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.) 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. 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. 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. 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. 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.