Federal Investigators Widen Probe of Doctors In Potentially Large Scale Disability Fraud Scheme

Social secruity

Social secruity (Photo credit: SalFalko)

Social Security administrative Law Judges (ALJ) are approving more claims for disability benefits in 2013 than in previous years. A federal probe in 2011 revealed wide spread disparities in the approval rates of different states and among ALJs in the same office. The chances of being awarded disability benefits appear to be influenced by the State one lives in and the ALJ who is assigned to hear your case. Your chances increase dramatically if the medical doctor who examines you files a report stating that you cannot work because of a physical or mental impairment that prevents you from sitting for long periods of time or from concentrating on specific job assignments.

Disorders of the back are the most common type of physical impairment. Physical evidence of a condition that can reasonably be expected to result in a serious impairment is easy to ascertain.  Mental impairments are harder to prove than physical impairments. They are more subjective. In the case of an allegation of a mental impairment, judges are forced to rely more heavily on the expert opinion of a trained mental health professional, usually a clinical psychologist or a psychiatrist.

Federal investigators on Wednesday, August 21, searched six facilities in Puerto Rico as part of a broadening probe into potential widespread disability fraud.

Investigators from the Federal Bureau of Investigation (FBI) and the Social Security Inspector General’s office (SSIG), among others, searched five doctors‘ offices and one other location as part of their sweep, a spokeswoman for the U.S. attorney said. The spokeswoman wouldn’t comment further, saying it was part of a continuing investigation and that the six search warrants were sealed.

Doctors play a big role in determining whether people qualify for federal disability benefits because their recommendations often sway state disability determiners and Federal Administrative Law Judges (ALJ) working for the Social Security Administration. Criminal investigators have been looking into whether doctors were paid to improperly create documents detailing applicants’ inability to work.

The federal investigation into disability fraud was launched in 2011 after a page-one article in The Wall Street Journal revealed widespread disparity in how some states and U.S. territories implement the Social Security Disability Insurance (SSDI) program. The chances of winning benefits could vary widely based on where someone applied for benefits, even though standards are supposed to be uniform.

 

In 2006, just 36% of initial applicants in Puerto Rico were awarded benefits. In December 2010, the award rate had jumped to 69%. By 2010, nine of the top 10 U.S. ZIP Codes for workers receiving disability benefits were on the island.

At the time, SSA officials said the high number of recipients and the high award rate was due to the island’s weak economy and a lack of adequate health care for workers.

The program is overseen by the Social Security Administration (SSA) in Baltimore, but the State Disability Determination Service (DDS) is responsible for performing an initial screening to determine eligibility. Social Security officials said in 2011 that Puerto Rico had rigorous standards and a virtually nonexistent error rate.

The characteristics of Puerto Rico’s beneficiaries differed from other areas. In addition to the large clusters in certain zip codes, federal data showed that 33.3% of Puerto Rican beneficiaries qualified because of “mood disorders,” a rate that is at least 10 percentage points higher than any U.S. state.

Disability examiners and federal judges say mental disorders are harder to measure. decisions are often based on medical opinions contained in Consultative Examinations (CE) issued by doctors to make a determination.

 This probe that has been ongoing for two years.  Federal authorities have made 68 arrests in Puerto Rico alone.

The inspector general from the U.S. Social Security Administration has stated that prosecutors have now also charged a former Social Security employee as well as three doctors with having taken part in assisting individuals in making false disability insurance claims. They worked to help individuals to falsely claim that they were too injured or sick to be able to work.

Disability InsuranceIn return, the suspects were allegedly provided a certain portion of the disability insurance payments of the scammers.

Typically, the cuts that they received from the disability insurance payments ranged from $150 to $6,000. Among those who were charged, dozens included individuals who had actually made these fake claims. The arrests come on the heels of an investigation that had been conducted by the Wall Street Journal in 2011, which looked into unusual claims that were being made in Puerto Rico.

This case also draws attention to an increasing problem that the federal government is currently facing, which is the ballooning disability insurance payments within a program that has standards that are notoriously soft regarding the actual definition of what a disability actually is. For instance, in 2011, when the investigation began from the news paper giant, the federal payments in that program reached $190 billion.

It has been suggested that the reason that disability insurance payments have been growing as quickly as they have – now paying out to over 14 million Americans – is that it has become a sneaky safety net for individuals who are unable to find adequate jobs, but who desperately need to make an income, as the average annual payment is up to twice the income of employment at minimum wage. Another contributor to the growth is that the average age of the workforce is getting higher, and older individuals have a higher risk of experiencing health problems.

SSDI was designed as a way to provide benefits for people who can’t work because of mental or physical health problems, and Americans can qualify for benefits because of ailments ranging from severe back pain to terminal cancer. A lifetime of benefits, including access to Medicare, can cost the government about $300,000 a person.

The program became a safety-net-of-last-resort for millions of Americans during the recent economic downturn, including many who had collected unemployment benefits and had hoped to return to the workforce. SSDI had 7.6 million beneficiaries in 2003, and that number swelled to 10.9 million by the end of 2012. More than 200,000 of the beneficiaries are in Puerto Rico, according to federal data.

SSDI paid out $136.7 billion in disability benefits last year, almost twice as much as the government spent on food stamps. The vast majority of people who receive disability benefits never leave the program to return to the workforce.

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