Audit Report - A-09-96-64204

Office of Audit

Monitoring Representative Payee Performance: The Accounting Form - A-09-96-64204 - 1/6/97

TABLE OF CONTENTS

EXECUTIVE SUMMARY

INTRODUCTION

FINDINGS

Approximately 86 Percent of Payees Responded to Mailed Accounting Requests

More Than 35 Percent of Responders Completed Accounting Forms in a Manner That Produced Exceptions

Payees Expressed Difficulties in Completing the Accounting Forms

Exception Rates Vary by Accounting Form

CONCLUSION

APPENDICES

A: Copies of Accounting Form

B: Detailed Methodology

C: Response Rates, Exception Rates, Payee Training

D: List of Contributors

EXECUTIVE SUMMARY 

PURPOSE

This report identifies the types, frequencies, and causes of representative payee generated exceptions to the Social Security Administration`s (SSA) annual accounting forms.

BACKGROUND

The Social Security Administration (SSA) administers two programs under The Social Security Act--title II (Retirement, Survivors, and Disability Insurance (RSDI)) and title XVI (Supplemental Security Income (SSI)). These two programs provide monthly benefit payments of about $25 billion to approximately 49.2 million beneficiaries who are aged, disabled, or survivors. If beneficiaries cannot manage their own finances, Congress has authorized SSA to pay the benefits to other individuals or organizations on their behalf. The SSA calls these individuals and organizations representative payees (hereinafter called payees).

Payees` responsibilities include submitting an annual accounting form report to SSA. The SSA uses the data collected from these forms to determine the continuing suitability of payees, the continuing need for representative payment, and whether payees used benefits properly during the 12-month report period. The SSA staff use a computer program to review the accounting forms and decide whether the responses are acceptable or need further review and/or explanation. (Responses requiring further review and/or explanation are referred to as "exceptions.") If all responses on an accounting form are acceptable, no further action is necessary.

The SSA has undertaken initiatives to strengthen the entire annual accounting process. To assist in this effort, SSA requested that the Office of the Inspector General (OIG) conduct a series of inspections to review and recommend improvements to the annual accounting process. This report is one in the series of reports that assess the risk of misuse of benefits associated with various categories of payees. Other reports will present data concerning demographics of payees, demographics of beneficiaries, misuse or questionable use of benefits by payees, poor performance by payees, the effectiveness and efficiency of the accounting review process, and nonresponding payees. A roll-up report will provide overall recommendations for improving the accounting process.

We combined data collection from SSA`s computerized beneficiary data bases and in-person interviews to determine payees` performance. In September and October 1994, SSA prepared computerized files of title II and title XVI beneficiaries with payees scheduled to receive initial accounting forms in October 1994. From these files, we extracted a sample of 3,010 payee cases for our study. We used all collected information (e.g., accounting forms, interviews) to describe:

1. payees` experiences with the current accounting process; and (2)
2. payees` difficulties in completing the annual accounting form.

FINDINGS

Approximately 86 Percent of Payees Responded to Mailed Accounting Requests

While more than 75 percent of payees responded to the first accounting request and 10 percent responded to the second accounting request, more than 14 percent of payees had to be contacted directly regarding completion of the accounting forms.

More Than 35 Percent of Responders Completed Accounting Forms in a Manner That Produced Exceptions

Common exceptions included:

1. failing to account for 90 percent of the total accountable amount; (2)
2. providing relationship information that did not correspond to SSA`s data bases or failing to answer the relationship question; (3)
3. stating that the beneficiary had changed custody during the report period; and
4. payees stating that they did not decide how all benefits were spent or saved.

Payees Expressed Difficulties in Completing the Accounting Forms

Incorrect responses were often the result of payees` confusion. This confusion may be the result of payees`:

1. limited understanding of the accounting process and their responsibilities; (2)
2. difficulty understanding what specific questions are asking; or (3) 
3. failure to maintain information necessary to complete the accounting forms.

Exception Rates Vary by Accounting Form

Payees completing the SSA-6230 (parents, stepparents, and grandparents with custody of title II child beneficiaries) were less likely to produce exceptions than payees completing the SSA-623.

CONCLUSION

Although the majority of payees respond to mailed accounting requests, SSA still must contact a large number of payees directly. Some contacts are to obtain missing or incomplete responses, while others are to clarify payees responses. Many of the latter contacts are necessitated by payees` confusion over completing the accounting forms. The SSA`s efforts to make the SSA-6230 a simpler and more direct form have proven successful, with payees completing the SSA-6230 generating fewer exceptions than payees completing the SSA-623.

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INTRODUCTION

PURPOSE

This report identifies the types, frequencies, and causes of representative payee generated exceptions to the Social Security Administration`s annual accounting forms.

BACKGROUND

Overview of the Representative Payee Program

The Social Security Administration (SSA) administers two programs under The Social Security Act--title II (retirement, survivors, and disability insurance) and title XVI (supplemental security income). These two programs provide monthly benefit payments of about $25 billion to approximately 49.2 million beneficiaries and recipients who are aged, disabled, or survivors.

Approximately 6.6 million beneficiaries, or slightly more than 13 percent, cannot manage their own finances. If beneficiaries cannot manage their own finances, Congress has authorized SSA to pay the benefits to other individuals or organizations on their behalf. The SSA calls these individuals and organizations representative payees (hereinafter called payees).

Sections 205(j)(1) and 1631(a)(2) of The Social Security Act authorize the Commissioner of SSA to appoint payees. Payees may include, but are not limited to, parents with or without custody of children, spouses, other relatives, legal guardians, friends who show strong concern for the beneficiary`s welfare, and institutions with or without custody of the beneficiary.

Payee Responsibilities

Payees` responsibilities include:

1. frequently monitoring the beneficiary`s well-being;
2. notifying SSA of situations that affect the beneficiary`s entitlement to or amount of benefits (e.g., work); and (3)
3. informing SSA of changes in the payee`s own circumstances that would affect the payee`s performance.

A major payee responsibility is to submit an annual accounting form to SSA describing their use of benefits. Payees receive the booklet, A Guide For Representative Payees, during the SSA interview which describes a payee`s responsibilities and the appropriate use of benefits. The booklet includes a worksheet to record the use of benefits and a sample accounting form.

The Jordan Court and the Establishment of the Annual Accounting Process

Prior to 1983, SSA did not have a mandate to conduct accountings of funds that payees received on behalf of beneficiaries. The Agency relied on its own initiative to create an accounting system. In 1979, Ms. Jeanne Jordan brought a certified class action suit against SSA challenging how it monitored payees. (Ms. Jordan alleged that her payee was not using her SSA benefits properly to meet her needs.) In its 1983 decision, the Jordan Court decided that payees should be required to give a full accounting of how they spend and save title II and title XVI benefits on behalf of beneficiaries. Subsequently, Congress amended The Social Security Act to require annual accounting of all payees except State mental institutions participating in the onsite review program.

The SSA, in consultation with the Jordan court, designed an annual accounting process--including the look and content of the accounting form--to gather data from payees. The data helps SSA determine:

1. the continuing suitability of the payee,
2. the continuing need for representative payment, and
3. whether the payee used benefits properly during the 12-month report period.

The Annual Accounting Forms

To handle a high volume of annual accounting, SSA developed standardized accounting forms--the SSA-623 and the SSA-6230 (Appendix A contains copies of these forms). The SSA-623 asks how payees used the funds for:

1. food and shelter; (2)
2. other items such as clothing, education, personal items, and medical and dental expenses; and (3)
3. savings.

The form also asks payees about:

1. changes in the beneficiary`s custody; (2)
2. whether the payee or another person controlled the use of the SSA benefits; and (3)
3. their own felony convictions during the previous 12 months.

In July 1990, SSA introduced the SSA-6230 accounting form for parents and, later, stepparents and grandparents with custody of minor children who receive title II benefits. These payees may report their use of benefits for up to four children on the same form. Since parents, stepparents, and grandparents represent the largest type of payee category, most title II payees now receive the SSA-6230.

The SSA-6230 differs from the SSA-623 primarily in: (1) the payees` ability to account for up to four children on the same form; and (2) the wording of the questions on custody and use of benefits. Also, questions about funds on the SSA-6230 are more general. Payees report: (1) the expenses for care and support of the children; and (2) savings.

The Current Accounting Process

Each month, SSA uses its computerized beneficiary databases (the Master Beneficiary Record and the Supplemental Security Record) to identify payees who are to receive annual accounting forms. The SSA usually schedules payees to receive forms on the anniversary of the month they were selected to be the payee, although SSA and/or payees may designate an alternate report period. As a result of this selection process, SSA sends initial accounting forms to approximately one-twelfth of all payees each month.

The SSA uses a contractor to mail accounting forms to payees. If payees have not returned accounting forms within 3 months of the first mailing, the contractor mails a second request. If the payees fail to respond to the second request, SSA staff attempt to contact payees directly to obtain a completed accounting.

When payees return the mailed accounting requests, SSA`s Wilkes-Barre Data Operations Center in Pennsylvania completes the initial screening, data verification, and review of the returned forms. The staff use a computer program to review the accounting forms and decide whether the responses are acceptable or need further review and/or explanation. (Responses requiring further review and/or explanation are referred to as "exceptions.") If all responses are acceptable and there are no relevant remarks, no further action is necessary.

SSA Initiatives and Changes in Annual Accounting

The SSA has initiated several activities to improve the annual accounting process. First, SSA: (1) introduced the SSA-6230 accounting form tailored for parents, stepparents, and grandparents with custody of minor children who receive title II benefits; and (2) has made periodic revisions to the SSA-623 to improve the clarity of the form. Second, SSA asked OIG to conduct a series of inspections that would review and recommend improvements to the annual accounting process. This report is one in the series of reports that assess the risk of misuse of benefits associated with various categories of payees. Other reports will present data concerning demographics of payees, demographics of beneficiaries, misuse or questionable use of benefits by payees, poor performance by payees, the effectiveness and efficiency of the accounting review process, and nonresponding payees. A roll-up report will provide overall recommendations for improving the accounting process. And third, independent of the OIG`s work, SSA appointed an external Representative Payee Advisory Committee in June 1995 to study all aspects of the accounting process from payee selection through monitoring payee performance. The Committee reported its findings and recommendations to the Commissioner of SSA in November 1996.

METHODOLOGY

We combined data collection from SSA`s computerized beneficiary data bases and in-person interviews to determine payees` performance. In September and October 1994, SSA prepared computerized files of title II and title XVI beneficiaries with payees scheduled to receive initial accounting forms in October 1994. From these files, we extracted a sample of 3,010 payee cases for our study. These cases were roughly divided for:

1. relatives and nonrelatives; (2)
2. custodial and noncustodial payees; and (3)
3. title II and title XVI programs.

For our sample cases, we mailed out accounting forms and, upon their return, determined the types and frequencies of exceptions. In addition, SSA staff attempted to interview every payee as well as beneficiaries, custodians, and collateral contacts as appropriate and possible. Interviewers attempted to conduct all interviews fact-to-face and in the respondents` homes. Interviewers used structured guides during these interviews.

We used the collected information to describe:

1. payees` experiences with the current accounting process; and (2)
2. payees` difficulties in completing the annual accounting form.

We weighted our results to the universe of beneficiaries with payees scheduled to receive initial accounting forms in October 1994. For analysis purposes, we weighted each case to the October 1994 universe. Appendix B contains a detailed description of our methodology.

This inspection was conducted in accordance with the Quality Standards for Inspections issued by the President`s Council on Integrity and Efficiency.

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FINDINGS

APPROXIMATELY 86 PERCENT OF PAYEES RESPONDED TO MAILED ACCOUNTING REQUESTS

We found that the majority of payees returned accounting forms when they received the requests in the mail. Approximately 75.5 percent responded to the first request--returning the forms an average of 25.1 days from the date we mailed the first request--and 10.3 percent responded to the second request--returning the forms an average of 135.1 days from the date we mailed the first request and 30.4 days from the date we mailed the second request (see graphic on the right). Refer to Appendix C for more information concerning response rates.

More Than 14 Percent of Payees Required Direct Contact Related to the Accounting Requests

The SSA had to contact some payees directly to obtain completed accounting forms. Approximately 11.7 percent of all payees (or more than 85 percent of those who did not respond to the first or second requests) completed an accounting after SSA`s contacts. An additional 0.5 percent produced photocopies of completed forms during the interviews. We did not receive the originals because the forms may have gotten "mixed in" with other documents that the payees returned to SSA or they may have gotten lost in the mail. Approximately 0.3 percent had to be contacted directly because the United States Postal Service returned the accounting requests as undeliverable, and we were unable to obtain better addresses. Only 1.7 percent of payees provided no accounting because they refused, could not be located, or died, or for other unspecified reasons.

MORE THAN 35 PERCENT OF RESPONDERS COMPLETED ACCOUNTING FORMS IN A MANNER THAT PRODUCED EXCEPTIONS

Approximately 122,000 payees (or 35.7 percent of responders) provided responses that produced exceptions (i.e., responses that required SSA to conduct further review of the accounting forms and/or contact payees directly) (see Appendix C for information on exception rates by type of payee). The most common exception came from payees writing comments on the accounting forms. Almost 61,000 payees (49.7 percent of exception cases and 17.7 percent of responders) wrote comments on the back of the accounting forms. Some remarks provided detail about responses given on the form, but many payees included superfluous remarks (e.g., general statements about the beneficiary that had no bearing on his or her entitlement to benefits, requests from payees for increased benefits, etc.). Although SSA usually can address these latter remarks quickly and easily, SSA staff still must review what is written. Other frequent exceptions included:

• Payees failing to account for at least 90 percent of the total accountable amount (the total of questions 3B, 3C, and/or 3D). Individual payees were more likely than agencies and institutions to have failed to meet the 90 percent threshold.

• Payees providing relationship information on form SSA-623 that does not correspond with SSA`s computerized data bases or failing to answer the relationship question altogether (question 7). For payees completing the SSA-6230, SSA checks whether responses fall into parents, stepparents, or grandparents. Since a significant portion of payees who complete the SSA-6230 have inconclusive payee coding (i.e., they have a type of payee code of "W"), SSA cannot verify the exact payee relationship. For this reason, we also did not verify relationship information for these payees. In general, we did find cases in which payees who completed form SSA-6230 failed to answer the question, provided inconclusive information, or answered the question incorrectly.\

• Payees stating that the beneficiary did not live with the same person or in the same institution during the entire report period--form SSA-623--or stating that the children named on the accounting form did not live with them during the entire report period--form SSA-6230-- (question 2).

• payees stating that they did not decide how all benefits were spent or saved (question 3A). The payees may have turned over the benefits to the beneficiary directly or may have given the benefits to another individual or organization.

Payees Frequently Completed the Accounting Form in a Manner That Generated More Than a Single Exception

Our review of the accounting forms frequently identified more than one exception per accounting form. We found that more than 46,000 accounting forms (37.8 percent of exception cases) had 2 or more exceptions on the accounting form, and 229 accounting forms (0.2 percent of exception cases) had 6 exceptions.

PAYEES EXPRESSED DIFFICULTIES IN COMPLETING THE ACCOUNTING FORMS

Although more than 80 percent of responders claimed to have read the instructions included with the accounting request, payees frequently mentioned difficulties completing the forms or understanding particular questions. Payees identified the questions regarding the use of benefits--3B, 3C, and/or 3D--most often as troublesome, but many payees mentioned that they had trouble with all questions. Several payees with difficulties mentioned their poor reading skills or limited English as a cause for their difficulties. Refer to Appendix C for a description of payee training and preparation.

Several factors appear to play a role in payees` difficulties. Payees expressing difficulties with completing the accounting forms were less likely to have received verbal instructions at the time they were appointed payee or recall receiving the booklet entitled A Guide for Representative Payees than those who expressed no difficulties. These payees were more likely to have limited education (completed 8 years or less of formal education) than payees who expressed no difficulties.

Incomplete and Incorrect Responses Generated Unnecessary Exception Cases

The SSA`s procedures require that staff contact payees directly to resolve many types of exceptions. Based on these contacts, we found that--had the payees answered the questions completely and correctly--more than 34,000 accounting forms (28.2 percent of all exception cases) would not have had exceptions. The SSA would have cleared these accounting forms through its automated review process.

Incorrect Responses Were Frequently the Result of Payee Confusion

Payees often claimed confusion as the cause of their incorrect responses. For example, 52.9 percent of payees who answered question 2 (custody of the beneficiary) "No"--which indicated a change in beneficiary custody--changed their answer to "Yes"--which indicated no change in beneficiary custody--when SSA contacted them. When asked why they answered the question incorrectly, payees frequently mentioned that they misunderstood the question.

Payees` accounting of benefits spent and saved provides further evidence of payee confusion. Although the accounting forms state the amount of benefits for which payees should account, 18.8 percent accounted for an amount in excess of the total accountable amount. Approximately 1.6 percent accounted for more than 4 times the total accountable amount, and 0.6 percent accounted for more than 10 times the amount. (Although these responses would not produce an exception--they exceeded the 90 percent threshold--they clearly demonstrate payees` confusion over what they are being asked to do.)

Many Payees Did Not Maintain Information Necessary to Complete Accounting Forms

Based on payee interviews, we found that many payees could not effectively break down how they spent and saved benefits on behalf of beneficiaries. Parent payees frequently deposited benefits into a general household account and used the benefits to cover the family`s needs (e.g., rent, groceries, utilities). Other payees did not keep sufficient records to differentiate how they used the benefits. They responded only in general terms about benefit expenditure during the interviews. Therefore, we can assume that payees` responses regarding benefit expenditure on the accounting forms are a "guess" rather than actual figures. (Overall, payees who did not meet the 90 percent threshold were less likely to have maintained financial records during the report period than those that met the threshold.)

EXCEPTION RATES VARY BY ACCOUNTING FORM

We found great disparity between the exception rates for payees completing the SSA-623 versus those completing the SSA-6230. Approximately 50.8 percent of payees completing the SSA-623 had exceptions, while 19.4 percent completing the SSA-6230 had exceptions. The SSA developed the latter form to be a simpler and more direct form. The result is that parents, stepparents, and grandparents with custody of children receiving title II benefits are the least likely to have exceptions.

Payees` Responses Indicate the Desire for Additional Accounting Form Variations

The two current accounting forms do not address the variations that exist in the payee population. As a result, SSA may be requiring payees to respond to inappropriate questions or payees may have difficulty responding altogether. For example, agencies and institutions cannot be convicted of felonies (question 1). Several agency and institutional payees strongly questioned why this question was included. In addition, due to their difficulty reading English, several payees would have preferred to receive the accounting form in a alternate language.

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CONCLUSION

Although the majority of payees respond to mailed accounting requests, SSA still must contact a large number of payees directly. Some contacts are to obtain missing or incomplete responses, while others are to clarify payees` responses. Many of the latter contacts are necessitated by payees` confusion over completing the accounting forms. The SSA`s efforts to make the SSA-6230 a simpler and more direct form have proven successful, with payees completing the SSA-6230 generating fewer exceptions than payees completing the SSA-623.

APPENDIX A

COPIES OF ACCOUNTING FORMS

The following pages contain copies (front and back) of the SSA-623 and SSA-6230.

(The Accounting Forms SSA-623 and SSA-6230 are unavailable at this time)

APPENDIX B

DETAILED METHODOLOGY

We combined information from The Social Security Administration`s (SSA) pre-existing computerized data bases with in-person, in-the-home interviews to provide data on the relative risk of misuse and poor performance for all categories and types of payees and beneficiaries.

Sample Selection

1. We requested data from SSA on all beneficiaries with payees from the Master Beneficiary Record (MBR) and the Supplement Security Record (SSR). Data included, but was not limited to, beneficiary`s name; payee`s name, address, and telephone number; payee category or type; and payment data. We analyzed the universe of payees to identify characteristics such as payee category, beneficiary type, and district office code.

2. After preliminary analysis of the universe, we selected a random sample of SSA district offices. We initially selected 150 offices from the MBR, but 1 office code was invalid and 5 offices were outside the continental United States. Therefore, we used 144 offices for our study.

3. From the computerized files SSA used to produce the October 1994 annual accounting forms, we selected all beneficiaries’ records containing the sampled district office codes. This resulted in 29,155 title II cases and 13,520 title XVI cases.

4. For each of the programs (title II and title XVI), we grouped the beneficiaries’ records into five strata according to type of payee coding. The strata are: (1) parents; (2) nonparent relatives; (3) institutions; (4) financial institutions, public officials, and social agencies; and (5) payees coded "other." We then grouped the records within each stratum by custody code (payee with or without custody of the beneficiary). The title II records had two additional strata, one for the "W" payee code and another for missing or miscellaneous codes. Therefore, we had 12 title II strata and 10 title XVI strata.

5. We randomly selected up to 145 cases from each of our 22 strata. If there were less than 145 cases in the strata, we selected the universe of cases. Our final sample included 3,010 cases--1,584 title II cases and 1,426 title XVI cases. The chart on the following page shows the sample distribution by strata.

TABLE 1: LIST OF 22 SAMPLE STRATA

*The SSA assumes that these payees are parents with custody.

Data Collection

1. We mailed the SSA-623 or SSA-6230 accounting forms to our sampled payees. For all returned forms, we entered the information into corresponding data bases and evaluated the data using SSA`s "four-phase" logic program.

2. We established folders on all sampled payees that SSA field staff used during the interviews. The folders contained: (1) the completed SSA-623 or SSA-6230, if received; (2) results of the four-phase analysis of the accounting form; (3) any exceptions needing follow-up with the payee; (4) the names, addresses, and telephone numbers of the payee and beneficiary; and (5) hard copy data produced at the time of selection from the MBR, SSR, and Master Representative Payee File.

3. We developed structured discussion guides for payees, beneficiaries, and custodians based on the SSA-624-F5 (Representative Payee Evaluation Report). We also developed structured guides for collateral contacts and a case summary. Collateral contacts would objectively verify self-reported information given by payees, beneficiaries, and custodians. Information included, but was not limited to:

a. biographical information about the payee and beneficiaries;

b. the relationship between the payee and the beneficiary;

c. the relationship between the beneficiary and the custodian;

d. the beneficiary`s level of satisfaction with the payee`s performance;

e. from the payee and beneficiary, details about how benefits were spent and/or saved on behalf of the beneficiary;

f. the extent of record keeping performed by the payee; and

g. whether the payee is responsible for accounting or reporting to any other government or private organizations about the benefits expended.

The case summary allowed interviewers another venue to analyze and highlight information not captured directly in the discussion guides. Interviewers often provided their overall professional impression of each case. In addition, interviewers drew from the interviews and collected information to determine if benefit misuse was indicated.

4. We trained SSA staff in nine sessions at five locations around the country. The training consisted of an introduction to the study, review of the discussion guides, and role-playing to identify potential questions about administering the guides. We also trained more staff by telephone using a condensed version of the onsite training.

5. The SSA staff--under our direction--conducted in-person or telephone interviews with payees, beneficiaries, custodians, and collateral contacts where applicable.

Data Analysis

1. We developed a computerized data entry system allowing us to record information from the accounting forms and each of the discussion guides and case summary sheets. If interviewers were not able to obtain completed forms or interviews, we indicated why.

2. Once interviewers returned virtually all cases (3,005 of 3,010 sampled cases as of April 1996), we validated the data entered into the data bases. We reviewed the data bases to identify and correct mis-keyed data.

3. Using a computerized statistical software package, we analyzed the resulting data to identify significant findings. We determined that the type of payee and custody data may be incorrect for some cases (see Monitoring Representative Payee Performance: Demographic Characteristics of Payees, A-09-96-64206). We continued to analyze data based on the original strata because it provides the most accurate information about the payees and beneficiaries whose records currently contain a given type of payee and custody code combination.

4. We developed weights that we applied to each sampled case. This allowed us to make projections to the universe of beneficiaries with payees scheduled to receive an initial accounting form in October 1994.

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APPENDIX C

TYPES AND FREQUENCIES OF EXCEPTIONS

Table 1: Accounting Response Rates (Payee Universe)

Table 2: Exception Rates and Key Exceptions By Type of Payee and Custody Arrangement

Table 3: Payee Training and Preparation By Type of Payee and Custody Arrangement

TABLE 1: ACCOUNTING RESPONSE RATES (PAYEE UNIVERSE)

Legend:

TABLE 2: EXCEPTION RATES AND KEY EXCEPTIONS BY TYPE OF PAYEE AND CUSTODY ARRANGEMENT

TABLE 3: PAYEE TRAINING AND PREPARATION BY TYPE OF PAYEE AND CUSTODY ARRANGEMENT

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APPENDIX D

LIST OF CONTRIBUTORS

This inspection report was prepared by the Office of Audit in San Francisco under the direction of Scott Patterson, Director, Division of Evaluations and Technical Services. Project staff included:

Deborah Harvey, Senior Evaluator
Brian Pattison, Senior Evaluator
Alan Stubbs, Senior Evaluator
Nellie Wong, Auditor

Special thanks to Robert Gibbons, Wm. Mark Krushat, Sc.D., and Linda Moscoe from the Department of Health and Human Services/Office of Inspector General for their contributions during the initial development of this project.