fraudulent activity in connection with claims for disability benefits is a major
concern. The Social Security Administration (SSA) is committed to assuring the
integrity of its various programs. One of SSA's major anti-fraud initiatives is
the Cooperative Disability Investigations (CDI) unit program. SSA’s Offices of
Operations and Disability Programs, and the Office of the Inspector General
(OIG) manage the CDI unit program. CDI units use the combined skills and
specialized knowledge of OIG special agents, personnel from SSA’s Office of
Operations, the Disability Determination Services (DDS), and State or Local law
enforcement. The CDI program mission is to:
• Provide evidence for DDSs to make timely and accurate disability
determinations;
• Seek criminal and/or civil prosecution of applicants and beneficiaries and
refer cases for consideration of civil monetary penalties and administrative
sanctions, as appropriate; and
• Identify, investigate and seek prosecution of doctors, lawyers, interpreters,
and other third parties who facilitate disability fraud.
Since Fiscal Year 1998, investigative units have become fully operational at 19
sites in 17 states: Atlanta, Georgia; Baton Rouge, Louisiana; Boston,
Massachusetts; Chicago, Illinois; Cleveland, Ohio; Dallas, Texas; Denver,
Colorado; Houston, Texas; Iselin, New Jersey; Los Angeles, California;
Nashville, Tennessee; New York City, New York; Oakland, California; Phoenix,
Arizona; Richmond, Virginia; Salem, Oregon; St. Louis, Missouri; Seattle,
Washington; and Tampa, Florida.
The National Association of Disability Examiners (NADE), a strong supporter of
the CDI units’ mission, encouraged Congress and SSA to provide resources to
expand the CDI units to the remaining 33 states. NADE further commented, “CDI
units are cost effective and provide a visible and effective front-line defense
against fraud, waste, and abuse in the SSA and SSI disability programs; they
also provide valuable protection to the Social Security Trust Fund, to the
American taxpayer and to the victims of those who are attempting to defraud the
program.” 1
By referring a case to the CDI unit, the DDS is able to obtain crucial
information to assist in making the correct decision on a case. CDI units gather
information that is not routinely available to DDSs when making a disability
decision. The CDI unit can perform surveillance to observe the claimant’s
activities at their residence or when they go out and can conduct unannounced
interviews of the claimant and neighbors or other
1 NADE Position Paper, Expansion of the Cooperative Disability Investigations
Units, July 1, 2004.
B-1
third parties. During formal investigations, obvious inconsistencies are often
found between what a claimant alleges and what they are actually observed doing
or formal investigations can confirm the limitations alleged by the claimant. In
addition, CDI units are often able to obtain information from employers,
neighbors, motor vehicle records and other sources to identify unreported or
under reported work activity.
SCOPE AND METHODOLOGY
To accomplish our objective, we:
• Reviewed –
• Program Operations Manual System DI 23025, DI 70005,
DI 80501, DI 80620, DI 80701, and GN 03103,
• Hearings, Appeals, and Litigation Law Manual I-2-1-5, I-2-1-15,
I-2-1-20, and I-5-1-15,
• 20 Code of Federal Regulations 404 and 416,
• CDI Manual, and
• OIG Special Agent Handbook.
• Obtained a file of 4,712 claimants2 denied disability benefits after an
investigation conducted by a CDI unit between July 1999 and April 2004. We
tested the data for accuracy and completeness and determined it to be
sufficiently reliable to meet our audit objective.
• From the file of 4,712 claimants, we excluded:
• 2,969 claimants - who did not file an appeal with the Office of Hearings and
Appeals (OHA) as of August 2, 2004,
• 607 claimants - who filed an appeal; however, the appeal was still open as of
August 2, 2004, and
• 229 claimants - who had their appeal dismissed by OHA.
Of the remaining 907 cases, we divided the cases based upon decision – 526
claimants were allowed benefits by an Administrative Law Judge (ALJ) and 386
claimants were denied benefits by an ALJ.3
2 This is not intended to represent all cases that were investigated by a CDI
unit for this time period because CDI units also conducted investigations on
cases that were allowed at the initial level and continuing disability review.
3 Some disability claimants that appealed concurrent benefits received different
ALJ decisions on their Title II and Title XVI disability claim. Disability
claimants that received favorable decisions on one claim and an unfavorable on
another claim were included as both an allowance and a denial. Therefore, the
total number of allowances and denial decisions totaled 912.
B-2
• Reviewed case folders for a sample of 50 allowance decisions4 and 50 denial
decisions5 issued by ALJs after an investigation was conducted by a CDI unit.
Our review identified circumstances that may have resulted in OHA allowing
disability benefits although an investigation was conducted by a CDI unit.
• Sent a questionnaire to 20 ALJs who each heard 10 or more cases where a CDI
unit investigation was conducted to obtain information on the ALJs use of the
investigative report in making their decision.6 We received responses from 16
ALJs, or 80 percent.
We conducted our audit between December 2004 and July 2005 in Kansas City,
Missouri. The entity audited was OHA within the Office of Disability and Income
Security Programs and CDI units managed by SSA's Office of Operations, Office of
Disability Programs and OIG. Our audit was performed in accordance with the
generally accepted government auditing standards.
4 To obtain case folders for 50 allowance decisions, we had to request 55 case
folders.
5 To obtain case folders for 50 denial decisions, we had to request 68 case
folders.
6 These 20 ALJs issued decisions on 30 percent of the cases in our population.
B-3
Appendix C
Overview of Actions for a Case from the Identification of Potential Fraud
through the Appeals Process
Yes No Yes No Allegation Sent to CDI Unit CDI Unit Screens AllegationAccept Not
Accept DDS Determines DisabilityDeny Benefits Claimant files appeal with Office
of Hearings and AppealsAdministrative Law Judge Reviews Evidence in CaseDeny
Benefits Cooperative Disability Investigations (CDI) Unit in the areaFurther
appeal possible Possible Fraud Identified at the Disability Determination
Services (DDS) DDS Develops the Case Issue Investigative Report Allow Benefits
No further action taken Allow Benefits May request the assistance of the field
office to help resolve potential fraud issues
Conduct Investigation
Appendix D
Electronic Case Folder
In 2002, the Social Security Administration (SSA) announced plans to improve the
disability process by moving to an electronic disability case folder through the
Electronic Disability (eDib) project. Beginning in 2004, Social Security offices
and Disability Determination Services (DDS) throughout the country began to
implement various components of the electronic claim process at varying
intervals.
Once the changes are fully implemented:
• Disability adjudicators will be able to request and receive medical evidence
electronically.
• Evidence received as paper will be scanned. SSA and DDS staff will work with
images of medical evidence.
• Cases will be electronically routed from office to office, rather than mailed.
Although the electronic folder (EF) will resemble the current paper folder,
procedures will be different to: (1) mark the EF to alert a user that a
Cooperative Disability Investigations (CDI) unit has conducted an investigation,
(2) file the CDI unit’s investigative report in the EF, and (3) create the
exhibit list to be used by Administrative Law Judges (ALJ) to identify documents
for consideration at the hearing.1
Mark the Electronic Folder
Flags are placed on the EF to alert other components of the need for special
processing of the disability claim or to provide additional case processing
information. SSA indicated that a specific flag is not available in the EF to
indicate a CDI unit investigation occurred, but a Special Handling Flag – F
(Alert/High Risk) could be used. Once a flag has been placed on the folder, it
remains on the folder unless removed.
Flags are displayed on the title bar in the EF (See Illustration 1). If there
are more than two flags, then the title bar displays the word “More.” To view
additional flags a user must select the “View Details/Edit” link to the left of
the first flag.
1 Illustrations used do not specifically show a special flag associated with an
investigation conducted by a CDI unit or list the investigative report. The
illustrations are provided as a general overview of how flags and documents are
presented.
D-1
Illustration 1
The “Flags” page displays a summary of the flags (See Illustration 2). Special
flags will be displayed first in the list in descending alphabetical order,
followed by the rest of the flags in descending alphabetical order.
Illustration 2
To view the flag description, edit, or delete an existing flag a user must
select the flag. Once the flag is opened you can add or modify the description
or select the “Delete” button to remove the flag (See Illustration 3).2
Illustration 3
File the Investigative Report
The investigative report should be filed in the EF as evidence to be considered
when the disability determination is made. SSA plans to change procedures to
allow CDI units to directly place the investigative report in the Medical
Records section of the “Case Documents” tab in the EF (See Illustration 4). Once
this access is established
2 Only employees with the permission to add, delete, or modify flags can remove
a flag.
D-2
the CDI units will create and print a barcode that contains identifying
information. The investigative report will then be faxed and electronically
placed directly into the folder based on the information provided in the
barcode. The investigative report will be viewable in the Medical Records
section of the EF.
Once the investigative report is placed in the EF, DDS and Office of Hearings
and Appeals (OHA) staff will have access that will allow them to view the
investigative report for use in making the disability decision. To view the
investigative report click on the title of the document.
Illustration 4
Evidence should not be removed from the Medical Records section, however, staff
at the DDS and OHA will have systems permission access that will allow them to
move the link for the investigative report to the temporary section of the EF.
When the case is closed, the temporary section of the EF is purged, thereby
removing access to the investigative report. The investigative report still
remains; however, the link to access the investigative report has been removed.
D-3
Create the Exhibit List
The electronic exhibit list was created to mirror the current paper exhibit list
used by ALJs to identify documents to be considered during the hearing. OHA
users create the exhibit list based on the documents in the EF. An exhibit list
is created from the case documents section of the EF. Electronic documents are
selected using the checkboxes to the right of the document. The “Add to Exhibit
List” button is used to create an exhibit list with the selected documents (See
Illustration 4).
Illustration 5
To mark documents with the exhibit number and page numbers, select the “Mark
Exhibit No. on Images” button (See Illustration 5). The images of the electronic
documents will be permanently marked with exhibit and page numbers at the top
right corner of every page. After the documents are permanently marked they
cannot be deleted from the exhibit list.
D-4
Appendix E
Agency Comments
SOCIAL SECURITY
E-1
MEMORANDUM
Date:
January 11, 2006
Refer To: S1J-3
To:
Patrick P. O'Carroll, Jr.
Inspector General
From:
Larry W. Dye /s/
Chief of Staff
Subject:
Office of the Inspector General (OIG) Draft Report "Office of Hearings and
Appeals Reversal of Disability Denial Decisions Involving Investigative
Information from Cooperative Disability Investigation Units" (A-07-05-15091) --
INFORMATION
We appreciate OIG’s efforts in conducting this review. Our comments on the draft
report content and recommendations are attached.
Let me know if we can be of further assistance. Staff inquiries may be directed
to Candace Skurnik, Director, Audit Management and Liaison Staff, at extension
54636.
Attachment:
SSA Response
COMMENTS ON THE OFFICE OF THE INSPECTOR GENERAL (OIG) DRAFT REPORT, "OFFICE OF
HEARINGS AND APPEALS REVERSAL OF DISABILITY DENIAL DECISIONS INVOLVING
INVESTIGATIVE INFORMATION FROM COOPERATIVE DISABILITY INVESTIGATIONS UNITS"
(A-07-05-15091)
Thank you for the opportunity to review the above-subject audit report. Overall,
we support the purpose of this audit but have several concerns regarding the
results.
It is difficult to identify the most effective solutions to address the missing
ROIs. The draft report is not conclusive as to why the ROIs are missing from the
folder and at what point in the adjudicative process they were not included in
the folder. This poses problems when assessing the effectiveness of the
recommendations. However, possible reasons for the omission of the report and
corrective actions have already been discussed. It is our understanding that OIG
is considering a change to the confidentiality statement on the ROI, since that
may be causing confusion for the staff filing the ROI in the folder. In
addition, OHA issued two memorandums in October to remind ALJs about the law,
policy, and responsibilities of OHA adjudicators when a CDI ROI is involved.
The OIG draft report (page 6) also cites memorandum communications between the
CDI and the DDS and notes that, in Region VII, there was a 100 percent finding
of investigative reports being in the case folder. This finding indicates that
enhanced communications and “best practices” (as cited on page 6) may
considerably improve the problem of absent ROIs in the folder.
Since the cause of missing reports may be occurring at any stage of
administrative appeal, increased communications from the CDI unit may
significantly alleviate this problem of missing investigative reports. To that
end, we will discuss with OIG the feasibility of posting, on the cover sheet of
the ROI, a summary (with citations) of the POMS and the HALLEX instructions for
handling the ROI. This would give prominent and direct notice to anyone who may
mistakenly believe that the ROI does not belong in the medical evidence section.
It would clearly remind staff of the folder handling procedures for the report
and serve as an alert about inappropriate removal of the report.
Our responses to the specific recommendations are as follows:
Recommendation 1
Provide instructions in POMS on what component is responsible to: (a) file the
investigative report in the paper folder and (b) flag the EF to identify cases
in which a CDI unit investigation was conducted.
Comment:
We agree.
Our responses to the specific subparts of this recommendation are as follows:
E-2
a) We agree. With regard to component responsibility for filing the CDI report
in the folder, the relevant component instructions are already in place to
ensure that the ROI is placed in the folder. DDS processing procedures (POMS DI
70005.005 B.6, DI 70005.005 F, and DI 70025.001) instruct that the investigative
report in the paper folder be readily available and should be filed on top of
all material in the medical records section. HALLEX I-2-1-15 D.6. instructs that
the ROI be filed on top of all medical material. This is reiterated at HALLEX
I-2-1-15 E.6. Each component is responsible to ensure that the ROI is properly
filed per POMS and HALLEX and that the report is addressed by the respective
adjudicator.
b) We agree. Instructions already exist to implement this recommendation. POMS
DI 80540.045 and DI 80740.045 both explain how to add a high risk factor flag to
the electronic folder.
Recommendation 2
Place restrictions on the EF to ensure the link to the investigative report
cannot be removed.
Comment:
We disagree. In order to implement the recommendation that the link to the
investigative document cannot be removed, business rules, requirements, and
software modifications would be needed, and this enhancement would need to be
prioritized with other requests for EF modifications. Given existing procedures,
implementation of this recommendation would not be cost-effective at this time.
Recommendation 3
Request the Chief ALJ to remind ALJs of the September 2005 instructions to
document the use of the investigative report in the disability decision
write-up.
Comment:
We agree and have implemented this recommendation. On September 28, 2005, OHA
issued revised provisions in the HALLEX to instruct OHA personnel to include the
ROI in the claimant file. See HALLEX I-2-1-15.
In addition, OCALJ issued “Reminders” about CDI information on October 29 and
October 31, 2005, to all OHA employees. These reminders emphasized to OHA ALJs
and to Decision Writers (DW) the evidentiary value of the ROI. ALJs and DWs were
also reminded of the need to address the ROI in the written decision when it is
relevant as explained in HALLEX I-2-8-25. Also, the appropriate employees were
reminded of where to place the ROI in the claim folder and on the Exhibit list
according to HALLEX.
In FY 2005, an ALJ Steering Committee comprised of subject matter experts and
training specialists was formed to update the training materials for future ALJ
training, including CDIs and ROIs.
E-3
Finally, OCALJ is scheduled to prepare and deliver during the fourth quarter of
FY 2006 an interactive video training program for OHA employees on fraud and
abuse issues.
Recommendation 4
Request the Chief ALJ to encourage ALJs to request CDI unit investigators and
third parties to testify at hearings when clarification of the investigative
report is needed, particularly the testimony of third parties, which might
otherwise be construed as hearsay evidence.
Comment:
We agree. OHA will inform ALJs of CDI unit investigators’ availability as
hearing witnesses to clarify the ROI and of the option of requesting additional
evidence from a CDI unit when warranted by case circumstances.
Recommendation 5
Request the Chief ALJ to encourage ALJs to request from SSA and DDSs additional
evidence from CDI units when warranted by case circumstances.
Comment:
We agree. See our response to Recommendation 3 regarding training and reminders.
Recommendation 6
Require surveillance videos to be included in the multimedia evidence section of
the EF.
Comment:
We disagree. Under current EF technology, this capability does not exist and,
therefore, should not be required. However, we note that we are making strides
in maintaining multimedia.
With the release of eView 9.0 in late November 2005, SSA introduced the first
item that can be stored in the multimedia section of the EF: a digital recording
of a hearing shown as a zipped file. The zipped file can be downloaded so that
the reviewer can listen to the hearing at his/her computer without using an
audio compact disc or tape. However, currently there is no standard format for
videos that can be stored in EF and then retrieved into all OHA, DDS, and SSA
systems equipment. Additionally, all CDI units have copies of the surveillance
video that are available for OHA when the ALJ begins to review the case.
E-4
Appendix F
OIG Contacts and Staff Acknowledgments
OIG Contacts
Mark Bailey, Director, Kansas City Audit Division (816) 936-5591
Shannon Agee, Audit Manager, Kansas City, Missouri (816) 936-5590
Acknowledgments
In addition to those named above:
Karis Gaukel, Auditor
Ken Bennett, IT Specialist
Cheryl Robinson, Writer/Editor
For additional copies of this report, please visit our web site at
www.ssa.gov/oig or contact the Office of the Inspector General’s Public Affairs
Specialist at (410) 965-3218. Refer to Common Identification Number
A-07-05-15091.
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Social Security Advisory Board
Overview of the Office of the Inspector General
The Office of the Inspector General (OIG) is comprised of our Office of
Investigations (OI), Office of Audit (OA), Office of the Chief Counsel to the
Inspector General (OCCIG), and Office of Resource Management (ORM). To ensure
compliance with policies and procedures, internal controls, and professional
standards, we also have a comprehensive Professional Responsibility and Quality
Assurance program.
Office of Audit
OA conducts and/or supervises financial and performance audits of the Social
Security Administration’s (SSA) programs and operations and makes
recommendations to ensure program objectives are achieved effectively and
efficiently. Financial audits assess whether SSA’s financial statements fairly
present SSA’s financial position, results of operations, and cash flow.
Performance audits review the economy, efficiency, and effectiveness of SSA’s
programs and operations. OA also conducts short-term management and program
evaluations and projects on issues of concern to SSA, Congress, and the general
public.
Office of Investigations
OI conducts and coordinates investigative activity related to fraud, waste,
abuse, and mismanagement in SSA programs and operations. This includes
wrongdoing by applicants, beneficiaries, contractors, third parties, or SSA
employees performing their official duties. This office serves as OIG liaison to
the Department of Justice on all matters relating to the investigations of SSA
programs and personnel. OI also conducts joint investigations with other
Federal, State, and local law enforcement agencies.
Office of the Chief Counsel to the Inspector General
OCCIG provides independent legal advice and counsel to the IG on various
matters, including statutes, regulations, legislation, and policy directives.
OCCIG also advises the IG on investigative procedures and techniques, as well as
on legal implications and conclusions to be drawn from audit and investigative
material. Finally, OCCIG administers the Civil Monetary Penalty program.
Office of Resource Management
ORM supports OIG by providing information resource management and systems
security. ORM also coordinates OIG’s budget, procurement, telecommunications,
facilities, and human resources. In addition, ORM is the focal point for OIG’s
strategic planning function and the development and implementation of
performance measures required by the Government Performance and Results Act of
1993.
Reversal of Disability Denial Decisions 
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