SSA Disability Benefits: Enhanced Policies and Management Focus Needed to Address Potential Physician-Assisted Fraud
Published: 2014-11-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: SSA relies on medical evidence to determine whether the millions of new claimants each year qualify for disability benefits. This evidence—and those who provide it—have been the subject of intense scrutiny as questions have been raised about the potential for fraud schemes that include falsified medical evaluations. GAO was asked to study physician-assisted fraud in SSA's disability programs.
GAO reviewed (1) how well SSA's policies and procedures are designed and implemented to detect and prevent physician-assisted fraud, and (2) the steps SSA is taking to improve its ability to prevent physician-assisted fraud. GAO reviewed relevant federal laws and regulations, visited 5 of the 54 DDS offices that were selected to obtain geographic and office structure variation, and analyzed DDS data to identify whether federally sanctioned physicians (as of the end of January 2014) may have submitted evidence on behalf of claimants. GAO also interviewed SSA officials, as well as private disability insurers and others knowledgeable about SSA's programs to identify key practices for fraud prevention.
section_title: What GAO Found
paragraphs: The Social Security Administration (SSA) has policies and procedures in place for detecting and preventing fraud with regard to disability benefit claims. However, GAO identified a number of areas that could leave the agency vulnerable to physician-assisted fraud and other fraudulent claims:
SSA relies heavily on front-line staff in the offices of its disability determination services (DDS)—which have responsibility for reviewing medical evidence—to detect and prevent potential fraud. However, staff said it is difficult to detect suspicious patterns across claims, as directed by SSA policy, given the large number of claims and volume of medical information they review. Moreover, DDS offices generally assign claims randomly, so staff said it would only be by chance that they would review evidence from the same physician.
SSA and, in turn, DDS performance measures that focus on prompt processing can create a disincentive for front-line staff to report potential fraud because of the time it requires to develop a fraud referral. Four of the five DDS offices GAO visited count time that staff spend on documenting potential fraud and developing fraud referrals against their processing time. Some staff at these DDS offices said this creates a reluctance to report potential fraud.
The extent of anti-fraud training for staff varied among the five offices GAO visited and was often limited. SSA requires all DDSs to provide training to newly hired staff that includes general information on how to identify potential fraud, but does not require additional training. The five DDS offices GAO visited varied in whether staff received refresher training and its content—such as how to spot suspicious medical evidence from physicians—and staff at all levels said they needed more training on these issues.
SSA has not fully evaluated the risk associated with accepting medical evidence from physicians who are barred from participating in federal health programs. Although information from these physicians is not necessarily fraudulent, it could be associated with questionable disability determinations.
SSA has launched several initiatives to detect and prevent potential fraud, but their success is hampered by a lack of planning, data, and coordination. For instance, SSA is developing computer models that can draw from recent fraud cases to anticipate potentially fraudulent claims going forward. This effort has the potential to address vulnerabilities with existing fraud detection practices by, for example, helping to identify suspicious patterns of medical evidence. However, SSA has not yet articulated a plan for implementation, assigned responsibility for this initiative within the agency, or identified how the agency will obtain key pieces of data to identify physicians who are currently not tracked in existing claims' management systems. Furthermore, SSA is developing other initiatives, such as a centralized fraud prevention unit and analysis to detect patterns in disability appeals cases that could indicate fraud. However, these initiatives are still in the early stages of development and it is not clear how they will be coordinated or work with existing detection activities.
section_title: What GAO Recommends
paragraphs: GAO recommends SSA identify ways to remove potential disincentives for detecting and referring potential fraud, enhance its training efforts, evaluate the threat of physician-assisted fraud, and ensure that new and existing fraud efforts are coordinated. SSA agreed with four of our five recommendations, partially agreed with one, and noted plans to address all of them.

section_title: Letter
paragraphs: The Social Security Administration (SSA) provides cash benefits to  millions of Americans with disabilities who are unable to work, with total  payments estimated to exceed $200 billion in fiscal year 2015. To  determine whether claimants qualify for disability compensation, federal  law requires evidence of a medically determinable impairment, which  SSA obtains from the claimant’s medical providers or by paying for its  own medical evaluations. This medical evidence—and those who either  provide or review it—has been the subject of intense scrutiny as some  alleged fraud schemes have recently been uncovered.
These alleged schemes not only include physicians, but typically consist  of other individuals who are knowledgeable about SSA’s disability   For example, in August 2013, 75  programs and eligibility criteria.individuals in Puerto Rico were arrested and indicted for Social Security  fraud. It is alleged that a former SSA employee serving as a  representative for the claimants colluded with several physicians to  provide documentation of non-existent impairments in return for kickbacks  from claimants who were granted benefits. While the full extent and  nature of physician-assisted fraud is difficult to measure, each fraudulent  claim allowed by SSA has the potential to cost the government several  hundred thousand dollars over the life of the claimant and places an  additional financial burden on these programs at a time when SSA  estimates that its disability trust fund will be depleted and unable to pay  full benefits to individuals starting in 2016.
Given the potential harm that physician-assisted fraud can cause to  SSA’s disability programs, you asked us to study this topic. In this report,  we examine (1) how well SSA’s policies and procedures are designed   and (2)  and implemented to detect and prevent physician-assisted fraud,the steps SSA is taking to improve its ability to prevent physician-assisted  fraud.
GAO, Medicare Fraud Prevention: CMS Has Implemented a Predictive Analytics  System, but Needs to Define Measures to Determine Its Effectiveness. GAO-13-104  (Washington, D.C.: Oct. 15, 2012).
To gain additional perspectives on how SSA policies are implemented  and any challenges to detecting physician-assisted fraud, we conducted  site visits to 5 of the 54 Disability Determinations Services (DDS) offices  in Alabama, California, Illinois, Maryland, and West Virginia. We selected  these sites to obtain variation in regional office and DDS operations (e.g.,  case management systems, office structure, and case processing). Given  the key role that SSA OIG Cooperative Disability Investigations (CDI)  units play in identifying potential fraud, we selected offices in states with  and without a CDI presence. During our site visits, we interviewed DDS  management, medical relations professionals, disability examiners, and  medical consultants. Additionally, we interviewed officials in the  corresponding regional offices, including those who oversee initial and  appeals determinations, as well as CDI unit staff. We conducted  additional interviews with the Michigan DDS which has its own fraud unit  and the NY regional office which oversees two DDSs—New York and  Puerto Rico—where recent instances of fraud allegedly occurred.
Additionally, we conducted in-depth testing of data from two states to  identify whether SSA is following its requirement not to allow certain  sanctioned medical providers to conduct exams on behalf of the agency.  We also sought to identify the extent to which sanctioned doctors may be  providing medical evidence on behalf of claimants. We matched provider  data from two of the states we visited—California and Illinois—with the  Department of Health and Human Services OIG’s List of Excluded  Individuals and Entities. This list identifies federally-sanctioned medical  providers, and SSA regulations prohibit DDSs from using these providers  to conduct exams on behalf of the agency. We selected California and  Illinois because we were able to more readily obtain lists of vendors and  because they use two different case management systems, allowing us to  identify differences in what information is captured by DDSs. We obtained  lists of providers as of February 2014 for California and April 2014 for  Illinois and matched these against a list of providers who were sanctioned  as of the end of January 2014. The results of our data matching are not  generalizable to other states or to the wider population of disability claims.  We conducted electronic testing and interviewed knowledgeable officials  to assess the reliability of these data. We determined that they were  sufficiently reliable for our purposes. See appendix I for a detailed  description of our scope and methodology.
We conducted this performance audit from July 2013 to November 2014  in accordance with generally accepted government auditing standards.  Those 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.
subsections: section_title: Background
subsections: section_title: SSA’s Disability Programs
paragraphs: SSA administers two main programs under the Social Security Act that  provide benefits to individuals with disabilities—Disability Insurance (DI)  and Supplemental Security Income (SSI). Individuals are generally  considered disabled if they are unable to do their previous work, and  considering age, education and work experience, engage in any other  kind of substantial gainful work and their disability has lasted or is   See  expected to last at least 1 year or is expected to result in death.table 1 for additional key features and requirements of the DI and SSI  programs.
SSA’s process for determining medical eligibility for disability benefits is  complex and can involve several state and federal offices. The  determination process—which is the same for both DI and SSI  claimants—involves an initial determination at a DDS office. SSA funds  the 54 DDSs, which are operated by state agencies, to process disability  claims in accordance with SSA policies and procedures. If a claim is  denied, claimants have several opportunities for appeal within SSA,  starting with a reconsideration at the state level; then a hearing before an  administrative law judge (ALJ); and finally at the Appeals Council, which  is SSA’s final administrative appeals level. Claimants can generally  submit new medical evidence throughout the disability determination  process. Claimants must file any further action in federal court. Claims at  all levels for which the claimant is determined to be eligible for DI or SSI,  also called favorable claims, are forwarded to other SSA offices for  payment. (See fig. 1.)
section_title: Development of Medical Evidence
paragraphs: Generally, DDSs are required to develop a complete medical history for  each claimant for at least a 12-month period prior to the application. SSA  guidance directs DDSs to request medical evidence records from all  providers who treated or evaluated the individual for the alleged or  documented impairment during this time period. For example, a DDS may  request laboratory reports; X-rays; doctor’s notes; and other information  used in assessing the claimant’s health and functioning from many types  of providers, including physicians or psychologists, hospitals, or  community health centers. According to SSA, DDSs generally pay  providers for these records in accordance with required state fee  schedules.
In claims where the evidence gathered is insufficient to make a  determination or where no evidence is present, the DDS may order its  own tests or evaluations—called consultative examinations—from  medical providers. SSA regulations specify the types of providers who  can perform consultative exams and require DDSs to recruit, train, and  oversee these providers in their states. State DDSs pay providers to  conduct exams and set the rates of payments for these exams. SSA’s  regulations prohibit DDSs from purchasing consultative exams from  medical providers who are excluded, suspended, or otherwise barred  from participation in the Medicare or Medicaid programs, or any other  federal or federally-assisted program, which includes providers on the List  of Excluded Individuals and Entities maintained by the Department of  Health and Human Services (HHS) Office of Inspector General (OIG).  SSA regulations also prohibit the agency from purchasing exams from  certain providers whose license to practice has been revoked by any  state licensing authority. HHS is legally required to exclude from  participating in federal health care programs individuals and entities  convicted of certain criminal offenses, such as defrauding Medicare,  Medicaid, or other federal or state health programs; patient abuse or  neglect; and felony convictions related to controlled substances. This  function is performed by the HHS OIG. The OIG also has discretion to  exclude individuals and entities based on a number of other grounds—  SSA instructs DDSs  both related and unrelated to programmatic fraud.to review the HHS list and verify medical licenses and credentials before  using the services of any consultative exam provider. DDSs are also  required to review the list for each existing exam provider at least  annually. DDSs are not required to check the status of the claimant’s  treating physician or other medical providers that submit evidence since  they are obtaining existing medical records and not paying for medical  services.
section_title: Fraud Identification and Referral Process
paragraphs: SSA has guidance on how examiners should document and report  suspected fraud. According to SSA’s policy, fraud generally occurs when  an individual makes or causes to be made false statements of material  facts or conceals such facts for use in determining rights to benefits, with  the intent to defraud. SSA employees should gather enough information  to either remove suspicion or determine that there is potential fraud. They  are also expected to develop the referral with as much information as  possible, including who allegedly committed fraud, how, when, and why. If  they determine that potential fraud exists, they should refer it to the SSA  OIG. For states with a CDI unit, cases can be referred directly to the CDI.  SSA and the OIG jointly established the CDI Program, in conjunction with  DDSs and state or local law enforcement agencies, to effectively pool  resources and expertise and prevent fraud in SSA’s disability programs.  The Units investigate disability claims under DI and SSI programs that  state disability examiners believe are suspicious.
Referral processes can vary by DDS. For example, some DDSs may  require management approval before referring a case to the SSA OIG.  Once a case is referred to the SSA OIG, that office determines whether it  will investigate the case.with other federal, state, and local agencies. See figure 2 for an overview  of SSA’s fraud referral process.
section_title: Despite Anti-Fraud Policies and Procedures, SSA Remains Vulnerable to Potential Physician-Assisted Fraud
subsections: section_title: Staff Reported Difficulty Identifying Potential Fraud and Lack Sufficient Incentives and Training
paragraphs: SSA relies heavily on front-line staff in DDS offices—those who are  responsible for reviewing medical evidence—to detect and prevent   The employees in the five DDS  potential physician-assisted fraud.offices we visited, however, said that they are not well-positioned to  identify signs of potential fraud, such as similar medical evidence across  multiple claims. Further, the performance measures used by the agency  and the DDSs may serve as a disincentive for front-line staff to spend  additional time documenting and reporting fraud allegations, and limited  training also reduces front-line staff’s ability to identify such fraud.
subsections: section_title: Identifying Patterns of Potential Fraud
paragraphs: Although SSA relies on front-line staff as their first line of defense to  detect potential fraud, it can be difficult for them to identify potential fraud  in claims. Instead of systematically using data systems or analytics to  detect patterns of potential fraud, SSA’s guidance instructs front-line staff  to identify suspicious patterns of medical evidence—such as boilerplate  or similar language from the same physician across multiple claims—as  well as other factors that may indicate potential fraud. However, SSA  regional officials, DDS management, and front-line staff said that it is  difficult to detect these patterns because staff may review claims  originating anywhere in the state or across a large geographic area,  leaving it in part to chance that staff would see evidence from a single  physician on more than one claim. As a result, DDS staff stated that they  must rely on coincidence—such as the receipt of consecutive claims with  evidence from the same physician—to be able to identify a suspicious  pattern. Additionally, single applications are generally seen by multiple  staff in the course of development and determinations. DDS and SSA  regional officials stated that, irrespective of how claims are distributed  amongst staff, the volume of claims and associated medical evidence  they review makes it difficult to detect patterns of potential fraud. Front- line staff are expected to review multiple claims every day, each of which  may be supported by medical evidence from multiple physicians. One  DDS director stated that the sheer number of physicians who submit  medical evidence make it challenging to identify suspicious patterns from  any one physician.
section_title: Possible Disincentives to Identify and Report Potential Fraud
paragraphs: SSA and DDS performance measures incentivize processing claims  quickly and may pose a barrier to front-line staff’s willingness to develop  referrals and report potential fraud. SSA assesses DDS performance, in  part, based on the length of time it takes to process claims. In turn, all  five DDSs we visited assess front-line staff on the speed by which they  process claims. According to SSA, disability applicants file at vulnerable  times in their lives and the agency and DDS offices focus on making  timely and fully considered objective decisions on applications and  develop performance measures in support of this objective. Our previous  work has found that there are positive aspects of aligning individual  performance expectations with organizational goals.noted the importance of balancing quality and timeliness goals, with the   We have also  potential for unintended perverse incentives.suspected, SSA policy states that staff should develop evidence to  support their suspicions and prepare referral forms that explain the basis  for their concern. During our site visits, some front-line staff stated that  they do not report suspicious physicians or potential fraud because  developing the evidence to report the allegation adversely affects their  ability to process claims promptly. Only one DDS we visited lessened the  potential disincentives to reporting suspected fraud by not counting the  time spent developing allegations of fraud against the employees’ claims  processing time. This DDS also provided recognition to staff when their  fraud allegation resulted in conviction or a denial of benefits. Front-line  staff we met with at this DDS stated that this recognition incentivized  them to be more vigilant about identifying and reporting suspicious  claims.
SSA’s focus on timeliness may also create a disincentive for front-line  staff to report sources of questionable information in claims that they have  denied. SSA guidance directs DDS staff to report all suspicious claims,  even if the claim is denied. However, staff in three of the five DDSs we  visited said they may not always report potentially fraudulent information  to the OIG if there is already sufficient evidence to make a denial because  of the additional time required to process the fraud referral. One DDS  director stated that denied claims are typically not reported to the OIG  because an investigation would be redundant and wasteful considering  that it would produce the same result—a denied claim. Nevertheless,  there is merit in reporting these denied claims with suspicious evidence  because they could either be appealed or the claimant could reapply at a  later date and there may not be any indication to the subsequent reviewer  that suspicious evidence exists. Moreover, without these referrals of  suspicious claims, SSA is missing key information that could help them  identify patterns of potential physician-assisted fraud.
DDS staff in some of the offices we visited also told us that they were  reluctant to report potential fraud because of a perceived lack of  communication from the OIG regarding the status or outcome of their  fraud referrals. According to the OIG, the office communicates the status  of investigations to DDS management approximately 1 month after the  fraud referral is received. However, staff in four of the five DDSs we  visited stated that the communication they receive from the OIG is  inadequate. For example, some staff reported that when cases were  denied for investigation, the OIG did not sufficiently explain the reason for  the denial. In some instances, staff never received a response about the  status of their referral. Some front-line staff we spoke to said that they  would report more cases of potential fraud if they received better  feedback on the outcome of their referrals.
section_title: Lack of Training on How to Identify or Report Potential Fraud
paragraphs: Staff from four of the five DDSs we visited stated that the anti-fraud  training they received was infrequent, insufficient, and that additional  training was needed. As part of their new employee training, front-line  staff receive a short segment of anti-fraud instruction. This training  defines fraud and provides an overview of SSA’s anti-fraud policies and  procedures. However, subsequent anti-fraud training is not mandatory  and varies by state. Federal internal control standards state that  management needs to identify appropriate knowledge and skills needed  for various jobs, such as identifying and preventing potential fraud, and  provide appropriate training. SSA does not require DDS employees to  receive training on fraud identification or reporting beyond their initial  training courses and SSA officials stated that DDSs are primarily  responsible for determining the training needs of their staff. We found that  additional anti-fraud training at the five DDSs we visited often occurred  infrequently or not at all. Without additional training, front-line staff may  not have the skills and knowledge to identify and report potential fraud.  For example, front-line staff at one DDS had not received any anti-fraud  training since their initial basic training and stated that they did not know  how to identify or report potential fraud. At another DDS, some staff  indicated they had not received training in several years.
Data we reviewed suggests that DDSs in states with CDI units are likely  to receive more training on how to identify and report potential fraud,  contributing to more referrals from these DDSs. According to OIG data,  28 of the 32 states and territories without a CDI unit did not refer any  suspicious claims to the OIG in 2013 compared to an average of 216  referrals from DDSs in states with a CDI unit, including the  Commonwealth of Puerto Rico (see fig. 3 for CDI unit and fraud referral  information). Front-line staff in the two states we visited with CDI units— California and Illinois—also noted the benefits of additional anti-fraud  training, including a better understanding of the fraud referral process.  Further, Illinois officials said that the number of suspicious claims referred  by staff increased after receiving training from the CDI unit. Nonetheless,  DDS staff in both states said that training was not provided regularly and  that they would like to receive additional training that includes examples  of fraud investigations—such as cases in which medical providers and  others may have colluded to help claimants obtain benefits—and  strategies to prevent similar events from occurring in the future. OIG  officials stated that they are reluctant to provide additional training to  states without established CDI units because they do not have the  resources to investigate the expected increase in fraud referrals from  those states.
section_title: SSA Policies and Procedures Allow Some Sanctioned Physicians to Provide Medical Evidence
paragraphs: Potential vulnerabilities exist in how DDSs screen and use medical  evidence from sanctioned physicians. SSA regulations prohibit DDSs  from purchasing consultative exams from medical providers who are  currently barred from participation in federal or federally-assisted  programs. To comply with these regulations, SSA instructs DDSs to  screen medical providers who conduct consultative exams against a list  of sanctioned providers maintained by the Department of Health and  Human Services Office of Inspector General. Regarding medical  records, federal law generally requires SSA to review all available  evidence and make every reasonable effort to obtain medical evidence  from the claimant’s treating physician and other treating health care  providers. However, under the Social Security Act, the agency is  required to disregard any evidence reviewed when there is reason to  believe that fraud or “similar fault” is involved with the determination.  The agency is also required to exclude from participation in SSA  programs, representatives and health care providers convicted of  violations of specific criminal offenses related to SSA programs. Such  offenses include making false statements related to DI or SSI  applications. SSA regulations set forth factors for how medical evidence  should be considered and weighted by DDS staff when making a   DDSs that we visited do not, however, screen  disability determination.physicians who submit medical evidence on behalf of a claimant against  the sanctioned list and therefore front-line staff do not know whether the  medical evidence they are basing their disability determination on came  from a sanctioned physician. While being on the sanctioned list does not  mean that a physician submitted fraudulent evidence to SSA, it could be  an indicator that the claim includes questionable evidence.
After matching vendor files from California and Illinois against the  sanctioned list, we found that neither state purchased consultative exams  from sanctioned physicians since 2010. In the same time period,  however, at least 37 sanctioned physicians in these states provided  medical evidence to the agency on behalf of claimants and 22 of these  physicians provided such evidence after they had been sanctioned,  potentially affecting the validity of those claims (see table 2). Our results  demonstrate that, in some instances, SSA is accepting medical evidence  from potentially questionable and unreliable physicians. We identified  sanctioned physicians who were convicted of health care fraud or other  program-related crimes who submitted medical evidence on behalf of  claimants. For example, one physician, who was placed on the  sanctioned list in 2011 for smuggling over $1 million in foreign  misbranded and unapproved drugs into the United States and  administering them to his patients, submitted evidence for at least 33  disability claimants in the past 2 years. Such information could be useful  to front-line workers in that they would be able to better determine  whether more scrutiny of the medical evidence may be warranted,  potentially resulting in a reduced risk of fraud. Further, front-line staff said  it would be helpful to have a list of suspicious physicians available when  reviewing claims. One DDS created such a list that includes physicians  who DDS staff identified as providing suspect evidence—such as a  pattern of exaggerated medical findings—in the past. However, frontline  staff who we spoke with said they were unaware of this list.
SSA faces barriers to identifying and addressing the potential risks  associated with medical evidence submitted by sanctioned physicians.  According to SSA officials, the agency has explored whether it would be  beneficial to consider physicians’ licensing status when making a  disability determination. The agency identified several logistical barriers to  checking licensure status for all physicians who submit medical evidence,  and also cited complex policy implications that they believe could result in  increased appeals and potentially disadvantage claimants, among other  challenges. For example, SSA would have to determine when and what  evidence from a physician to exclude and the type of sanctions to  consider, among other things. The SSA OIG also reported in 2013 on  hurdles regarding screening evidence against the sanctioned list.According to SSA’s OIG, SSA and the DDSs request more than 15 million  health records from over 500,000 physicians every year. Further, the SSA  OIG also reported that because the sanctioned list generally contains the  names of individual physicians, a sanctioned physician who provides  medical evidence on behalf of a claimant may not be detected by the  DDS if they work for a hospital or clinic. We found similar limitations with  the data that DDSs currently collect. For instance, SSA does not require  DDSs to routinely and uniformly record the names and addresses of  physicians who submit medical evidence on behalf of claimants. As a  result, DDSs collect inconsistent and incomplete data on medical  providers, which limits SSA’s ability to identify sanctioned physicians. For  example, hospitals or similar institutions that employ hundreds of  individuals may have only one source recorded in DDS vendor files.
Despite these barriers, as SSA moves forward on key information  technology initiatives, the agency has an opportunity to assess several  risk factors, including whether sanctioned physicians are providing  medical evidence, and the likelihood that such evidence could be  fraudulent. Federal internal control standards state that agencies should  identify and analyze the relevant risks from external sources, such as  potentially questionable evidence from sanctioned physicians. the process of transferring state vendor information from 54 distinct DDS  data systems into a National Vendor File that will include information on  all medical providers whom the agency pays for medical evidence. Such  a consolidation may present an opportunity for the agency to better  assess the threat of sanctioned physicians submitting medical evidence  on behalf of claimants and reduce the administrative cost of identifying  such physicians on a DDS by DDS basis. Having national-level data  could help SSA better determine risk factors for potential fraud as well as  what medical evidence should be subject to additional scrutiny.  Additionally, consolidating vendor data gives the agency an opportunity to  gain a better understanding of the inconsistencies in the information  collected at the DDS level and determine whether it should implement  more uniform data collection and policy requirements.
GAO/AIMD-00-21.3.1.
section_title: SSA Has Launched Several Initiatives to Better Detect Fraud but Faces a Number of Implementation Challenges
subsections: section_title: SSA Is Developing a Fraud Analytics Model, but Lacks an Implementation Plan
paragraphs: Recognizing that it must do more to systematically detect potential fraud,  SSA is in the early stages of exploring the use of computerized tools to  enhance its efforts. Known as predictive analytics, these are automated  systems and tools that can help identify patterns of potentially fraudulent  claims—such as patterns of suspicious behavior involving physicians and  claimants—before claims are paid. A system such as this would give SSA  the ability to systematically check large numbers of claims for potential  fraud in addition to using front-line staff to spot suspicious patterns in  claims. Staff from SSA’s Office of Information Security began this  analytics effort in February 2014 and piloted these capabilities in two  stages. In the first stage, SSA developed its initial computer model and  identified existing sources of data within the agency. SSA tested and  refined its model by using recent cases of alleged fraud in Puerto Rico,  New York, and West Virginia to determine whether it would have detected  characteristics of potential fraud in those cases. SSA reported that it  completed this stage in May 2014 and that its efforts were successful. In  the second stage, SSA will explore purchasing a tool from a vendor and  using analytics to spot suspicious claims in other locations. SSA will also  explore purchasing data—such as arrest records—from an external  vendor to integrate into its system that could help SSA to identify links  between disability claims, physicians, and attorney representatives  through social network analysis that may not be apparent from existing  SSA data. For example, SSA staff said these data could identify  individuals who are seemingly unconnected but who shared an address in  the past. External data also proved to be helpful in the recent case of  suspected fraud in New York, where investigators made use of local  government data to determine that beneficiaries made false statements  when applying for benefits. SSA told us that while it completed its second  phase of testing, which consisted of a preliminary risk-scoring model for  disability claims, significant work remains to be done before it has a  working analytics system in place. See figure 4 for an illustration of how a  predictive model would differ from SSA’s current approach.
SSA’s analytics efforts have potential, but we have concerns regarding  the agency’s ability and capacity to implement such a system on a large  scale going forward. For example, SSA does not consistently collect  some data that may aid in its analytics effort. As part of its analytics  efforts, SSA plans to look for relationships between physicians who  provide medical evidence and potentially fraudulent claims. However, as  we noted earlier, SSA and DDS officials told us that existing data systems  often do not identify individual physicians. Instead, the systems may  capture the hospital or clinic that provided medical records, or in some  cases, a third-party company that manages medical records or payments  on behalf of physicians. An SSA official working on analysis efforts noted  that SSA currently lacks the ability to distinguish between individual  physicians and clinics or hospitals. Without the ability to consistently  identify individual physicians, SSA’s ability to detect potential physician- assisted fraud may be hampered. SSA must also contend with obtaining  physician data from a number of case management systems. For  example, the agency is in the process of transitioning DDSs from five  different legacy case management systems to a unified Disability Case  Processing System that will be used by all DDSs. SSA officials stated  that the National Vendor File that will be linked to this system has the  ability to capture individual physician license numbers. This vendor file  currently only collects the same information as the DDS’s existing legacy  systems, which may or may not include this information because SSA  does not require DDSs to collect unique identifiers for physicians. Further,  while SSA is also pursuing external data sources to perform social  network analysis, its ability to fully make use of this information could be  limited by its inability to readily identify the physicians involved in disability  claims.
Alleged Puerto Rico Disability Fraud  Scheme  In August 2013, 75 individuals in Puerto Rico  were indicted for disability fraud. This included  a claimant representative (and former Social  Security employee), three physicians, and 71  claimants. The representative allegedly  conspired with three doctors to fabricate and  submit false medical evidence to support  unwarranted disability claims for his clients.  According to the Department of Justice (DOJ),  these physicians received kickbacks of  between $150 and $500 to submit false  medical evidence to SSA, and the  representative received a lump-sum payment.  Although the investigation continues, 34 of the  75 individuals charged have pled guilty as of  March 2014.
Moreover, SSA has yet to detail how it will first operationalize any  analytics efforts into its ongoing business practices and then investigate  potential leads generated. Officials we spoke with at the Centers for  Medicare & Medicaid Services (CMS)—who implemented their own fraud  analytics program in 2011—and several private disability insurers told us  that analytics are helpful for determining which claims are at risk for  potential fraud and where to focus investigative resources. However, they  noted that organizations cannot rely on analytics alone to determine  whether fraud is occurring and that considerable staff resources are often  needed to develop leads that result from the initial analysis. For instance,  officials at one private disability insurer said that analysts may spend half  a day examining a claim before deciding whether additional investigation  is warranted. This sentiment was shared by participants at a 2013 GAO  forum on data analytics who noted that having knowledgeable staff was  critical for interpreting the results of analytics and identifying investigative  leads.challenges facing SSA, including declining staff levels at DDSs and   However, we and the SSA OIG have previously reported on  difficulty in meeting SSA performance goals. We also recommended  that SSA develop a long-term plan to address service delivery challenges,  including those related to human capital and information technology  initiatives. The agency has noted the benefit of using data analytics to  prevent fraud and has mentioned data analytics in its Strategic Plan, 2015  budget request, and Information Resource Management Strategic Plan.  However, these agency documents do not provide concrete steps or  identify the needed resources to make this undertaking successful.  Additionally, staff working on the analytics pilot told us that SSA has yet to  determine which component of SSA will ultimately have responsibility for  following up on leads. One analytics firm cautioned that analytics cannot  just be a software tool, but must fit into a larger cultural change regarding  fraud and how business is conducted. It added that an organization that  jumps into analytics without a clear plan and goals risks failure.
Alleged West Virginia Disability Fraud  Scheme  SSA is investigating claims stemming from  West Virginia. According to a staff report from  the Senate Committee on Homeland Security  and Government Affairs, an attorney  conspired with an SSA administrative law  judge (ALJ) to allow disability benefits for  undeserving claimants. As part of this alleged  scheme, the ALJ’s office would schedule  exams with doctors favored by the attorney.  The attorney is said to have provided pre-filled  medical forms to these doctors, which often  contained similar language. The ALJ was  placed on administrative leave and later  retired, and the attorney continues to practice  disability law.
Additionally, without more details on its plans, it is unclear whether SSA  can adhere to key practices that organizations must use to successfully  implement fraud analytics. We identified these practices in past work and  by interviewing other organizations that have implemented analytics (see  table 3). In its early efforts, SSA has so far followed some key practices.  For example, SSA has publicized its efforts, including announcing its  plans during a congressional hearing. SSA has also consulted with other  organizations, such as CMS, which already have analytics in place.  Agency officials identified other steps they have taken that align with  these key practices, but when we requested additional details on how it  will carry out these efforts, SSA did not yet have any concrete plans.
section_title: The Effectiveness of Recent Fraud Detection Initiatives Could Be Hindered by SSA’s Management Approach
paragraphs: In addition to predictive analytics, other SSA components are  implementing several efforts that may have the potential to detect and  prevent potential physician-assisted fraud.
SSA OIG Disability Fraud Pilot: The SSA OIG is piloting an effort to  augment its CDI units and target organized fraud schemes, such as  those that allegedly occurred in New York and Puerto Rico. OIG  officials told us that this effort will differ from existing CDI efforts,  which generally investigate potential fraud before SSA makes a  disability determination and are focused on claimants. The fraud pilot  will instead focus on third-party facilitators—including physicians and  attorneys—and their involvement in systematic efforts to defraud  SSA’s disability programs. OIG officials noted that the pilot  incorporates new performance measures that allow for prolonged  investigations as opposed to the quicker investigations normally  conducted by CDI units. The OIG began the pilot in the summer of  2013 in four locations and will consider expanding the effort in fiscal  year 2015 after evaluating the success of the pilot and the effect it has  had on SSA disability programs.
Disability Fraud Prevention Units: SSA established a centralized  fraud prevention unit based in New York City to identify instances of  potential fraud and look for trends nationwide. Initially, this unit will  utilize 20 disability examiners with experience in investigating claims  associated with the New York City and Puerto Rico fraud cases. SSA  recently established additional units in Kansas City and San  Francisco. SSA expects that these units will provide ongoing  investigative support to the OIG as well as analytical and  programmatic support to federal and local prosecutors pursuing cases  of potential fraud.
Office of Disability Adjudication Review (ODAR) data analysis  efforts: ODAR—which is responsible for overseeing the claims  appeals process—has an ongoing effort analyzing data from claims  decided at the appeals level. ODAR officials told us that this effort was  intended to provide better oversight of administrative law judges, as  well as to identify errors in decisions to be better able to target training  resources. ODAR is also using these data to look for irregularities— such as repeated instances of similar language from a physician—and  identify potential fraud, referring those cases to the OIG. Additionally,  ODAR is working with the OIG disability fraud pilot to provide data in  support of their efforts.
Although SSA officials indicated that several of these efforts will be under  the purview of the recently reinstituted National Anti-Fraud Committee,  the agency lacks detailed plans describing how these various efforts will  be implemented or how they will relate to each other. In prior work, we  have reported that clearly delineating activities and timelines, and defining  problems and goals, are key elements of sound planning. Specifically,  agencies should identify activities needed to complete projects and be  able to describe how these activities are related to each other. However,  SSA has yet to articulate how these efforts will relate to each other. For  example, while the fraud analytics pilot, the OIG disability fraud pilot, the  disability fraud prevention units, and ODAR’s efforts all involve some  analysis of disability claims data, SSA’s plans do not address how these  efforts will support each other or how it will avoid duplication across  efforts. Additionally, SSA was unable to provide us with detailed  information regarding the development of these initiatives or describe how  they differed from each other.
Competing priorities may compromise SSA’s ability to follow through on  plans to enhance fraud detection and maintain this focus. As stated  earlier, SSA has not sufficiently balanced the need to quickly process  claims and pay benefits with the need to ensure program integrity.  Moreover, SSA officials told us that the role of the agency and DDSs is to  help claimants navigate a complex application process and that searching  out fraud—while a concern—does not align with SSA’s core mission. In  addition, employees at two of the DDSs we visited told us that SSA only  began to emphasize the need to look for potential fraud after the  announcement of alleged schemes; and they were concerned about the  agency’s ability to maintain a sustained focus in this area. One DDS  director added that SSA needs to build fraud detection into its regular  business operations in order to sustain it. The director added that SSA  currently budgets only enough resources to its DDSs to maintain their  current business practices.
section_title: Conclusions
paragraphs: While the full extent and nature of physician-assisted fraud is difficult to  measure, any occurrence has the potential to undermine confidence in  SSA’s ability to award benefits only to deserving individuals. The agency  relies on front-line workers, including those who collect and assess  claimants’ medical records at DDS offices, to be the first line of defense  against potential fraud. They are also expected to make timely and  accurate disability determinations. In some instances, the agency’s focus  on making determinations quickly has been a disincentive to reporting  suspicious physicians or potential fraud. Unless SSA and the DDSs work  to remedy performance measures that primarily focus on and reward  timeliness, possibly at the expense of delving into potentially problematic  claims, the agency will remain vulnerable to potential fraud. Further,  absent enhanced and consistent training, front-line staff may lack the  expertise to identify and report potential fraud.
SSA has some controls in place to help ensure that sanctioned  physicians do not perform exams on behalf of the agency. However, the  agency could be exposing itself to risk by using medical evidence from  physicians who are sanctioned by either federal or state governments.  While there are numerous reasons a physician can be sanctioned,  without knowing whether such physicians have provided medical  evidence and why they were sanctioned, SSA could be missing  information needed to identify and flag for additional scrutiny potentially  falsified medical evidence.
Lastly, as the agency begins to shift its focus to better detection and  prevention of potential fraud through analytics, it will be important to  balance these new efforts with the existing workload demands on front- line staff. Furthermore, even though substantial resources and  collaboration will be needed to fully implement a successful analytics  system and follow up on resulting leads, SSA has not systematically  identified the data and actions needed to implement and make them  successful. Given the lack of details that the agency was able to provide  on its plans, we have concerns about their potential success. Absent a  coordinated and cohesive effort, SSA could undermine the success of its  new initiatives and remain vulnerable to physician-assisted fraud in the  future.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Commissioner of the Social Security  Administration take the following actions to improve the ability of the  agency to detect and prevent potential physician-assisted fraud:  1.  To address potential disincentives for staff to detect and prevent  physician-assisted fraud, SSA should review the standards used to  assess DDS performance; and develop and distribute promising  practices to incentivize staff to better balance the goal of processing  claims promptly with the equally important goal of identifying and  reporting evidence of potential fraud.  2.  To ensure that the agency captures complete information on  suspicious claims, SSA should issue guidance to remind DDSs of its  existing policy to report all claims with potentially fraudulent medical  evidence to the SSA OIG, even if sufficient evidence exists to deny a  claim.  3.  To help front-line staff identify potentially fraudulent activity, SSA  should enhance its training efforts by ensuring it provides fraud- related refresher training to all DDS employees on a regular basis.  Such training should include the identification of suspicious medical  evidence and providers, as well as the processes and procedures for  reporting such information. To facilitate its efforts, the agency could  coordinate with the SSA OIG and draw on the type of training  provided by CDI units.  4.  To address the potential risks associated with medical evidence  submitted by sanctioned physicians, SSA should evaluate the threat  posed by this information and, if warranted, consider changes to its  policies and procedures.  5.  To help ensure new initiatives that use analytics to identify potential  fraud schemes are successful, SSA should develop an  implementation plan that identifies both short- and long-term actions,  including: data requirements, e.g., the collection of unique medical provider  timeframes for implementation;  resources and staffing needs; how technology improvement will be integrated into existing  technology improvements such as the Disability Case Processing  System and National Vendor File; and how different initiatives will interact and support each other.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this product to the Social Security Administration  for comment. In its written comments, reproduced in appendix II, SSA    agreed with 4 of our 5 recommendations and partially agreed with one of  them. SSA partially agreed with our recommendation to review its  standards used to assess DDS performance; and develop and distribute  promising practices to incentivize staff to better balance the goal of  processing claims promptly with the equally important goal of identifying  and reporting evidence of potential fraud. SSA did not specify why it did  not agree fully, but did outline the critical role that field and DDS office  staff play in identifying and detecting potential fraud. In our report, we  acknowledge that these employees are the first line of defense against  fraud. We also noted that based on our interviews, and review of agency  and DDS performance standards, that there is a potential disincentive to  report suspicious claims. If properly designed and managed, performance  standards that include identifying and reporting suspicious claims could  provide incentives to encourage staff to devote more time to program  integrity issues while maintaining their ability to process claims in a timely  manner. Such standards would also further demonstrate to DDS staff  SSA management’s commitment to preventing potential physician- assisted fraud in its disability programs.
SSA agreed with the remainder of our recommendations and provided  additional information about the actions it has taken in the past year to  enhance its fraud detection and prevention efforts and steps they will take  going forward.
SSA also provided technical comments on our report, which we  incorporated as appropriate. In these comments, the agency noted that  our report implies that fraud schemes are more commonplace than they  actually are. Our report states that the full extent and nature of physician- assisted fraud is difficult to measure and that even one instance of this  type of fraud could result in a large number of beneficiaries improperly  receiving benefits, as well as substantial costs to the government. SSA  also commented that our report overemphasized the potential utility of the  List of Excluded Individuals and Entities for identifying potential physician- assisted fraud. In our report, we noted key limitations and challenges to  using this list. Nonetheless, we maintain that some physicians—an  important component of the disability determination process—have been  at least suspected of fraudulent activities by others and this is important  information for SSA to consider. We believe SSA can improve staffs’  ability to identify cases that deserve closer scrutiny by more fully  assessing the potential threat posed by sanctioned physicians. Such an  assessment would also help the agency identify actions that DDS offices  could take to better track and screen for evidence from these providers. In  the long-term it could also assist with the agency’s new fraud analytics  efforts.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Commissioner of  Social Security and other interested parties. In addition, the report will be  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 III.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: In conducting our review of potential physician-assisted fraud in the  Social Security Administration’s (SSA) disability programs, our objectives  were to examine (1) SSA’s policies and procedures for detecting and  deterring physician assisted fraud, and (2) the steps SSA is taking to  improve its ability to detect physician-assisted fraud. We reviewed  relevant federal laws and regulations, as well as SSA program  documentation including policies, procedures, training manuals, and  performance plans, as well as reports and testimonies from SSA and the  Office of the Inspector General (OIG) on fraud detection and prevention  efforts. We evaluated SSA’s efforts against its own policies and  procedures, federal internal control standards, and other key fraud  analytics practices to detect and prevent potential fraud. We also  interviewed key officials in SSA and conducted site visits to five states  where we interviewed Disability Determination Services (DDS) and SSA  regional office staff. Additionally, we interviewed organizations that  represent DDS management and front-line SSA employees, in addition to  meeting with private disability insurers and other organizations involved in  preventing fraud. We compared the medical provider vendor lists in two  states to a list of federally sanctioned doctors.
subsections: section_title: Interviews and Site Visits
paragraphs: To understand SSA’s policies and efforts to improve fraud detection, we  interviewed officials in a number of SSA components. These included:
The Office of the Deputy Commissioner, Operations, which is  responsible for overseeing the initial disability determination process  and state DDS offices;
The Office of Disability Adjudication and Review (ODAR), which is  responsible for overseeing the disability appeals process;
The Office of the Chief Strategic Officer;
The Office of Information Security; and
The Office of the Inspector General (OIG).
To gain additional perspectives on how SSA policies are implemented  and challenges regarding detecting physician-assisted fraud, we  conducted site visits to a non-generalizable sample of five states. We  chose these states in order to provide diversity in terms of their  geographic location, whether the state had a single or multiple DDS  locations, the presence of an OIG Cooperative Disability Investigations  (CDI) unit, and the data system used by a state. During our site visits, we  interviewed DDS management, medical relations professionals, disability  examiners and supervisors, and medical consultants. When possible, we  randomly selected examiners and consultants, who worked with the DDS  for at least 1 year, to interview based on rosters provided by DDS  management. In three of the states, we met with examiners individually.  In the other two states, we met with examiners in a group setting because  of challenges with scheduling individual interviews. In addition to  providing information on SSA’s policies and procedures, DDS officials  and staff provided insights on SSA’s newer fraud detection initiatives.  Additionally, we spoke with regional SSA officials in each of the regions  that correspond with our site selection. We also spoke with OIG CDI staff  in each location where they were present. The information we obtained at  our site visits is illustrative and not intended to reflect the experiences of  DDSs in other states. See table 4 for key characteristics of our site visit  locations.
We also interviewed officials from SSA’s New York regional office to  better understand how recent alleged fraud cases in New York and  Puerto Rico—both within that SSA region—were uncovered, as well as  changes made in response to these incidents. In addition, we interviewed  officials at the Michigan DDS because it has a dedicated fraud unit.
To supplement our site visits, we interviewed national organizations that  represent DDS examiners, managers, and Administrative Law Judges,  including:
Association of Administrative Law Judges
National Council of Social Security Management Associations
National Association of Disability Examiners
National Council of Disability Determination Directors  To provide additional context, we interviewed a number of other federal  agencies, private insurers, and other organizations that are familiar with  the disability determination process, detecting fraud, or with implementing  predictive analytics. These organizations included:
American Academy of Disability Evaluating Physicians (a professional  organization serving physicians involved in disability management and  evaluations)
Coalition Against Insurance Fraud (an anti-fraud alliance that includes  public and private insurers)
Centers for Medicare and Medicaid Services
Department of Health and Human Services, Office of Inspector
Elder Research Inc. (a consulting company focused on predictive  analytics and data mining)
The Recovery Accountability and Transparency Board
Unum (a private insurer that uses predictive analytics to identify  potential fraud)
section_title: Analysis of Medical Provider Data
paragraphs: We conducted data matching using information from California and Illinois  to help determine the extent to which sanctioned medical providers  submitted evidence in disability decisions. We attempted to find providers  who appeared in both of these two data sources:  1.  The List of Excluded Individuals and Entities (LEIE): The list is  maintained by the Department of Health and Human Services OIG,  and lists individuals who are excluded from federal health care  programs for a number of reasons, including health care fraud.  2.  State Vendor Files: Vendor files are maintained by each DDS and list  medical providers who were reimbursed for providing medical  evidence in support of disability claims. These vendors include  claimants’ treating physicians who are reimbursed for providing copies  of medical records, and consultative exam providers, who conduct  medical exams for the DDS under contract, among others.
We conducted matching between each state vendor file and the LEIE on  the basis of tax identification numbers—Social Security Numbers or  Employee Identification Numbers. In instances when we found a match  between both sources, we gave the DDSs (through SSA) summary  information on the providers and obtained information on when they last  submitted evidence or conducted exams in support of claims. The Illinois  DDS provided us with additional information on our matches in June 2014  and the California DDS in August 2014. Providers can be sanctioned for a  number of reasons not related to health care fraud; therefore, the results  of our matching do not indicate that fraud occurred in either federal health  care or disability programs. Additionally, the results of our data matching  are not generalizable to other states or to the wider population of disability  claims.
There were several limitations in both the state vendor files and the HHS  LEIE that could have affected the results of our matching, including:
DDS vendor data did not include all physicians who submitted medical  evidence on behalf of claimants or individual physicians who  performed consultative examinations on behalf of SSA. Since these  files are used for payment purposes, DDSs only maintain tax  identification numbers for vendors (e.g., physicians, clinics, or third- parties managing records on behalf of physicians) who they pay for  records or services; not necessarily the individual physicians who see  claimants.
According to the HHS OIG, the LEIE may not reflect all sanctioned  medical providers, given limitations on OIG’s authorities, appeals of  exclusions, and occasional delays in referrals to the OIG. The SSA  OIG also noted that sanctioned physicians may move on and off the  list depending on the outcome of appeals and reinstatements.  Therefore, a doctor providing medical evidence to SSA on behalf of a  disability claimant may be on the exclusions list one quarter and off  the next.
As a result of these limitations, any results in matching are likely to be a  lower bound.
We conducted data reliability assessments on both states’ vendor data  and found these data sets to be sufficiently reliable for our analysis. We  restricted these assessments to the specific variables and records that  were pertinent to our analyses. We conducted interviews with SSA staff  familiar with the data and requested additional information from the  DDSs. We also assessed the completeness of the data, including  frequency analysis of relevant fields, testing for population of variables,  out of range values, and duplicate records. In both states, the data’s  unique identifiers that we used for matching were not populated for all  records. We followed up with SSA and the DDSs to gain an  understanding of why some fields were not populated. Because the  vendor files are used for payment purposes, the DDSs only collect tax  identification numbers for entities they pay for medical records or  consultative examinations. We restricted our matching to vendor data that  we determined had a legitimate tax identification number and eliminated  duplicates in the data. We then asked the DDSs to verify the last date of  payment for providers whom we matched to assess whether they were  receiving payment while they were sanctioned.
We conducted similar data reliability steps for the HHS LEIE, including  electronic testing and interviews with the HHS OIG officials responsible  for maintaining the list. We found these data to be sufficiently reliable for  our analysis.
section_title: Identification of Key Practices for Implementing Fraud Analytics Systems
paragraphs: We identified a number of key practices that organizations should  consider when implementing analytics to uncover potential fraud in  disability claims. These practices are based on our past work that  examined the use of analytics to detect Medicare fraud. To validate  these practices and determine their relevance for disability programs, we  shared the list of practices with private sector entities that have  experience implementing analytics for disability programs. We also asked  these entities whether there were additional practices that should be  added to our list. These entities generally agreed with the practices from  our prior work and suggested that we add mining text data to our list  because this capability is critical to identifying similar medical language  across claims.
We conducted this performance audit from July 2013 to November 2014  in accordance with generally accepted government auditing standards.  Those 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 based  on our audit objectives.
section_title: Appendix II: Comments from the Social Security Administration
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Gretta L. Goodwin (Assistant  Director), Nyree Ryder Tee (Analyst-in-Charge), Daniel Concepcion,  Brian Schwartz, and Melinda Cordero made key contributions to this  report. Additional contributors include: James Bennett, Sarah Cornetto,  David Chrisinger, Alex Galuten, Sheila McCoy, Zachary Sivo, Almeta  Spencer, Vanessa Taylor, and Walter Vance.
section_title: Related GAO Products
paragraphs: Highlights of a Forum: Data Analytics for Oversight and Law  Enforcement. GAO-13-680SP. Washington, D.C.: July 15, 2013.
Social Security Administration: Long-Term Strategy Needed to Address  Key Management Challenges. GAO-13-459. Washington, D.C.: May 29,  2013.
Medicare Fraud Prevention: CMS Has Implemented a Predictive  Analytics System, but Needs to Define Measures to Determine Its  Effectiveness. GAO-13-104. Washington, D.C.: October 15, 2012.
Social Security Disability: Collection of Medical Evidence Could Be  Improved with Evaluations to Identify Promising Collection Practices.  GAO-09-149. Washington, D.C.: December 17, 2008.
Results-Oriented Cultures: Insights for U.S. Agencies from Other  Countries’ Performance Management Initiatives. GAO-02-862.  Washington, D.C.: August 2, 2002.
Supplemental Security Income: Additional Actions Needed to Reduce  Program Vulnerability to Fraud and Abuse. GAO/HEHS-99-151.  Washington, D.C.: September 15, 1999.
Supplemental Security Income: Action Needed on Long-Standing  Problems Affecting Program Integrity. GAO/HEHS-98-158. Washington,  D.C.: September 14, 1998.