From the U.S. Government Accountability Office, www.gao.gov

Transcript for: Physician-Assisted Fraud in SSA Disability Benefits

Description: Audio interview by GAO staff with Daniel Bertoni, Director,
Education, Workforce, and Income Security 

Related GAO Work: GAO-15-19: SSA Disability Benefits: Enhanced Policies
and Management Focus Needed to Address Potential Physician-Assisted
Fraud

Released: December 2014


[ Background Music ]

[ Narrator: ] Welcome to GAO's Watchdog Report, your source for news and
information from the U.S. Government Accountability Office. It's
December 2014. Each year the Social Security Administration relies on
medical evidence to determine whether millions of new disability benefit
claimants are qualified. This evidence, and those who provide it, have
raised questions about potential fraud. A team led by Dan Bertoni, a
director in GAO's Education, Workforce, and Income Security team
recently studied SSA's efforts to detect and prevent physician-assisted
fraud in its disability programs. GAO's Jacques Arsenault sat down with
Dan to talk about what they found.

[ Jacques Arsenault: ] What is physician-assisted fraud and how big of a
potential problem is it?

[ Dan Bertoni: ] This type of fraud can happen in different ways but
generally involves a doctor working in collusion with some other third
party such as a disability attorney or non-attorney representative. And
they provide fraudulent medical diagnoses or some type of other
fraudulent medical information in support of bogus disability claims.
And they generally do this for a fee or for some other financial gain.
And, no, the full extent of this type of fraud is not known because SSA
lacks good data and, more than that, a systematic way to detect it.
However, there have been some more recent high-profile investigations in
Puerto Rico and New York City involving police officers and firefighters
that were actually filing these fraudulent claims, and in West Virginia.
And in all of these examples the players were quite organized and
operating for many years so we do know it's happening.

[ Jacques Arsenault: ] Let me ask then, does the Social Security
Administration have the right procedures in place to detect and prevent
this type of fraud?

[ Dan Bertoni: ] No, not entirely—for a couple reasons. SSA relies on
its frontline staff to be its eyes and ears in detecting fraud, to
detect suspicious patterns of activity, and develop fraud referrals and
push that information forward for investigation. However, the way they
process claims makes this very difficult. Cases are assigned randomly
across many claims examiners and offices over a broad geographic region.
Combine that with the number of doctors they deal with and the volume of
medical evidence they handle on a given day, and it's near impossible
for a single examiner to spot systematic patterns of fraud. For example,
a doctor who may be providing boilerplate diagnoses or the same medical
information for multiple applicants in a particular town or city would
be very difficult to spot that pattern. Beyond that, SSA's performance
measures also focus primarily on quickly processing and paying claims.
And we found that this can be a disincentive for staff to even want to
take on and develop fraud referrals.

[ Jacques Arsenault: ] What then is SSA doing to get better at
preventing this?

[ Dan Bertoni: ] SSA is doing a number of things. They stood up fraud
investigation units in about 30 states and they have been pretty
successful at going after this organized fraud and these fraudsters.
They have plans to expand these units to more states going forward and
we think that that's a good thing in GAO. They have fraud awareness and
detection training. But I think most importantly, they are just now
beginning to explore computer modeling or data analytics to
electronically mine their case-processing data to identify patterns of
potential fraud to make connections between physicians, the attorneys
they may be working with, the claimants that they're actually serving,
and even the medical evidence that's being provided by the physician,
essentially using data to take this out of the hands of claims examiners
who are tasked making those very difficult connections today. However,
it's very early on in the process. There's a lot to be done. There's a
lot of upfront work to be done. Some of this is still conceptual in
nature. So they have a way to go and they have to get better information
including gathering better information on the many physicians that
they're working with and the medical evidence that's most subject to
fraud.

[ Jacques Arsenault: ] What recommendations is GAO making in this report
to address physician-assisted fraud?

[ Dan Bertoni: ] We have several recommendations including asking SSA to
explore options for addressing the potential disincentives that staff
have for not wanting to make fraud referrals; that they shore up the
current fraud training; they conduct some additional risk assessments to
get a better understanding of their exposure to physician-assisted
fraud; and lastly and perhaps most importantly to develop more concrete
tactical and long-term plans around their data analytics efforts to help
them be more successful going forward.

[ Jacques Arsenault: ] And finally, given the millions of new claims
made each year for disability benefits, what do you see as the bottom
line of this report for taxpayers?

[ Dan Bertoni: ] Bottom line. I'd say the bottom line is that this type
of fraud is occurring. We know it is. And any instance can be very
costly to the taxpayer. And SSA can and should do more to get ahead of
it.

[ Background Music ]

[ Narrator: ] To learn more, visit GAO.gov and be sure to tune in to the
next episode of GAO's Watchdog Report for more from the congressional
watchdog, the U.S. Government Accountability Office.