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    Subject Term: "Medical evidence"

    1 publication with a total of 3 open recommendations including 1 priority recommendation
    Director: Daniel Bertoni
    Phone: (202) 512-7215

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To improve the ability of the agency to detect and prevent potential physician-assisted fraud, and 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.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA partially agreed with this recommendation, citing that their employees take their stewardship responsibilities seriously and that field office and disability determination services (DDS) employees are the agency's first and best line of defense against fraud. In 2016, the agency reported that it was working with experts in its OIG and Office of Anti-Fraud Programs to develop and disseminate promising practices on identifying and reporting fraud. We will close this recommendation once SSA takes steps to review its standards for assessing DDS performance and disseminates the best practices it is developing.
    Recommendation: To improve the ability of the agency to detect and prevent potential physician-assisted fraud, and to address the potential risks associated with medical evidence submitted by sanctioned physicians, SSA should evaluate the threat posed by this information and, if warranted, consider changes to its policies and procedures.

    Agency: Social Security Administration
    Status: Open

    Comments: As of 2016, SSA reported that it was pursuing several options to address the potential risks of medical evidence submitted by sanctioned physicians. This included determining how it could use licensure information from the List of Excluded Individuals and Entities. SSA stated that it believes the best opportunity to further evaluate the possible review of the license statuses of medical evidence providers is in conjunction with the implementation of the National Vendor File, part of the national Disability Case Processing System, which is under development. In addition, SSA reported it had drafted two Social Security Rulings to define fraud and to provide processes for disregarding evidence and making redeterminations in disability claims when there is reason to believe that fraudulent evidence was provided. We will close this recommendation once SSA articulates a strategy for using license status information in the vendor file and it finalizes its rulings.
    Recommendation: To improve the ability of the agency to detect and prevent potential physician-assisted fraud, and to help ensure new initiatives that use analytics to identify potential fraud schemes are successful, SSA should develop an implementation plan that identifies both short- and long-term actions, including: (1) timeframes for implementation; (2) resources and staffing needs; (3) data requirements, e.g., the collection of unique medical provider information; (4) how technology improvement will be integrated into existing technology improvements such as the Disability Case Processing System and National Vendor File; and (5) how different initiatives will interact and support each other.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: Since fiscal year 2015, SSA has taken several steps that will help the agency to combat fraud, waste, and abuse. SSA established the Office of Anti-Fraud Programs to provide centralized oversight and accountability for the agency's initiatives, which, in consultation with the Office of the Inspector General and other SSA components, will lead the development of SSA's anti-fraud initiatives and activities. This includes efforts to mitigate fraud through data analytics that utilize SSA's existing data systems. SSA developed a strategic plan for fiscal years 2016-2018 to guide its anti-fraud efforts that includes the use of data analytics. However, this plan does not specifically address actions to combat potential physician-assisted fraud. As of April 2017, SSA stated that it continued to develop a fraud management strategy that is consistent with the leading practices identified in GAO's report. Once the strategy is complete, SSA plans to conduct a fraud risk assessment on its major lines of business, beginning with the disability program in fiscal year 2017. We will continue to monitor SSA's progress to identify and prevent fraud schemes that include physicians.