Social Security Disability Benefits: Agency Could Improve Oversight of Representatives Providing Disability Advocacy Services
Published: 2014-12-03T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: For years, states and counties have helped individuals who receive state or county assistance apply for federal disability programs. Federal benefits can be more generous, and moving individuals to these programs can allow states and counties to reduce their benefit costs or reinvest savings into other services. Some states have hired private organizations to help individuals apply for federal benefits, but the extent and nature of this practice is not well-known. GAO was asked to study this practice.
This report examines (1) what is known about the extent to which states have SSI/DI advocacy contracts with private organizations, (2) how SSI/DI advocacy practices compare across selected sites, and (3) the key controls SSA has to ensure these organizations follow SSI/DI program rules and regulations. GAO reviewed relevant federal laws, regulations, and program rules; selected three sites to illustrate different contracting approaches; reviewed prior studies, including one by SSA's Office of the Inspector General with a generalizable sample of disability claim files; and interviewed SSA, state, and county officials and contractors.
section_title: What GAO Found
paragraphs: Little is known about the extent to which states are contracting with private organizations to help individuals who receive state or county assistance apply for federal disability programs. Representatives from these private organizations help individuals apply for Supplemental Security Income (SSI) and Disability Insurance (DI) from the Social Security Administration (SSA). Available evidence suggests that this practice—known as SSI/DI advocacy—accounts for a small proportion of federal disability claims. Using a variety of methods, including interviewing stakeholders, GAO identified 16 states with some type of SSI/DI advocacy contract in 2014. In addition, GAO analyzed a sample of 2010 claims nationwide and estimated that such contracts accounted for about 5 percent of initial disability claims with nonattorney representatives, or about 1 percent of all initial disability claims. Representatives working under contract to other third parties, such as private insurers and hospitals, accounted for an estimated 30 percent of initial disability claims with nonattorney representatives.
Three selected sites represented different approaches to SSI/DI advocacy, but were similar in many respects. For example, Minnesota contracted with 55 nonprofit and for-profit organizations, while Hawaii and Westchester County, New York, each had a single contractor: a legal aid organization, and a for-profit company, respectively. At the same time, all three sites targeted recipients of similar state and county programs, such as General Assistance, and generally paid contractors only for approved disability claims, among other similarities.
SSA has controls to ensure representatives follow program rules and regulations, but these controls are not specific to those working under contract to states or other third parties and may not be sufficient to assess risks and prevent overpayments—known by SSA as fee violations. Specifically:
Despite the growing involvement of different types of representatives in the initial disability determination process, SSA does not have readily available data on representatives, particularly those it does not pay directly. This hinders SSA's ability to identify trends and assess risks, a key internal control. SSA's existing data are limited and are not used to provide staff with routine information, such as the number of claims associated with a given representative. SSA has plans to combine data on representatives across systems, but these plans are still in development.
SSA does not coordinate its direct payments to representatives with states or other third parties that might also pay representatives, a risk GAO identified in 2007. In cases involving SSI/DI advocacy contracts, a representative may be able to collect payments from both the state and from SSA, potentially resulting in an overpayment—a violation of SSA's regulations.
section_title: What GAO Recommends
paragraphs: GAO recommends that SSA (1) consider ways to improve data and identify and monitor trends related to representatives, and (2) enhance coordination with states, counties, and other third parties with the goal of improving oversight and preventing potential overpayments. SSA partially agreed with our recommendations and noted that it may consider additional actions related to representatives.

section_title: Letter
paragraphs: State and local governments throughout the United States are grappling  with budgetary challenges and have sought ways to reduce spending on  state- and county-funded benefit programs, while also providing eligible  individuals with benefits to address their needs. To that end, some states  and counties have contracted with organizations to (1) identify individuals  with disabilities who are receiving assistance from state or local programs  and might be eligible for two of the federal government’s largest disability  programs—Supplemental Security Income (SSI) and Disability Insurance  (DI)—and (2) help them with the disability application process. Even  though this practice—referred to as SSI/DI advocacy—has been around  for quite some time, little is known about the various forms state and local  efforts can take. Media attention on states’ use of SSI/DI advocacy comes  on top of questions about the fiscal health and integrity of the federal SSI  and DI programs, administered by the Social Security Administration  (SSA).
Against this backdrop, you asked us to review the SSI/DI advocacy  services provided by private organizations. Specifically, we examined (1)  what is known about the extent to which states are contracting with  private organizations to identify and move eligible individuals from state-  or county-administered benefit programs to Social Security disability  programs, (2) how SSI/DI advocacy practices compare across selected  sites, and (3) the key controls SSA has in place to ensure these  organizations follow SSI/DI program rules and regulations.
To address these objectives, we reviewed relevant federal laws and  regulations and SSA program documentation, including policies and  procedures. To gather more information about the extent to which states  and other government entities are contracting with private organizations  to provide SSI/DI advocacy services, we interviewed SSA and  Department of Health and Human Services (HHS) officials; numerous  state, county, and local officials; and stakeholders and researchers who  work in this area. We also worked with national professional organizations  representing state Temporary Assistance for Needy Families (TANF)  agencies and state Disability Determination Services (DDS) directors to  help identify states that may be engaged in these practices. In addition,  we reviewed relevant studies; in particular, we reviewed findings from a  recent SSA Office of the Inspector General (OIG) report, including the  OIG’s generalizable sample of disability claims with nonattorney  representatives in 2010. In order to obtain in-depth information on states’  and organizations’ SSI/DI advocacy practices, we selected three sites— Hawaii; Minnesota; and Westchester County, New York—with SSI/DI  advocacy contracts. We selected sites that had an established history of  contracting for SSI/DI advocacy and represented a variety of approaches,  such as contracting at the state or county level, or contracting with a  single organization or multiple for-profit and nonprofit organizations.  Specifically, we selected a state with a single, statewide nonprofit  contractor; a state with multiple for-profit and nonprofit contractors; and a  county with a single, for-profit contractor. We requested data from each  site on the number of SSI and DI claims that were approved and the total  amounts paid under the contract in state fiscal year or contract year 2013.  We also collected SSA data on the total number of claims approved in the  same state or county in calendar year 2012, the most recent year these  federal data were available. We assessed the reliability of these data by  interviewing knowledgeable SSA, state, and contractor officials and  comparing data provided by the state or county and the contractors, and  determined the data were sufficiently reliable for the purposes of  providing contextual information on the size of these contracts. To  analyze national trends in the involvement of representatives over time,  we reviewed SSA data on initial SSI and DI claims with attorney and  nonattorney representatives, from calendar year 2004 to 2013. We  assessed the reliability of these SSA data by interviewing knowledgeable  officials. We determined that these data were sufficiently reliable for the  purposes of providing contextual information on national trends in  representation.
To determine what data and key controls SSA has regarding  organizations and representatives, we reviewed relevant federal laws and  regulations, policies, and procedures in SSA’s Program Operations  Manual System. We also interviewed SSA headquarters officials, as well  as SSA officials in selected regional offices, field offices, and state  DDSs. In addition, we assessed SSA’s controls against GAO Standards  for Internal Control in the Federal Government.
We conducted this performance audit from September 2013 through  December 2014 in accordance with generally accepted government  auditing standards. These standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives. See appendix I  for additional information on our objectives, scope, and methodology.
subsections: section_title: Background
subsections: section_title: Overview of Federal Disability Benefit Programs
paragraphs: The Social Security Administration administers two main programs that  provide benefits to individuals with disabilities: SSI and DI. Adults are  generally considered disabled if (1) they cannot perform work that they  did before; (2) they cannot adjust to other work because of their medical  condition(s); and (3) their disability has lasted, or is expected to last, at  least 1 year or is expected to result in death.
SSI is a means-tested income assistance program that provides monthly  cash benefits to individuals who are disabled, blind, or aged and meet,  among other things, the program’s assets and income restrictions. In  fiscal year 2015, SSA expects to pay an estimated $60 billion in SSI  benefits to about 8.5 million recipients.
SSA’s primary disability program, the DI program, provides monthly cash  benefits to adults not yet at full retirement age when the individual is  disabled and has worked long enough to qualify for disability benefits. In  fiscal year 2015, SSA expects to pay an estimated $147 billion in DI  benefits to about 11 million workers with disabilities and their spouses  and dependents. Some disability recipients receive both SSI and DI  benefits because of their work history and the low level of their income  and resources. SSA expects costs for these programs to increase in the  coming years.
section_title: SSA’s Disability Determination Process
paragraphs: SSA’s disability determination process is complex and involves offices at  the federal and state level (see fig.1). The process begins at an SSA field  office, where a staff member determines whether a claimant meets the  programs’ nonmedical eligibility criteria. Claims from individuals meeting  these criteria are then evaluated by state DDS staff, who review medical  and other evidence and make the initial disability decision. SSA funds the  DDSs, which are run by the states, to process disability claims in  accordance with SSA regulations, policies, and guidelines. Some DDSs  may be independent state agencies, while others may be part of other  state agencies with broader missions, such as departments of human  services. If an initial claim is denied, claimants have several opportunities  for appeal within SSA, starting with a reconsideration; then a hearing  before an SSA administrative law judge (ALJ); and finally at the Appeals  Council, which is SSA’s final administrative appeals level. If the claimant  is determined to be eligible for SSI or DI, SSA will calculate the benefit  amount and begin to pay benefits. A claimant may also be entitled to  past-due benefits for the months in which his or her SSI or DI cash  payments were pending during the disability decision-making process.
section_title: Role of Appointed Representatives
paragraphs: Claimants may choose to appoint a representative to assist them through  the disability application process and in their interactions with SSA.
Appointed representatives can be attorneys or nonattorneys, and, as long  as they meet SSA’s requirements for representatives, their experience  can range from being a family member appointed as a representative on  a one-time basis to a professional representative working at a for-profit or  nonprofit organization. A representative may act on a claimant’s behalf in  a number of ways, including helping the claimant complete the disability  application, obtaining and submitting evidence in support of a claim, and  supporting the claimant during the hearings and appeals process.
To appoint a representative, a claimant must sign a written notice  appointing the individual to be his or her representative in dealings with  SSA and file the notice with SSA. Representatives can file this notice  using a standard form, which contains the name and address of the  representative. The standard form also indicates whether and how the  representative would like to be paid—by the claimant, directly by SSA out  of a claimant’s past-due benefits (known as a direct payment), or by a  third party.
Representatives have commonly been involved at SSA’s hearings and  Appeals Council levels, but evidence suggests that representatives have  become increasingly involved at the initial stage of the disability  determination process. SSA data compiled for this report show that the  proportions of SSI and DI claims with a representative at the initial level  increased between 2004 and 2013. From 2004 to 2013, initial SSI claims  with a representative increased dramatically, from almost 11,000 claims  in 2004 (less than 1 percent of all initial SSI claims) to about 278,000  claims in 2013 (about 14 percent of claims). Initial DI claims with a  representative also increased over the same time period, from almost  100,000 claims (about 8 percent of claims) to more than 413,000 claims  (about 20 percent of claims). (See fig. 2.) In 2013, two-thirds of the  representatives associated with initial claims were attorneys and one-third  were nonattorneys.
These trends may, in part, reflect legislative actions that expanded  payment options for representatives in the disability determination  process. For example, the Social Security Protection Act of 2004  temporarily allowed attorney representatives to receive direct payments  from SSA, out of claimants’ past-due benefits, for SSI claims, and also  required a demonstration project under which SSA’s direct payment  system applied to qualified nonattorney representatives. These policy  changes were made permanent in 2010.
section_title: SSI/DI Advocacy Initiated by States, Counties, and Other Third Parties
paragraphs: States and counties have engaged in SSI/DI advocacy efforts for years  because it can benefit individuals with disabilities as well as the state and  counties. When states are successful in helping eligible individuals on  state- or county-administered assistance programs navigate the complex  disability application process and obtain federal disability benefits, the  individuals and their families not only may generally receive a higher  monthly income but can also potentially receive benefits on a long-term  basis. At the same time, successful SSI/DI advocacy efforts allow states  to reduce benefit costs or reinvest cost savings into expanding services or  serving other individuals.
The financial incentives for states to pursue SSI/DI advocacy increased in  two ways with the creation of the TANF program in 1996 and subsequent  changes to TANF requirements. As some researchers noted, under the  former program, Aid to Families with Dependent Children, states received  less than half of any savings achieved through transferring individuals to  SSI. Under TANF, however, states retain the savings from federal and  state funds that would have been used to support those individuals and  can use those funds for other allowable benefits or services. At the same  time, the new work participation requirements of the TANF program  required a percentage of each state’s caseload to participate in  employment-related activities. States that do not meet required work  participation rates are at risk of having their annual TANF block grants  reduced. Therefore, the work requirements provided incentives for states  to remove certain families from the calculation of the work participation  rate, including individuals with disabilities who have significant barriers to  work.
States have taken different approaches to SSI/DI advocacy. Some states  designate state employees to provide SSI/DI advocacy services, while  others contract with for-profit or nonprofit organizations or legal aid  groups. Some states do not have SSI/DI advocacy programs at all.  Furthermore, some SSI/DI advocacy efforts are at the county or local  level. In addition to states and counties, other third parties—such as  hospitals and private insurance companies—also contract for SSI/DI  advocacy services. For example, hospitals contract with companies to  obtain reimbursement for medical care provided to patients who do not  have health insurance by helping patients establish eligibility for various  federal, state, and county programs, such as SSI and Medicaid.  Insurance companies may also contract with companies to help  individuals receiving long-term disability benefits apply for federal  disability benefits, in part because federal disability benefits can reduce  the amount the insurance company must pay.
section_title: State Assistance Programs Serving Individuals Who May Qualify for Federal Disability Benefits
paragraphs: States—and county and local governments, in some cases—administer a  number of assistance programs for low-income individuals and families,  some of whom have disabilities that may qualify them for federal disability  programs. In many instances, these low-income individuals can qualify for  SSI due to their income and assets, among other factors. Some may also  qualify for DI benefits, if they have a sufficient work history. As a result,  states may direct SSI/DI advocacy services to people receiving benefits  from any of the following programs:
TANF: This federal block grant provides funds to states for a wide  range of benefits and services, including state cash assistance  programs for needy families with children. TANF is administered by  HHS’s Administration for Children and Families at the federal level  and by state and, in some cases, county agencies. State TANF  programs provide temporary, monthly cash payments to low-income  families with children while preparing parents for employment. A  percentage of each state’s caseload must participate in a minimum  number of hours of employment-related activities unless they are  exempt.
State General Assistance: These programs provide cash assistance  to poor individuals who do not qualify for other assistance programs  (e.g., they do not have children and are not elderly). As of January  2011, 30 states had General Assistance programs, and most states  require individuals to be unemployable generally because of a  physical or mental condition.
Other State Assistance Programs: Other populations or programs  states may target for SSI/DI advocacy include, for example, homeless  individuals or individuals receiving state medical assistance or foster  care payments.
section_title: Interim Assistance Reimbursement to States
paragraphs: Some states may receive funds from SSA, known as Interim Assistance  Reimbursement (IAR), for assistance they provide (i.e., cash assistance  provided through state programs like General Assistance to meet basic  needs) to an individual who is waiting for approval of SSI benefits. If  the individual’s SSI claim is successful, SSA uses the claimant’s past-due  benefits to reimburse the state for this interim assistance. States may, in  turn, use these funds to finance their SSI/DI advocacy efforts. To qualify  for reimbursement, any interim assistance an individual receives while  awaiting SSA’s decision must be funded only from state or local funds.  Interim assistance payments to a needy individual that contain any  federal funds do not qualify for reimbursement. For example, IAR is  generally not payable to states for assistance payments related to  programs like Medicaid and TANF because the federal government  partially funds these programs. To participate in the IAR program, a  state must have an IAR agreement with SSA and a written authorization  from the individual allowing SSA to reimburse the state from his or her  past-due benefits. As of 2014, 36 states and the District of Columbia  have IAR agreements with SSA.
section_title: Little Is Known About the Extent of Advocacy Contracts, but Evidence Suggests Such Contracts Account for a Small Proportion of Claims Nationwide
subsections: section_title: Limited Information Exists, but We Identified 16 States with Some Type of SSI/DI Advocacy Contract in 2014
paragraphs: Little is known about the extent to which states or counties contract for  SSI/DI advocacy services. While SSA has oversight of the federal SSI  and DI programs, officials told us that they do not know which states or  counties are contracting for SSI/DI advocacy services, in part because  that information is not necessary to achieve SSA’s mission, which  includes delivering retirement, survivor, and disability benefits and  services to eligible individuals and their families. While SSA collects some  data on representatives working on behalf of claimants, it does not collect  information on whether these representatives are working under contract  to a state or county. Similarly, HHS has oversight of the federal TANF  program and collects information about how states use TANF block grant  funds but, according to HHS officials, the agency does not have statutory  authority to collect information on states’ contracts for SSI/DI advocacy. In  addition to the absence of comprehensive data from SSA and HHS, it is  difficult to determine the extent of these contracts nationwide because  this practice is diffused among different agencies and different levels of  government, depending on the state.
Furthermore, we did not identify research that provides a national picture  of state SSI/DI advocacy contracting practices. For example, one study  we reviewed looked at the overlap between the TANF and SSI  populations, but it was not the purpose of the study to examine the extent  to which states were contracting for SSI/DI advocacy services. The study  did not include recipients of other benefit programs, like state-funded  General Assistance, that we found were commonly served by SSI/DI  advocacy contracts.
Despite limited national-level data, we identified at least 16 states, as of  August 2014, that had some type of active contract or grant for SSI/DI  advocacy in 2014: California, Colorado, Delaware, Hawaii,  Massachusetts, Minnesota, Nevada, New York, Ohio, Oklahoma, Oregon,  Pennsylvania, Rhode Island, Tennessee, Virginia, and Wisconsin. (See  fig. 3.)
Half of the 16 states we identified contracted with multiple organizations  in 2014, including for-profit, nonprofit, and legal aid organizations,  according to state and county officials we contacted. For example,  according to state officials, the Wisconsin Department of Children and  Families contracted with 8 organizations (both for-profit and nonprofit) for  SSI/DI advocacy services, with each covering different geographic areas,  as part of a larger contract for TANF employment support services. At the  same time, 7 states reported they had a state contract or grant with a  single nonprofit or legal aid organization. For example, Tennessee  officials stated they provided a grant to a legal aid organization to work  with about 100 TANF recipients per year who may be eligible for federal  disability benefits.
Within states, we identified SSI/DI advocacy contracts at different levels  of government. In several states, we identified only county-level contracts  (see fig. 3), and in one state, New York, we identified at least one contract  at the state, county, and city level. Specifically, according to state officials,  New York had a statewide Disability Advocacy Program that provided  grants to a group of nonprofit and legal aid organizations to help  individuals appeal their claim after it was initially denied. Westchester  County also had a contract with a for-profit organization for SSI/DI  advocacy. In addition, officials from New York City’s Wellness,  Comprehensive Assessment, Rehabilitation and Employment (WeCARE)  program reported that they contract with two nonprofit organizations to  provide SSI/DI advocacy services.
We also observed recent changes in states’ SSI/DI advocacy contracting  practices. We identified multiple states that have ended, or plan to end,  their SSI/DI advocacy contracts, and at least one state that is planning to  renew a contract it ended several years ago. Several state officials and  experts cited reasons for ending or renewing SSI/DI advocacy contracts,  including financial considerations. For example, according to state  officials, Maryland had a contract for over a decade with an organization  to work with TANF recipients who may be eligible for federal disability  benefits. The state paid this organization for each disability application  submitted; however, state officials told us they ended this contract in 2009  because it was no longer financially practical. According to state officials,  in 2014, the state planned to issue a new request for proposals for SSI/DI  advocacy that will only pay the contractor for approved claims. Officials  told us that they expect that the performance-based compensation  structure of the contract will make it financially practical again. In contrast,  officials in Delaware told us they had a contract with a single nonprofit  organization for about 6 years to work with TANF recipients, but the  contract expires in 2014 and will not be renewed due to the relatively low  success rate achieved by the contractor. After the contract expires, state  employees will provide these services instead, which officials believe will  be a better use of resources. Similarly, we identified two additional states  that have opted to have state employees provide SSI/DI advocacy  services.
section_title: State SSI/DI Advocacy Contracts May Account for a Small Proportion of Disability Claims Nationwide, but Other Third-Party Contracts May Be More Prevalent
paragraphs: While state and county SSI/DI advocacy contracts may account for a  small proportion of disability claims nationwide, SSI/DI advocacy  contracts held by other third parties, such as hospitals and long-term  disability insurance companies, may be more prevalent. Since information  on SSI/DI advocacy contracts is not available in SSA’s databases, and  data on representatives, in general, are limited, we used available data  from a 2014 SSA OIG report to estimate the percentage of claims  associated with SSI/DI advocacy contracts. Specifically, these data  indicate that nonattorney representatives working on behalf of a  government entity accounted for an estimated 5 percent of all initial SSI  and DI claims with nonattorney representatives adjudicated in 2010.  Claims from these government SSI/DI advocacy contracts represent  about 1 percent of all initial SSI and DI claims in 2010. By comparison,  data indicate that claims associated with contracts held by other third  parties—specifically, hospitals and long-term disability insurance  companies—were more prevalent, accounting for an estimated 30  percent of initial SSI and DI claims with nonattorney representatives  adjudicated in 2010. (See fig. 4.)
section_title: Selected Sites Represented Different Approaches to SSI/DI Advocacy but Were Similar in Many Respects
paragraphs: We selected three sites—Hawaii; Minnesota; and Westchester County,  New York—to illustrate different approaches to SSI/DI advocacy, in terms  of the number and types of organizations they contracted with and  geographic coverage. Despite these differences, however, the three sites  were similar in many respects. For example, all three sites articulated a  similar goal for their SSI/DI advocacy contracts, targeted similar  populations, and generally paid SSI/DI advocacy contractors only for  approved claims, among other similarities (see table 1). See appendix II  for more detailed information on each site.
Each site articulated a two-part goal for its SSI/DI advocacy contract:  maximizing assistance for individuals with disabilities while also reducing  state or county expenditures. Helping individuals on state or county  benefits apply for Social Security disability benefits is allowable under  current program rules and may result in greater financial support to  individuals and their families if they are eligible. In all three sites, the  maximum SSI disability benefit was higher than the maximum benefit  provided by General Assistance or TANF. For example, Minnesota  officials explained that Minnesota’s General Assistance benefits are lower  than SSI. In addition, individuals receiving SSI may also be eligible for  other support programs, such as medical assistance and food  assistance. At the same time, officials from all three sites told us that  moving individuals off state benefit programs and onto federal disability  programs has financial benefits for the state or county. As discussed  earlier, when the federal government pays the SSI or DI benefits, states  can use the funds saved for other purposes, such as expanding services  or serving other individuals.
subsections: section_title: Populations Served
paragraphs: All three sites targeted SSI/DI advocacy services to General Assistance  and TANF populations. Each site also targeted recipients of at least one  other program. For example, in addition to General Assistance and TANF,  Minnesota’s contract specified that recipients of a state-funded Group  Residential Housing program are eligible for SSI/DI advocacy services. In  another example, Westchester County’s contract included children in  foster care who may be eligible for SSI.
section_title: Services Provided
paragraphs: The contractors we selected in the three sites generally reported  providing similar services to the state or county, and to claimants,  including performing an initial disability screening, assisting with filling out  the SSI and/or DI application, and representing the claimant throughout  the disability determination process. Each of the contractors reported  receiving referrals from sources such as state or county caseworkers or  TANF employment services contractors and then screening these  individuals to identify those likely to meet Social Security disability criteria.  For example, the Westchester County contractor receives monthly lists of  individuals receiving General Assistance or TANF benefits who have  been determined to be unable to work due to a disability. Contractor  officials mail a letter to individuals on these lists, introducing their services  and inviting individuals to call their toll-free number to set up an initial  screening. Similarly, Hawaii’s SSI/DI advocacy subcontractor reported  that, under the new contract, it will receive referrals from the primary state  contractor. The screening process varied across contractors; some had  structured tools to guide the process while others had a more informal  initial intake appointment.
The four contractors we selected reported a wide range in the percentage  of referrals for which applications were filed, from less than 20 percent for  one contractor to over 90 percent for another. Further, contractors  reported a range of approval rates, and the contractor that likely filed  applications for the smallest percentage of referred individuals reported  achieving the highest approval rates at SSA (over 80 percent) of the  contractors for which we obtained data. However, there are a number of  factors contributing to these rates that we could not examine, such as the  nature and quality of the referrals and the level of the claimant’s  participation in the process. Two of the contractors noted that screening  out obviously ineligible individuals benefits SSA in that the contractors are  not contributing to SSA workloads by submitting claims unlikely to be  approved.
After the contractors determine that an individual is potentially eligible for  federal disability benefits, they assist him or her with completing an  application for SSI and/or DI. With the claimant’s permission, staff from  these organizations also become the claimant’s appointed representative,  which allows the staff person to interact with SSA on behalf of the  claimant during the disability determination process. Representatives  from these organizations told us they generally focus on gathering and  summarizing available medical evidence rather than providing referrals to  doctors and specialists to obtain new medical evidence. The contractors  reported that they generally file concurrent applications for SSI and DI.  They generally file the DI application online, but they differed in how they  filed the SSI application. Two of the organizations we selected—the for- profit contractor in Minnesota and the contractor in Westchester County— reported filling out the SSI application on the claimant’s behalf, while the  other two organizations reported sending or accompanying the claimant  to the SSA field office to file the application. The organizations also  reported supporting claimants up to the hearings and Appeals Council  levels, if necessary. See table 2 for a comparison of the SSI/DI advocacy  services the contractors in our three selected sites reported providing.
The representatives in each site generally reported interacting frequently  with local SSA field offices and, to a lesser extent, the state DDS, in  conducting their SSI/DI advocacy work. For example, the for-profit  contractor we selected in Minnesota had offices across the street from  SSA’s Minneapolis field office, and representatives from this contractor  reported hand-delivering SSI paper applications. In another example,  officials from the Westchester County contractor reported having good  working relationships with all of the SSA field offices in the county, noting  that their representatives typically talk with field office staff daily by phone.
Staff we interviewed in each of the local field offices we selected  generally had positive feedback on their interactions with representatives  from the selected SSI/DI advocacy contractors. For example, they noted  that the representatives are helpful and easier to get in touch with or more  responsive than other representatives. In addition, staff we interviewed  generally said that claims submitted by these representatives are of equal  or better quality than claims submitted by other representatives. In  general, the DDS staff we interviewed did not express an opinion on the  responsiveness of the representative or on the overall quality of claims.
section_title: Compensation
paragraphs: In each site, SSI/DI advocacy contractors were generally paid only for  disability claims that SSA approved. Payments ranged from $900 to  $3,000 per approved claim. One site paid the same amount for an  approved claim, regardless of the level of the adjudication process in  which it was approved, while contractors in two sites were paid higher  amounts for claims approved at the reconsideration and/or hearings or  Appeals Council levels. Two of the sites—Minnesota and Westchester  County, New York—also offered payments for assisting claimants  undergoing continuing disability reviews, which SSA conducts to  determine whether individuals receiving benefits continue to meet  program disability requirements. Hawaii was unique among the three  sites in that the state paid the primary contractor a set monthly fee but the  primary contractor paid the SSI/DI advocacy subcontractor per approved  claim.
The relatively “flat fee” compensation structure in the SSI/DI advocacy  contracts differs from SSA’s direct payment structure and may create an  incentive for representatives to submit claims that can be favorably  decided in a more timely manner. Whereas selected SSI/DI advocacy  contractors’ fees are a set amount, regardless of how long it takes to  decide a claim, under the Social Security Act eligible representatives can  elect to be paid by SSA directly out of a claimant’s past-due benefits and  potentially earn more when claims take longer to be approved. Their fee  is a maximum of 25 percent of the past-due benefits for approved claims,  up to $6,000.
section_title: Funding Sources
paragraphs: All sites at least partially offset the costs of their advocacy contracts with  federal Interim Assistance Reimbursement (IAR) funds from SSA. In two  of the sites—Hawaii and Minnesota—officials reported that they received  more IAR money than they spent on their SSI/DI advocacy contracts.  Through the IAR program, SSA reimburses participating states for the  assistance they provided to individuals while awaiting the approval of SSI  benefits. In order for the state to receive reimbursement, the state must  have the claimant sign a written authorization that allows the state to be  paid out of the claimant’s past-due benefits.
section_title: Approved Claims
paragraphs: The number of individuals moved onto federal disability programs as a  result of the SSI/DI advocacy contracts in all three sites accounted for a  small percentage of the total number of approved SSI and DI claims in  their respective states or county. Specifically, Minnesota was the largest  of the three sites in all respects: amount paid under the contract,  geographic reach, and number of approved claims. Yet the 1,112 claims  approved statewide in state fiscal year 2013 was relatively small  compared to the roughly 24,000 disability claims approved by SSA in the  state in calendar year 2012, the most recent year available. Similarly,  Hawaii and Westchester County’s 342 and 136 claims approved in state  fiscal or contract year 2013, respectively, each represented small  proportions of all disability claims approved by SSA in the state or county  in calendar year 2012.
section_title: SSA’s Controls over Representatives Providing SSI/DI Advocacy Services to States and Other Third Parties Are Limited
subsections: section_title: SSA Does Not Have Specific Controls and Readily Available Data on Representatives, Particularly Those Paid by States and Other Third Parties
paragraphs: SSA has a number of controls in place—including rules and  regulations—related to appointed representatives in the disability  determination process, but it does not have controls specific to  organizations providing SSI/DI advocacy services to states and other third  parties. SSA’s existing controls over representatives include broad  guidelines regarding who may represent disability claimants, including  qualifications for attorneys and nonattorneys. SSA regulations also set  forth specific rules of conduct that apply to all representatives. For  example, representatives are required, with reasonable promptness, to  obtain evidence in support of the claim, submit such evidence as soon as  practicable, help claimants respond to requests for information from SSA  as soon as practicable, and to be familiar with relevant laws and  regulations. Representatives are prohibited from, among other things,  knowingly collecting any fees in violation of applicable law or regulation.  In addition, nonattorney representatives who wish to be eligible for direct  payment of their fees out of a claimant’s past-due benefits also must  satisfy a number of statutory criteria. Nonattorney representatives who do  not wish to be eligible for direct payment of their fees, such as those  waiving direct payment and working under contract to a state or county,  do not have to satisfy these criteria but are still required by SSA’s  regulations to be capable of giving valuable help to claimants and to have  good character and reputation.
SSA’s controls apply to individual representatives, and not to the  organizations they work for, including those under contract to states or  other third parties, because SSA only conducts business with and  recognizes individuals as representatives. In 2008, SSA issued proposed  rules that would have recognized organizations, in addition to individuals,  as representatives. In other words, under the proposed rules a claimant  could appoint an organization or firm to represent them rather than a  single individual from that organization. In the proposed rules, SSA stated  that the business practices of those who represent claimants have  changed, and many representatives practice in group settings and  provide their services collectively to claimants. However, the agency did  not issue final rules on this topic. SSA officials told us that they still  believe that having organizations serve as appointed representatives  would be beneficial, but the agency would face challenges implementing  this change, including modifying SSA’s current data systems.
SSA also does not have readily available data on representatives,  particularly those paid by third parties. Specifically, SSA’s current data on  representatives are limited, kept in separate systems, and are not used to  monitor or report trends on claims with representatives (see table 3). In  particular, SSA collects less information about representatives the agency  does not directly pay out of claimants’ past-due benefits, and information  on these representatives is not tracked in SSA’s data systems.
Federal government internal control standards state that agencies should  have adequate access to timely data and information, and mechanisms in  place for routinely assessing risks related to interactions with entities and  parties outside the government that could affect agency operations. In  order to make timely and accurate decisions, identify trends, and assess  risks—including those related to program integrity—SSA needs ongoing  and up-to-date information on representatives. This is particularly  important given that representatives have become increasingly involved  at the initial levels of the disability determination process, according to our  analysis of SSA data.
section_title: SSA Has Several Initiatives That Could Improve Information on Representatives but Uncertainties Exist
paragraphs: SSA has several efforts under way to improve its collection and use of  data as well as its ability to assess risks related to representatives. First,  SSA recently initiated the Registration, Appointment, and Services for  Representatives project, with the goal of providing staff more accurate,  up-to-date information about the representatives who assist claimants in  the disability process. SSA officials stated that the agency currently  captures information on representatives in separate, stand-alone systems  that are not well-integrated, which has resulted in concerns about  payment inefficiencies and privacy. SSA plans to integrate information  from the various systems on representatives, creating one system as the  sole source for information on representatives. SSA officials told us that  the agency may identify new data elements related to representatives to  capture in the system, such as the organizations they are associated with,  but there currently is no plan to collect this information.
Another facet of this initiative involves giving representatives expanded  access to the disability eFolder, SSA’s electronic system containing all of  the documents pertaining to a disability claim. Once implemented,  authorized and registered representatives will have the ability to view  documents for their clients contained in the eFolder and download and  print them. Officials from two professional organizations of  representatives and some SSA staff we interviewed reported that giving  representatives access to the eFolder would be beneficial. By requiring  representatives to register to gain access, SSA could gather more  information on representatives. According to SSA’s vision statement for  this project, successful implementation would provide SSA more readily  available data—and enhanced abilities to respond to management  requests for information—on representatives. However, as of September  2014, SSA officials reported that this project is in the early planning  phase, future funding is uncertain, and no timeline for completion has  been established.
Enhanced collection and use of data on appointed representatives may  also be important for planned initiatives related to the detection of  potential fraud. SSA is in the early stages of exploring computerized tools  to enhance efforts to systematically detect potential fraud.
Using data from recent alleged fraud cases involving representatives,  SSA plans to use computer analytics to examine various characteristics  of disability claims and determine those which may be fraudulent. Known  as predictive analytics, these computer systems and tools can help  identify patterns of potentially fraudulent disability claims. However, as  discussed earlier, SSA does not consistently collect some data that may  aid in its analytics effort, such as information on the organizations or firms  with which individual representatives may be associated. The absence of  readily available data on representatives hinders SSA’s ability to detect  patterns of potential fraud. Specifically, SSA’s current data systems do  not allow staff to identify, in a timely manner, large volumes of claims with  the same representative and the same impairments, which can be a risk  factor for potential fraud, according to SSA officials we interviewed.
section_title: SSA Does Not Coordinate with Third Parties Contracting for SSI/DI Advocacy, Which May Result in Overpayments
paragraphs: SSA does not coordinate its direct payments to representatives with  states and other third parties that might also pay representatives. As a  result, it is possible that both SSA and a state or third party could pay the  representative, resulting in more than one payment. More specifically,  under the current system of payments, a representative working under  contract to a state could (1) request direct payment from SSA (deducted  from the claimant’s past-due benefits) for representing a particular  claimant, and (2) also submit an invoice to the state requesting payment  under the terms of the SSI/DI advocacy contract. Generally, SSA  prescribes the maximum fee allowed, and representatives may not  knowingly collect more than the fee that SSA authorizes them to receive  for a case. However, we found that in cases involving SSI/DI advocacy  payments, representatives might be able to collect payments from the  state as well as through SSA fee withholding, totaling more than the  authorized amount. 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 may receive both SSA and state  payments that total more than the SSA-authorized fee.
In 2007, we reported on this risk of overpayments to representatives and  recommended that SSA take steps to address it. However, SSA has not  fully implemented our recommendation because SSA did not know which  states were paying representatives or the true extent of the problem,  according to a senior agency official. SSA has taken some steps to clarify  authorized payments for representatives. For example, in 2011, SSA  revised the form a claimant uses to appoint a representative (form 1696)  to more clearly indicate how a representative would like to be paid.  Specifically, the updated form requires representatives to declare whether  they intend to be paid by (1) the claimant directly,(2) SSA, out of the  claimant’s past-due benefits, or (3) a third party. (See fig. 5.)
Although the revised form more clearly delineates allowable fee  arrangements, SSA officials acknowledged that this overpayment  vulnerability still exists. Officials told us that the agency would not know if  a representative was paid from another source outside SSA. The agency  is dependent upon the claimant or the third party to inform SSA about an  overpayment to a representative. Although the updated appointment form  makes it more clear that representatives must choose one type of fee  arrangement, some SSA staff we interviewed reported that claimants  often do not fully understand the forms they are signing or the  implications.
One state we studied has developed practices in an attempt to avoid  these types of overpayments, but these practices are not universal.  Officials in Minnesota stated that they recently began requiring contracted  organizations to submit copies of their signed form 1696 so the state  could verify that the representatives checked the appropriate box for  payment. By looking more closely at the award notices SSA sends to  claimants and representatives, state officials reported discovering three  instances in 2014 when a representative did not check the appropriate  box to waive direct payment from SSA and could have received an  overpayment. Minnesota officials plan to work with a local SSA field office  to conduct an audit of a sample of claims to identify such cases.  According to a Minnesota official, this effort would begin in December  2014. Officials we interviewed in the other two selected sites reported that  they do not require representatives from contracted organizations to  submit these signed SSA forms, nor did they have plans to audit claims to  detect overpayments.
SSA does not systematically coordinate with states and other third parties  on the payment of representatives. For example, SSA has not issued  guidance to states or third parties or shared any best practices on  preventing overpayments. SSA and state officials in Minnesota reported  that as SSA expands representative access to the eFolder during the  disability determination process, providing controlled third party access  could efficiently facilitate the detection of potential overpayments. For  example, states could use their access to portions of the eFolder to easily  check the form 1696 submitted by the representative and any additional  documents, such as fee agreements, to prevent overpayment. However,  SSA can only provide access to an eFolder if it is permissible under  federal privacy laws. In general, coordination is important because the  risk of overpayment goes beyond the 16 states we identified with state or  county SSI/DI advocacy contracts. As discussed earlier, we estimated  that about 30 percent of all initial disability claims with nonattorney  representatives are potentially associated with SSI/DI advocacy contracts  held by other third parties, such as hospitals and long-term disability  insurers.
section_title: Conclusions
paragraphs: SSI/DI advocacy, while serving a practical purpose for states, counties,  and individuals, raises questions about the role third parties and  representatives play in the disability determination process. Many of  these questions—such as the extent of SSI/DI advocacy and the impact  of this practice—cannot be answered because so little data exist. Since  representatives are increasingly involved in this process and are working  on behalf of a diverse set of third parties, it is critical that SSA  management and employees have mechanisms for monitoring trends and  patterns related to claims with representatives. SSA anticipates being  able to combine data across its systems in order to evaluate data  variations on representatives but those plans are under development.  SSA’s current efforts also face a number of uncertainties which, if left  unaddressed, may undermine the agency’s ability to improve data on  representatives. In the absence of readily available data—particularly  data on those representatives paid by third parties—SSA is poorly  positioned to identify trends or patterns that may present risks to program  integrity.
One such risk is making overpayments to representatives who are also  being paid by third parties. SSA has not taken steps to adequately  eliminate this vulnerability. Without enhanced coordination between SSA  and third parties, some representatives may improperly receive  payments. This financial vulnerability presents a strong case for  enhanced oversight over representatives in the disability determination  process.
section_title: Recommendations for Executive Action
paragraphs: 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:  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;  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
Establish mechanisms for routine data extracts and reports on claims  with representatives.
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.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this product to the Social Security Administration  (SSA) and the Department of Health and Human Services (HHS) for  comment. SSA and HHS provided technical comments, which we have  incorporated as appropriate. In its written comments, reproduced in  appendix III, SSA partially agreed with our two recommendations and  raised its overall concern that our report misrepresents and overstates the  nature of states’ payments to representatives. The agency did not provide  any further support for this assertion; it is unclear the basis on which SSA  could make this statement, given that officials repeatedly told us during  the course of our work that the agency has no information or data on  states’ contracts. Our report makes it clear that the full extent of states’  and counties’ SSI/DI advocacy practices is unknown, given the absence  of national-level data. Given these limitations, we believe that our work  fairly and accurately describes what is known about the extent of SSI/DI  advocacy contracts and payments nationwide.
SSA also noted that our report did not address other types of SSI/DI  advocacy contracts, such as those held by insurance companies. Indeed,  it was not within the scope of our report to do so. We did note that other  types of SSI/DI advocacy contracts—such as those held by insurance  companies or hospitals—represented an estimated 30 percent of initial  disability claims with nonattorney representatives in 2010. The prevalence  of these SSI/DI advocacy contracts, and the growing involvement of  representatives at the initial disability determination level, presents a  strong case for SSA to have greater information on these third parties and  the payments they may receive.
SSA partially agreed with our first recommendation to consider actions to  provide more timely access to data on representatives and enhance  mechanisms for identifying and monitoring trends and patterns related to  representation. SSA acknowledged that the report accurately describes  initiatives the agency has underway to improve the use and collection of  data related to representatives. SSA stated that, as part of these efforts,  the agency may identify additional data elements that may be helpful to  collect and consider any necessary policy changes. SSA raised concerns,  however, that expanding data collection to a more detailed level could  negatively affect other agency priorities. We fully acknowledge that SSA  has competing priorities and limited resources. With this in mind, we  wrote the recommendation to provide SSA flexibility in implementation,  including suggesting that the agency leverage current initiatives. We  continue to believe that SSA should consider steps to improve available  data on appointed representatives to better monitor the involvement of  these third parties in the disability determination process.
SSA partially agreed with our second recommendation to take steps to  enhance coordination with states, counties, and other third parties with  the goal of improving oversight and preventing and identifying potential  overpayments. In its general comments, SSA stated that its rules allow  representatives to receive fee payments, and that any payments made by  states are outside of SSA’s authority for oversight purposes. SSA also  stated that our report did not provide sufficient evidence to warrant  enhanced coordination and noted that the agency takes the necessary  actions to recoup fees when it learns of a potential fee violation. Our  report notes, however, that SSA is dependent upon the claimant or the  third party to inform SSA about an overpayment to a representative. In  our audit work in selected states, we also noted three instances when a  representative attempted to be paid by SSA and the state. While we  recognize that payments made by states to representatives are outside of  SSA’s jurisdiction, SSA has established rules of conduct for  representatives, and these rules prohibit a representative from collecting  fees over the amount SSA has authorized. Enhanced coordination could  increase SSA’s and third party payers’ ability to detect potential  overpayments.
Finally, SSA suggested that we explicitly state in our report that we did  not find any indications of fraud committed by representatives working  under contracts to states or other third parties (referred to by SSA in its  comments as “facilitators”). The objectives of this work were focused on  (1) identifying the extent to which states are involved in SSI/DI advocacy,  (2) examining different approaches to this work, and (3) assessing the  key controls that SSA has in place to ensure that organizations working  under contract to states and other third parties follow program rules and  regulations. As such, we did not have any findings on the extent of any  possible fraudulent activity associated with these SSI/DI advocacy  contracts. We do note in the report, however, that SSA field office staff we  interviewed in our three selected sites generally had positive feedback on  their interactions with representatives working under contract to the state  or county, and that claims they submitted were of the same or better  quality than claims submitted by other representatives.
As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days from its  issue date. At that time, we will send copies of this report to the  appropriate congressional committees, the Secretary of the Department  of Health and Human Services, the Commissioner of the Social Security  Administration, and other interested parties. In addition, the report will be  made available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or bertonid@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: In conducting our review of state Supplemental Security Income  (SSI)/Disability Insurance (DI) advocacy practices, our objectives were to  examine (1) what is known about the extent to which states are  contracting with private organizations to identify and move eligible  individuals from state- or county- administered benefit programs to Social  Security disability programs, (2) how SSI/DI advocacy practices compare  across selected sites, and (3) the key controls the Social Security  Administration (SSA) has in place to ensure these organizations follow  SSI/DI program rules and regulations. We conducted this performance  audit from September 2013 through December 2014 in accordance with  generally accepted government auditing standards. These standards  require that we plan and perform the audit to obtain sufficient, appropriate  evidence to provide a reasonable basis for our findings and conclusions  based on our audit objectives. We believe that the evidence obtained  provides a reasonable basis for our findings and conclusions based on  our audit objectives.
This appendix provides a detailed account of the data sources used to  answer these questions, the analyses we conducted, and any limitations  we encountered. The appendix is organized into three sections. Each  section presents the methods we used for the corresponding objective.  Specifically, section I describes the information sources and methods we  used to identify state SSI/DI advocacy contracts, estimate the proportion  of claims associated with these contracts, and analyze national trends in  claims with representatives. Section II describes the information sources  and methods we used to explore selected SSI/DI advocacy approaches.  Section III describes the information sources and methods we used to  assess SSA’s policies and controls related to representatives.
subsections: section_title: Section I: Identifying the Extent of State SSI/DI Advocacy Contracts
paragraphs: To determine the extent to which states are contracting with private  organizations for SSI/DI advocacy services, we used a multi-faceted  approach. Due to the absence of national-level data on SSI/DI advocacy  contracts, we combined information from various sources. Specifically, we  analyzed data from SSA’s Office of the Inspector General (OIG);  performed independent research, including conducting Internet searches  and following up on contracts identified in past GAO work; and  interviewed government officials, representatives from organizations  providing SSI/DI advocacy services, and a wide range of stakeholders  and experts.
subsections: section_title: Data Analysis
subsections: section_title: Analysis of a Random Sample of Social Security Disability Claims
paragraphs: We used data from a 2014 report issued by SSA’s OIG to estimate the  percentage of initial claims in 2010 with nonattorney representatives  working under a government SSI/DI advocacy contract, as well as the  percentage that were potentially working under contract with another third  party, such as a hospital or long-term disability insurance company.
As part of its report, the OIG selected a random sample of 275 SSI and DI  adjudicated claims from the population of 857,855 adjudicated claims with  a representative in calendar year 2010, 201 of which were for initial claim  determinations. Of these 201 initial claim determinations, 83 were  represented by nonattorney representatives, while the remainder had  attorney representatives. The OIG used information in the claim files, as  well as Internet research, to determine the type of nonattorney  representative associated with each sampled claim. The OIG did not  conduct similar work for claims with attorney representatives.
We independently reviewed and verified the OIG’s work papers for the  sampled claims with a nonattorney representative, including selected  documents from the electronic claim files. To verify that the OIG’s  categorizations of the type of representative were correct, we completed  a blind categorization of the type of representative involved in each claim  (that is, we completed our own categorization of the type of  representative, without first reviewing the OIG’s determination) for the  sample of 83 cases. A second analyst then confirmed the categorization.  We discussed any discrepancies between our categorizations and the  OIG’s with the OIG staff who performed the work. We obtained additional  information about the claim in several cases and documented the final  categorization. Using methods appropriate for a simple random sample,  we estimated the percentage of initial claims with determinations in 2010  with nonattorney representatives working under SSI/DI advocacy  contracts with government entities, as well as the percentage that were  potentially working under contract with another third party, such as a  hospital or long-term disability insurance company. Because the sample  was selected using a probability procedure based on random selections,  the sample is only one of a large number of samples that might have  been drawn. Since each sample could have provided different estimates,  we express our confidence in the precision of our particular sample’s  results as a 95-percent confidence interval (e.g., plus or minus 7  percentage points). This is the interval that would contain the actual  population value for 95 percent of the samples we could have drawn. All  estimates in this report have a margin of error, at the 95-percent  confidence level, of plus or minus 10 percentage points or fewer. Based  on our discussions with the OIG and our verification process, we  determined that the estimates were sufficiently reliable for the purposes of  this report.
section_title: Analysis of SSA Data on Trends in Representation
paragraphs: We also analyzed SSA data extracted from the Appointed Representative  Database, the Modernized Claims System, and the Supplemental  Security Income Record, for calendar years 2004-2013 to provide  information regarding total SSI and DI claims as well as claims with  attorney and nonattorney representatives, as context for our findings. We  interviewed SSA officials regarding these data and reviewed the  computer code SSA used to extract these data, and determined they  were sufficiently reliable for these purposes.
section_title: Review of Prior GAO Work and Internet Research
paragraphs: To identify states and counties that were likely to have an SSI/DI contract,  we followed up on prior GAO work and performed Internet research.  Specifically, we contacted officials in the states that, in 2007, reported  paying representatives to assist individuals with their SSI claims to  determine if these payments were part of a contract and, if so, if the  contract was still in place as of 2014. We also performed an Internet  search to identify additional SSI/DI advocacy contracts or requests for  proposals. Using a uniform set of search terms, we performed this search  for all states (and the District of Columbia) for which we did not have  information regarding their potential SSI/DI advocacy contracting activity  from our interviews (see below). We confirmed the status of these  contracts or proposals with state, county, or city officials, as appropriate.
section_title: Interviews
paragraphs: To supplement our data analyses and Internet searches, we conducted  interviews with a number of stakeholders to learn more about this  contracting practice and obtain leads for states that may have current  SSI/DI advocacy contracts. Specifically, we interviewed officials from SSA  and the Department of Health and Human Services (HHS) to determine  what information each agency collected and maintained regarding state  contracts for SSI/DI advocacy. Through these interviews, we also  explored what other data were readily available that could be used to  determine the extent of this contracting practice.
To obtain leads on potential state or county contracts, we worked with two  professional groups—the National Association of State TANF  Administrators and the National Council of Disability Determination  Directors—who contacted their members on our behalf.
With regard to state or county contracts identified through these  interviews and from information provided through these professional  groups, we followed up directly with state or county officials to confirm this  information.
To learn more about this contracting practice and obtain leads for states  that may have current SSI/DI advocacy contracts, we also interviewed  researchers at academic and advocacy organizations. These included:
American Enterprise Institute
American Public Human Services Association
Center on Budget and Policy Priorities
Center for Law and Social Policy
Consortium for Citizens with Disabilities
Federal Reserve Bank of San Francisco
Mathematica Policy Research
MDRC
National Association of Disability Examiners
National Association of Disability Representatives
National Association of State TANF Administrators
National Council of Disability Determination Directors [representing  state Disability Determination Services (DDS) directors]
National Council of Social Security Management Associations  (representing SSA field office and teleservice center managers)
National Organization of Social Security Claimants’ Representatives
Social Security Advisory Board  In addition, we interviewed representatives from organizations that, based  on our preliminary audit work, were providing SSI/DI advocacy services to  states or counties. These included Chamberlin Edmonds, the Legal Aid  Society of Hawaii, MAXIMUS, Public Consulting Group, and South Metro  Human Services. We also interviewed officials from Policy Research  Associates, which provides technical assistance, under a contract to the  Substance Abuse and Mental Health Services Administration, for the  national SSI/SSDI Outreach, Access and Recovery (SOAR) program.
section_title: Section II: Exploring Selected SSI/DI Advocacy Approaches
paragraphs: In order to obtain in-depth information on the different ways in which  states and counties contract with private organizations for SSI/DI  advocacy services, we selected a nongeneralizable sample of three sites  with SSI/DI advocacy contracts that had an established history of  contracting for SSI/DI advocacy services and represented a variety of  approaches. We also selected one state in which the Temporary  Assistance for Needy Families (TANF) administering agency and the  state DDS were divisions under the same state agency, in light of  concerns about potential conflicts of interest (the agency issuing the  contract to help people apply for federal disability benefits is under the  same state agency as the agency making the decision about eligibility for  federal disability benefits).
Specifically, we selected (1) a state that contracts with a nonprofit, legal  aid organization (Hawaii), (2) a state that contracts with multiple  organizations, including for-profit, nonprofit, and legal aid organizations  (Minnesota), and (3) a county that contracts with a for-profit company  (Westchester County, New York).
In each site, we obtained key documents—such as the request for  proposals and the signed, current contracts—and data in order to  describe the various aspects of the sites’ SSI/DI advocacy practices. For  example, we gathered information on how the states or county and their  contractors identified potentially eligible individuals, the types of services  provided by the organizations to claimants, compensation structures, and  other information. We obtained data on the total amounts paid to the  contractors in state fiscal year or contract year 2013. We also obtained  information on how the site funds its SSI/DI advocacy contracts, and  whether any funding was provided through an Interim Assistance  Reimbursement (IAR) agreement with SSA. We collected and analyzed  available data from the three sites on the number of individuals referred to  the contractor and the number of claims filed and approved by SSA in  state fiscal year 2013, or the most recent complete year available. We  interviewed state/county and contractor officials knowledgeable about the  data and compared states’/counties’ and contractors’ reported data and  determined the data were sufficiently reliable for our purposes. To put  these sites’ data on approved claims in context, we also obtained data  from SSA on the number of SSI and DI approved claims in each state or  county in calendar year 2012, the most recent year these federal data  were available.
In each site, we also conducted in-depth interviews with (1) the  government agency administering the contract, (2) officials from the  organization(s) working under the contract, (3) SSA officials in the  relevant regional office and at least one field office, and (4) state DDS  administrators and staff. In the field offices and state DDSs, we randomly  selected staff to interview who met certain qualifications. We conducted  these interviews either in person or by phone. We also contacted the  state auditors for each state, and in all three sites, they confirmed they  had no current work regarding SSI/DI advocacy contracting, nor had they  done any work in this area within the past 10 years.
Prior to issuing this report, we shared a statement of facts with officials  from the state or county agency and the selected contractor(s) in the  three sites to confirm that the key information used to formulate our  analyses and findings were current, correct, and complete. These entities  provided technical comments, which we incorporated, as appropriate.
section_title: Section III: Assessing SSA Policies and Controls Related to Representatives
paragraphs: In order to assess the controls SSA has in place related to  representatives contracted by third-party organizations to perform SSI/DI  advocacy, we reviewed relevant documents and reports, and conducted  interviews with key officials from SSA.
subsections: section_title: Review of Documents Describing SSA’s Controls
paragraphs: We reviewed relevant federal laws; proposed and final regulations;  program policies and procedures, such as SSA’s Program Operations  Manual System; and other program documentation, as well as reports  and testimonies from SSA, SSA’s OIG, and the Social Security Advisory  Board. We compared SSA’s efforts with their own policies and  procedures, federal government internal control standards, and prior  recommendations from GAO and the Social Security Advisory Board.
section_title: Interviews with SSA Officials
paragraphs: To understand SSA’s policies, procedures, and data controls related to  appointed representatives, we interviewed officials in a number of SSA  departments in headquarters. These included:
Office of Disability Adjudication and Review
Office of Disability Determinations
Office of Disability Programs
Office of Income Security Programs
Office of the Inspector General
Office of Research, Evaluation, and Statistics
Office of Retirement and Survivors Insurance Systems  To gain additional perspectives on how SSA policies are implemented  and challenges regarding appointed representatives in the disability  determination process, particularly those under contract to a state or  county, we incorporated relevant questions into the interviews conducted  in our three selected sites. Also, as noted above, we interviewed  representatives from national organizations representing SSA field office  managers, administrative law judges, DDS administrators, and DDS  examiners.
Approach to SSI/DI advocacy  In the beginning of 2014, Hawaii had a contract with a legal aid  organization to provide Supplemental Security Income (SSI)/Disability  Insurance (DI) advocacy services statewide. In July 2014, this  organization became a subcontractor to a company that performs medical  and psychological evaluations for the state’s cash assistance programs.  Specifically, the primary contractor is responsible for determining whether  applicants and recipients of the state’s General Assistance (GA) and  Temporary Assistance for Needy Families (TANF) programs have  disabilities that prevent them from engaging in work at a certain level.  Previously, the state had two separate contracts for SSI/DI advocacy and  medical and psychological evaluations. State officials told us that they  combined those services into a single contract, in part, to streamline the  referral process for SSI/DI advocacy. If the primary contractor determines  that an individual’s disability meets Social Security criteria, they refer the  individual directly to their advocacy subcontractor rather than indirectly  through state caseworkers, as was done under the prior contract.
Disability screening process  Previously, a prospective claimant could be referred by a state caseworker  or walk into the legal aid office. Referrals now come from the primary  contractor. Hawaii’s SSI/DI advocacy subcontractor told us they conduct a  screening assessment to obtain basic information—such as information on  the individual’s impairments, the doctors they have seen, and medications  they are taking—and have the claimant sign key forms, including the  Social Security Administration (SSA) form required to formally appoint the  advocacy worker as their representative. If an individual does not appear  eligible for federal disability benefits, the representative would decline to  officially represent them but might provide some assistance.
Assistance filing a claim  Hawaii’s SSI/DI advocacy subcontractor reported that most  representatives fill out available portions of the SSA disability application  online, such as the DI portion. They call the local SSA field office to  schedule an appointment for the claimant to meet with an SSA claims  representative to complete the SSI portion of the application, which is not  available online. They said representatives typically do not accompany the  claimant to the field office, nor do they refer claimants to doctors or  medical specialists.
Representation during the disability determination process  The advocacy subcontractor reported that its representatives will provide  additional information to SSA or the state Disability Determination  Services (DDS) on the claimant’s disabilities or functioning, upon request.  The representative may also check to ensure the claimant attends any  examinations scheduled by the DDS. If an initial application is denied, the  representative may schedule another appointment with the claimant to  review the case and determine whether to file a reconsideration or, later,  an appeal.
Approach to SSI/DI advocacy  In 2014, Minnesota contracted with 55 organizations across the state,  ranging from small law firms to large for-profit and nonprofit  organizations. Some organizations served individuals statewide, while  others served specific geographic areas or populations, such as tribal  communities.
Minnesota’s request for proposals for SSI/DI advocacy services had two  components: one for its general SSI/DI advocacy program and another for  its SSI/SSDI Outreach, Access, and Recovery (SOAR) program.  Minnesota’s SOAR program is based on a national advocacy model that  focuses on homeless individuals or individuals at risk of homelessness  who have a mental illness and/or a co-occurring substance abuse  disorder. Organizations could submit proposals to provide services under  one or both components. Minnesota offered higher payments under the  SOAR program because, according to state officials, the homeless  population requires more intensive services. Specifically, the state  provided a $2,500 payment for approved applications that included a  complete medical summary report—a key component of the SOAR  model.
subsections: section_title: Contractor(s) 55 total:
paragraphs: Disability screening process  Officials at the for-profit contractor we selected—operating under the  SSI/DI advocacy component of the contract—reported that they receive  referrals from county or hospital caseworkers. Officials at the nonprofit  contractor we selected—operating mainly under the SOAR component of  the contract—reported that it receives informal referrals from staff at  homeless shelters or mental health or urgent care clinics. The for-profit  officials also reported having limited access to a state database, which  allows them to verify that a referred individual is a recipient of one of the  eligible state programs. Both organizations conduct initial screenings to  obtain information, such as the individual’s impairments and work history.  The nonprofit organization also gathers information on the individual’s  history of homelessness. If it appears that the individual will meet Social  Security disability criteria, both organizations’ staff reported that they will  meet with the claimant to fill out the application and sign key forms,  including the form required to formally appoint the SSI/DI advocacy staff  as their representative.
Assistance filing a claim  Representatives from both organizations reported filling out available  portions of the application online, such as the DI portion, but they differed  in how they completed the SSI portion of the application, which is not  available online. Representatives from the for-profit organization fill out the  SSI application on behalf of the claimant and either mail or hand-deliver it  to the local SSA field office. Representatives from the nonprofit  organization typically accompany the claimant to the field office to  complete the application and often provide transportation to ensure the  claimant attends the appointment.
Representatives from both organizations said they typically gather  available medical information but refer the claimant to medical providers or  specialists, as needed, if the existing records are insufficient. The  nonprofit organization also has a psychologist on staff to perform  evaluations and psychological testing if existing records are insufficient.
Representation during the disability determination process  Representatives from both organizations work with the claimant to ensure  he or she attends any examinations the DDS schedules and provide the  DDS, upon request, with additional information on the claimant’s  disabilities or functioning. If an initial application is denied, the  representatives will review the case with the claimant and determine  whether to file a reconsideration or, later, an appeal.
Approach to SSI/DI advocacy  Westchester County’s contractor, a national for-profit organization,  performed its SSI/DI advocacy services from its office in another state.  Officials from Westchester County and the organization told us that  providing services by phone can be particularly beneficial for individuals  with severe disabilities.
Approved claims: 136  Contractor(s)
For-profit company  Compensation structure  Payment for each approved claim: $3,000 (adult disability claim) $2,000 (foster care SSI claim) $1,500 (CDR)
Disability screening process  Westchester County’s SSI/DI advocacy contractor reported that it receives  referrals on a monthly basis from the county’s three employment services  contractors. According to county officials, these contractors identify people  receiving GA or TANF who are unable to work for reasons such as a  disability, and provide lists of these people to the SSI/DI advocacy  contractor. The advocacy contractor mails a letter to each referred  individual, introducing their services and inviting them to call a toll-free  number to determine their potential eligibility for Social Security disability  benefits. During this screening, a representative from the organization  gathers information on the individual’s current medical condition, work  history, and educational level. If it appears that the individual will meet  Social Security disability criteria, the representative will fill out the  application and have the claimant sign key forms, including the form  required to formally appoint the SSI/DI advocacy worker as their  representative.
Targeted populations
GA (known as Safety Net  Assistance)
Assistance filing a claim  Officials from the advocacy organization said that representatives fill out  available portions of the disability applications online, such as the DI  application. The representative also fills out the SSI application on behalf  of the claimant and mails it to the appropriate SSA field office.  Representatives gather available medical information, but do not refer  claimants to additional doctors or specialists. Instead, if claimants have a  limited medical history, the representatives will refer them to the county for  treatment or request that their physicians provide treatment notes or an  assessment of their functioning.
Representation during the disability determination process  Representatives work with the claimant to ensure he or she attends any  examinations the DDS schedules and provide the DDS with additional  information on the claimant’s disabilities or functioning, upon request. If an  initial application is denied, the representative will review the case and  schedule a telephone appointment with the claimant to discuss options  and determine whether to file a request for a hearing.
section_title: Appendix III: Comments from the Social Security Administration
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Daniel Bertoni, Director, (202) 512-7215 or bertonid@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Erin Godtland (Assistant  Director), Rachael Chamberlin (Analyst-in-Charge), Julie DeVault, Alison  Grantham, and Michelle Loutoo Wilson made key contributions to this  report. Additional contributors include: James Ashley, James Bennett,  David Chrisinger, Rachel Frisk, Alexander Galuten, Monika Gomez,  Kimberly McGatlin, Daniel Meyer, Matthew Saradjian, Monica Savoy,  Almeta Spencer, Nyree Ryder Tee, Shana Wallace, Margaret Weber, and  Candice Wright.