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. 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. 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. 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. 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. 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. 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. 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.) 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Daniel Bertoni, Director, (202) 512-7215 or bertonid@gao.gov. 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.

Summary: 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. 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. 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.