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    Subject Term: "Claims settlement"

    9 publications with a total of 22 open recommendations including 2 priority recommendations
    Director: Kathryn A. Larin
    Phone: (202) 512-7215

    8 open recommendations
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop a formal and systematic approach to gathering information to identify potential conditions for the CAL list, including by sharing information through SSA's website on how to propose conditions for the list and by utilizing research that is directly applicable to identifying CAL conditions.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen its Compassionate Allowance initiative (CAL).
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop formal procedures for consistently notifying those who propose conditions for the CAL list of the status of their proposals.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop and communicate internally and externally criteria for selecting conditions for the CAL list.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should take steps to obtain information that can help refine the selection software for CAL claims, for example by using management data, research, or DDS office feedback.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should clarify written policies and procedures regarding when manual addition and removal of CAL flags should occur on individual claims.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should assess the reasons why the uses of manual actions vary across DDS offices to ensure that they are being used appropriately.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop a schedule and a plan for updates to the CAL impairment summaries to ensure that information is medically up to date.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop a plan to regularly review and use available data to assess the accuracy and consistency of CAL decision-making.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it is committed to looking for opportunities to strengthen CAL.
    Director: Alicia Puente Cackley
    Phone: (202) 512-8678

    1 open recommendations
    Recommendation: As Congress considers reauthorizing NFIP, it should consider comprehensive reform to improve the program's solvency and enhance the nation's resilience to flood risk, which could include actions in six areas: (1) addressing the current debt, (2) removing existing legislative barriers to FEMA's revising premium rates to reflect the full risk of loss, (3) addressing affordability, (4) increasing consumer participation, (5) removing barriers to private-sector involvement, and (6) protecting NFIP flood resilience efforts. In implementing these reforms, Congress should consider the sequence of the actions and their interaction with each other.

    Agency: Congress
    Status: Open

    Comments: When we determine what steps the Congress has taken, we will provide updated information.
    Director: Alicia Puente Cackley
    Phone: (202) 512-8678

    1 open recommendations
    Recommendation: To improve the transparency and accountability over the compensation paid to WYO companies and set appropriate compensation rates, the FEMA administrator should take into account WYO company characteristics that may impact companies' expenses and profits when developing the new compensation methodology and rates.

    Agency: Department of Homeland Security: Directorate of Emergency Preparedness and Response: Federal Emergency Management Agency
    Status: Open

    Comments: According to FEMA officials, FEMA is responding to this recommendation as part of its development of a final rule on WYO compensation practices, required by the Biggert-Waters Act.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    1 open recommendations
    Recommendation: To help support DOD management of its FECA responsibilities, the Secretary of Defense should direct the Office of the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Secretaries of the military departments and other defense agency leaders, to monitor timelines associated with significant FECA claims-management actions in order to identify the extent to which delays or inefficiencies may be occurring and at what points in the process; to identify any known reasons for the delays; and to communicate this information to DOL as appropriate for consideration and action.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To help provide reasonable assurance that VHA achieves its long-term goal of modernizing its claims processing system, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that the agency develops a sound written plan that includes the following elements: (1) a detailed schedule for when VHA intends to complete development and implementation of each major aspect of its new claims processing system; (2) the estimated costs for implementing each major aspect of the system; and (3) the performance goals, measures, and interim milestones that VHA will use to evaluate progress, hold staff accountable for achieving desired results, and report to stakeholders the agency's progress in modernizing its claims processing system.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: As of June 2017, VHA's Office of Community Care is in the process of consolidating VA's community care programs, and as part of this process it plans to transition to a third party administrator for the purposes of claims processing. While an active procurement is underway, VHA still needs to develop a written plan to fully implement this recommendation. VHA's written plan must include details about the schedule, cost estimates, performance goals, and interim milestones associated with transitioning to a third party administrator for the purposes of processing claims for VA community care.
    Director: Kathleen King
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, Office of Medicare Hearings and Appeals (OMHA), or Departmental Appeals Board (DAB) to modify the various Medicare appeals data systems to collect information on the reasons for appeal decisions at Level 3.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, OMHA and DAB were considering the cost and technical feasibility of collecting this information within their appeals data systems. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to capture the amount, or an estimate, of Medicare allowed charges at stake in appeals in Medicare Appeals System (MAS) and Medicare Operations Division Automated Case Tracking System (MODACTS).

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, this information was not captured in any CMS system, including MAS. HHS reported that if MAS is modified to capture the amount of Medicare allowed charges at stake, OMHA will consider modifying its Electronic Case Adjudication and Processing Environment (ECAPE) to include this information as well, and DAB can capture it in a new case management system currently being developed by the agency. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to collect consistent data across systems, including appeal categories and appeal decisions across MAS and MODACTS.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, HHS reported taking several initial steps to standardize data across Medicare appeals systems. Specifically, HHS stated that, in November 2016, CMS will modify MAS to standardize appeal categories between Levels 1 through 3 and that OMHA will incorporate the standardized MAS appeal categories for Levels 1 and 2 into ECAPE in its next release. DAB will also work to incorporate these standardized categories into its new appeals data system. In addition, HHS reported that CMS is working to modify MAS to collect additional information related to appeal decisions. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: James R. McTigue, Jr.
    Phone: (202) 512-9110

    2 open recommendations
    Recommendation: To further encourage whistleblowers to provide information to IRS about serious tax noncompliance and to protect whistleblowers, Congress should consider legislation that would provide protections for tax whistleblowers against retaliation from their employers.

    Agency: Congress
    Status: Open

    Comments: On March 29, 2017, the Senate Finance Committee introduced the IRS Whistleblower Improvements Act of 2017, which would provide anti-retaliation protections for whistleblowers who bring information on tax noncompliance to IRS. The act would provide protections for employees from discharge, demotion, suspension, threats, harassment, or any other discrimination in reprisal for lawful actions to provide information to the IRS or to participate in a judicial action taken by the IRS relating to an alleged underpayment of tax or violation of tax laws. On April 20, 2016, the Senate Finance Committee approved provisions to improve the IRS's whistleblower program and protect tax whistleblowers from retaliation from their employers. The provision extends anti-retaliation provisions to IRS whistleblowers that are presently afforded to whistleblowers under the False Claims Act and Sarbanes-Oxley. However, no action passed on this Senate bill in the 114th congress. We will continue to monitor legislative action in this area.
    Recommendation: The Commissioner of Internal Revenue should direct the Whistleblower Office Director to establish a process to ensure whistleblower addresses are being properly updated in E-TRAK to ensure the WO does not send whistleblower mail to outdated or incorrect addresses. This process could include developing a change of address form specific to whistleblowers and including a blank copy of it in every correspondence with whistleblowers or referencing the importance of updating the WO with any address change in every correspondence with whistleblowers.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: In a January 29, 2016 letter, the IRS Deputy Commissioner for Services and Enforcement said that the Whistleblower Office will emphasize in education materials, fact sheets, and other communications with whistleblowers the importance of whistleblowers providing updates to the IRS of any address changes, along with reminders of how to submit address changes to the Whistleblower Office. In August and September of 2016, IRS revised templates for standard letters sent to whistleblowers reminding them of the importance of updating their addresses with the Whistleblower Office and providing direction for how to do so. IRS also published a fact sheet for whistleblowers, which is available on www.irs.gov, that also provides information on how whistleblowers should notify the Whistleblower Office of any address change. As of February 2017, IRS had not taken action to establish a process to ensure that address changes are being properly updated in E-TRAK and that mail is being sent only to the correct address. We will continue to follow-up with IRS on this recommendation.
    Director: Bertoni, Daniel
    Phone: (202) 512-7215

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To help ensure that Total Disability Individual Unemployability (TDIU) decisions are well supported and TDIU benefits are provided only to veterans whose service-connected disabilities prevent them from obtaining or retaining substantially gainful employment, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to update the TDIU guidance to clarify how rating specialists should determine unemployability when making TDIU benefit decisions. This updated guidance could clarify whether factors such as enrollment in school, education level, and prior work history should be used and if so, how to consider them; and whether or not to assign more weight to certain factors than others. Updating the guidance would also give VBA the opportunity to re-examine the applicability, if at all, of other factors it has identified as extraneous.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA reported in March 2017 that an internal workgroup is in the final stage of collecting and analyzing the data to determine if age should be a factor in deciding Total Disability Individual Unemployability (TDIU), and whether or not to use positive vocational assessments to disallow TDIU claims. VA reported that the workgroup is also in the process of completing an Inter-Rater Variability Assessment (IRVA) to examine the disparity in rating decisions involving entitlement to TDIU and service connection. After completion of the internal study on TDIU and the IRVA, targeted for September 30, 2017, the workgroup will submit its preliminary analysis and recommendations to VBA leadership for a decision on the next courses of action for future policy decisions and will then update any related guidance, as appropriate.
    Recommendation: To help ensure that TDIU decisions are well supported and TDIU benefits are provided only to veterans whose service-connected disabilities prevent them from obtaining or retaining substantially gainful employment, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to verify the self-reported income provided by veterans (a) applying for TDIU benefits and (b) undergoing the annual eligibility review process by comparing such information against IRS earnings data, which VBA currently has access to for this purpose. VA could also explore options to obtain more timely earnings data from other sources to ensure that claimants are working within allowable eligibility limits

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: VA is developing an upfront verification process by expanding the data sharing agreement with Social Security Administration (SSA), which enables VA to receive federal tax information via an encrypted electronic transmission through a secure portal. Once a Total Disability Individual Unemployability (TDIU) claim is received, VA will request the reported income through the secured SSA portal and receive a response within 10-16 days. VA reported that process will serve as a more efficient way to receive income data in a timely manner and maintain the integrity of the TDIU benefit while reducing improper payments. The development and implementation of the upfront verification process for TDIU claimants is anticipated to be completed by July 21, 2017. Meanwhile, VA has reinstituted the data match agreement with SSA through December 2017, which collects earned income (employment wages). The agreement allows VBA to compare reported income earnings of TDIU beneficiaries to earnings actually received. In addition, VA completed the upfront income verification manual guidance and is planning to pilot the guidance prior to implementation. VA also has drafted new manual guidance for the annual eligibility review process and the documents are currently under review. As of March 2017, VA reported delays and stated it planned to fully implement the annual eligibility review process by June 30, 2017.
    Recommendation: To help ensure that TDIU decisions are well supported and TDIU benefits are provided only to veterans whose service-connected disabilities prevent them from obtaining or retaining substantially gainful employment, in light of VA's agreement with the recommendations made by the Advisory Committee on Disability Compensation, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to develop a plan to study the complex TDIU policy questions on (1) whether age should be considered when deciding if veterans are unemployable and (2) whether it is possible to disallow TDIU benefits for veterans whose vocational assessment indicated they would be employable after rehabilitation.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of March 2017, a VA workgroup is in the final stages of collecting and analyzing the data to determine if age should be a factor in deciding TDIU, and whether or not the agency will use positive vocational assessments to disallow TDIU claims. Additionally, the workgroup is in the process of completing an Inter-Rather Variability Study (IRVA) to examine the disparity in rating decisions involving entitlement to TDIU and service connection. After completion of the internal study on TDIU and the IRVA, targeted for September 30, 2017, he workgroup will submit its preliminary analysis and recommendations and VA will then decide on the next courses of action for future policy decisions. Due to VA's earlier conclusions, in April 2015, that no immediate changes to its current guidance were necessary, and in the spirit of this recommendation, the status will remain open until the completion of these ongoing efforts.
    Director: Daniel Bertoni
    Phone: (202) 512-7215

    2 open recommendations
    Recommendation: As part of initiatives currently under way to improve agency information on claims with appointed representatives and detect potential fraud associated with representatives, the Commissioner of the Social Security Administration should consider actions to provide more timely access to data on representatives and enhance mechanisms for identifying and monitoring trends and patterns related to representation, particularly trends that may present risks to program integrity. Specifically, SSA could (1) Identify additional data elements, or amendments to current data collection efforts, to improve information on all appointed representatives, including those under contract with states and other third parties; (2) Implement necessary policy changes to ensure these data are collected. This could include enhancing technical systems needed to finalize SSA's 2008 proposed rules that would recognize organizations as representatives; and (3) Establish mechanisms for routine data extracts and reports on claims with representatives.

    Agency: Social Security Administration
    Status: Open

    Comments: In July 2017, SSA reported that it is approaching the conclusion of the first phase of a new initiative, called Registration, Appointment and Services for Representatives (RASR). This initiative aims to register all appointed representatives and improve relevant business processes and data collection. SSA reported that it had to postpone the first release of RASR, originally targeted for December 2016, due to some systems issues. SSA stated that it has not yet set a new target date for the first release. SSA stated that this new application will enhance data collection and management of representatives' information and that it will help make strides toward better oversight and improved data analysis and reporting. We will consider closing this recommendation when these efforts are completed.
    Recommendation: To address risks associated with potential overpayments to representatives and protect claimant benefits, the Commissioner of the Social Security Administration should take steps to enhance coordination with states, counties, and other third parties with the goal of improving oversight and preventing and identifying potential overpayments. This coordination could be conducted in a cost-effective manner, such as issuing guidance to states and other third parties on vulnerabilities for overpayment; sharing best practices on how to prevent overpayments; or considering the costs and benefits, including any privacy and security concerns, of providing third parties controlled access to portions of the eFolder to facilitate the detection of potential overpayments.

    Agency: Social Security Administration
    Status: Open

    Comments: In July 2017, SSA stated that it added a section to a new form--Form SSA-1698, Fee Agreement for Representation before the Social Security Administration--that claimants and representatives can use to enter into fee agreements. According to SSA, this form requires the disclosure of fees that the representative will receive from a third party and the amount of those fees. SSA expects this form to be in use upon OMB approval. Similar language already exists in another form--Form SSA-1560-U4, Petition to Obtain Approval of a Fee for Representing a Claimant before the Social Security Administration--that claimants and representatives can use for fee petitions. SSA stated that these forms are (and will be) included in the folder of evidence that adjudicators may review before determining whether and how much to authorize in fees. According to SSA, disclosure and approval of any third party fees, with potential adjustment of the fee, by both the claimant and SSA should help prevent excessive fees. While the proposed change to the form may help improve transparency of fee arrangements, the potential for a representative to receive a payment from SSA and also receive a payment from a state or other third party still exists. Unless SSA and the state or other third party share information on their payments or have policies and procedures in place to prevent such cases, representatives could still receive both SSA and state payments that total more than the SSA-authorized fee. In order to address this vulnerability, we continue to believe that SSA should enhance coordination or issue guidance to states and other third parties about this vulnerability, which could include SSA sharing best practices for preventing these types of overpayments. For example, one state requires contracted organizations to submit copies of their signed form 1696 (Appointment of Representative) so the state could verify the representative checked the appropriate box for payment.