OFFICE OF
THE INSPECTOR GENERAL
SOCIAL SECURITY ADMINISTRATION
CHILDHOOD CONTINUING
DISABILITY REVIEWS
AND AGE 18 REDETERMINATIONS
December 2006 A-01-06-21093
AUDIT REPORT
Mission
We improve SSA programs and operations and protect them against fraud, waste, and abuse by conducting independent and objective audits, evaluations, and investigations. We provide timely, useful, and reliable information and advice to Administration officials, the Congress, and the public.
Authority
The Inspector General Act created independent audit and investigative units, called the Office of Inspector General (OIG). The mission of the OIG, as spelled out in the Act, is to:
To ensure objectivity, the IG Act empowers the IG with:
Vision
By conducting independent and objective audits, investigations, and evaluations, we are agents of positive change striving for continuous improvement in the Social Security Administration's programs, operations, and management and in our own office.
Date: December 20, 2006 Refer To:
To: The Commissioner
From: Inspector General
Subject: Childhood Continuing Disability Reviews and Age 18 Redeterminations
(A-01-06-21093)
OBJECTIVE
Our objective was to determine whether the Social Security Administration (SSA) (1) completed continuing disability reviews (CDR) for Supplemental Security Income (SSI) recipients under age 18 timely and determined whether recipients received appropriate medical treatment and (2) completed eligibility redeterminations in a timely manner using adult eligibility criteria for SSI recipients attaining age 18.
BACKGROUND
Under Title XVI of the Social Security Act, SSA is required to:
SSA generally schedules CDRs at least every 3 years for recipients under age 18 whose impairments may improve. The scheduled disability review date alerts the Agency to the need to initiate a CDR, which can take up to a full year to complete. For this reason, we considered a CDR to have been performed timely if completed no later than 12 months after the scheduled disability review date.
The Agency generally initiates Age 18 Redeterminations when recipients turn 18; however, if a review cannot be started because the benefits are suspended, SSA’s systems will keep trying to initiate the Redetermination until the 19th birthday. Therefore, we considered an Age 18 Redetermination timely if completed by the individual’s 20th birthday.
For this review, we analyzed a file of about 1.2 million SSI recipients who were receiving benefits in June 2005 and identified:
For each group of recipients, we selected a random sample of 275 sample cases—for a total of 550 cases.
We performed a preliminary analysis of the 550 sample cases in February 2006. We
asked the Agency to review the Childhood CDRs and Age 18 Redeterminations that
may not have been conducted timely. Although SSA agreed with our definition
of “timely” for the Age 18 Redetermination cases, the
Agency had concerns with our definition of “timely” for the Childhood
CDR cases:
“OIG’s definition of “timely” for the under age 18
childhood cases (i.e., 12 months from the date of the CDR review diary)
is too rigid. SSA estimates that it takes approximately 1 year to complete
a case requiring a full medical review. Some cases take less than 1 year
while other cases take longer than 1 year to reach an initial determination. Consequently,
we believe it is appropriate to focus on average processing time for the entire
sample of cases but not individual cases when assessing the timeliness of this
workload.”
The Agency did not agree with our preliminary analysis that the following cases did not have CDRs completed timely:
Additionally, 18 recipients had permanent impairments (of the 140 Childhood CDR cases we referred to SSA). Since 3-year reviews were not required for these cases under the Social Security Act, we updated our analysis accordingly.
RESULTS OF REVIEW
SSA generally made determinations as to whether the recipients under 18 years of age were receiving appropriate medical treatment. However, the Agency did not complete all Childhood CDRs and Age 18 Redeterminations in a timely manner. Based on our sample results, 39 percent of Childhood CDRs and 12 percent of Age 18 Redeterminations were not completed timely. As a result, we estimate:
-- IMAGE OMITTED FROM THIS TEXT-ONLY VERSION --
CHILDHOOD CDRs
Our review of 275 sample cases found:
Of the 106 CDRs not completed timely, 55 were never initiated, 7 were initiated but not completed as of October 2006, and 44 were completed more than a year after the scheduled review date—35 had benefits continued and 9 had benefits ceased. Because CDRs were not completed timely, the Agency paid about $100,000 that should not have been paid. Additionally, the Agency will continue to pay the 62 recipients who did not have CDRs initiated or completed about $50,000 annually until these CDRs are finished. Examples of Childhood CDRs that were not completed timely include:
DETERMINATIONS REGARDING APPROPRIATE MEDICAL TREATMENT
For SSI recipients under age 18, a CDR will result in a continuance of benefits unless (1) there has been any medical improvement in the child's impairment(s) and (2) the child's impairment(s) does not result in marked and severe functional limitations.
For continuances in which the child has a payee, the Agency must determine whether the child is and has been receiving treatment to the extent considered medically necessary and available for the condition(s) that was the basis for providing benefits.
SSA conducted initial level CDRs for 152 of our 275 Childhood CDR sampled cases. Of these 152 CDRs:
In all four cases in which SSA did not make a determination about medical treatment, the CDR was completed prior to April 2000—when the Agency put an edit in place that prevents the childhood CDRs from being cleared without a determination about medical treatment.
AGE 18 REDETERMINATIONS
-- IMAGE OMITTED FROM THIS TEXT-ONLY VERSION --
Our review of 275 sample cases found:
Of the 32 Age 18 Redeterminations not completed timely, 8 were never initiated, 21 were initiated but not completed as of October 2006, and 3 were completed after the recipient’s 20th birthday—1 had benefits continued and 2 had benefits ceased. Because these reviews were not completed timely, the Agency paid
about $25,600 that should not have been paid. The Agency will continue to pay the 29 recipients who did not have redeterminations initiated or completed about $49,700 annually until these reviews are finished.
For example, one beneficiary with a psychiatric disorder received benefits since age 16 in 2002. SSA initiated an Age 18 Redetermination in September 2003—3 months prior to her 18th birthday. However, the file was not sent for a medical review until we asked for a status on the case in March 2006. The Agency completed the review in June 2006 and determined that she was no longer eligible for benefits under the disability criteria for adults. SSA has paid her over $3,600 since her 20th birthday.
CDR FUNDING
In FYs 1996 through 2002, SSA received special funding for processing CDRs. When
SSA did not receive special funding, it began reducing the number of CDRs conducted. (See
Appendix C for information on CDR workloads in FY 1996 through FY 2007). The
Agency is aware of the impact of reducing the CDR workload, as stated in its
Performance Plan for FY 2007:
“Because of limited resources in FY 2006, in order to maintain service
levels for initial claims, the Agency has had to make adjustments in program
integrity workloads. Specifically, the Agency was not able to perform
as many CDRs or SSI non-disability redeterminations as was planned. The
reduction in CDRs has potentially allowed some individuals to continue being
eligible for benefits when they may no longer qualify. For FY 2007, legislation
has been introduced to earmark funds for conducting increased numbers of CDRs.”
On May 11, 2006, the Commissioner testified before the Subcommittee on Social
Security of the House Committee on Ways and Means:
“We…fulfill our fiscal stewardship responsibility by conducting
CDRs, which ensure that those who receive disability benefits continue to meet
our definition of disability. CDRs are a cost-effective program integrity
workload, saving $10 in program benefits for every $1 spent in administering
them…We are doing fewer CDRs than called for in the President’s
budget request for FY 2006 because we have given priority to our claims
processing workloads including applications for disability benefits. An
increase in the number of CDRs conducted in FY 2007 will result in greater
program savings, but let me stress that we need our full request for administrative
resources for CDRs, whether provided in our appropriation within the discretionary
spending cap, or provided as an adjustment to the cap.”
CONCLUSIONS AND RECOMMENDATIONS
SSA generally made determinations as to whether the recipients under 18 years of age were receiving appropriate medical treatment. However, the Agency was not compliant with the Childhood CDR and Age 18 Redetermination provisions in the Social Security Act requiring these reviews to be completed within specific time periods. By conducting these reviews timely, SSA can identify recipients no longer eligible to receive disability benefits and stop their payments. Therefore, we recommend SSA:
AGENCY COMMENTS
SSA agreed with the recommendations. (See Appendix D.)
Patrick P. O’Carroll, Jr.
APPENDICES
APPENDIX A – Acronyms
APPENDIX B – Scope, Sampling Methodology and Results
APPENDIX C – Continuing Disability Review Funding and Cost Effectiveness
APPENDIX D – Agency Comments
APPENDIX E – OIG Contacts and Staff Acknowledgments
Appendix A -- Acronyms
CDR |
Continuing Disability Review |
FY |
Fiscal Year |
SSA |
Social Security Administration |
SSI |
Supplemental Security Income |
U.S.C. |
United States Code |
Appendix B -- Scope, Sampling Methodology and Results
To accomplish our objective, we:
For each population, we selected a random sample of 275 cases—for a total of 550 cases—and projected our sample results to each population.
For the Childhood CDR cases, we determined whether a CDR was completed timely and if SSA made a determination regarding whether the recipient was receiving appropriate medical treatment. Specifically, we:
For Age 18 Redetermination cases, we determined whether a redetermination was completed timely (by the recipient’s 20th birthday).
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We conducted our audit between February and October 2006 in Boston, Massachusetts. The entities audited were the Office of Disability Programs under the Deputy Commissioner for Disability and Income Security Programs and the Office of Disability Determinations under the Deputy Commissioner for Operations. We conducted our audit in accordance with generally accepted government auditing standards.
SAMPLE RESULTS AND PROJECTIONS
Table 1: Payments Issued Because SSA Did Not Complete Childhood CDRs Timely |
|
Population size |
534,155 |
Sample size |
275 |
Dollar Projections |
|
Sample results |
$100,232 |
Point estimate |
$194,689,762 |
Projection lower limit |
$130,827,956 |
Projection upper limit |
$258,551,569 |
Note: All projections were calculated at the 90-percent confidence level.
Table 2: Payments SSA Could Potentially Save By Completing All Childhood CDRs Timely |
|
Population size |
534,155 |
Sample size |
275 |
Dollar Projections |
|
Sample results |
$49,868 |
Point estimate |
$96,862,918 |
Projection lower limit |
$77,309,676 |
Projection upper limit |
$116,416,159 |
Note: All projections were calculated at the 90-percent confidence level.
Table 3: Childhood CDRs Not Completed Timely |
|
Population size |
534,155 |
Sample size |
275 |
Attribute Projections |
|
Sample cases |
|
Point estimate |
205,892 |
Projection lower limit |
179,729 |
Projection upper limit |
233,047 |
Note: All projections were calculated at the 90-percent
confidence level.
Table 4: Payments Issued Because SSA Did Not Complete Age 18 Redeterminations Timely |
|
Population size |
48,097 |
Sample size |
275 |
Dollar Projections |
|
Sample results |
$25,588 |
Point estimate |
$4,475,347 |
Projection lower limit |
$2,926,223 |
Projection upper limit |
$6,024,470 |
Note: All projections were calculated at the 90-percent confidence level.
Table 5: Payments SSA Could Potentially Save By Completing All Age 18 Redeterminations Timely |
|
Population size |
48,097 |
Sample size |
275 |
Dollar Projections |
|
Sample results |
$49,684 |
Point estimate |
$8,689,694 |
Projection lower limit |
$5,846,451 |
Projection upper limit |
$11,532,937 |
Note: All projections were calculated at the 90-percent confidence level.
Table 6: Age 18 Redeterminations Not Completed Timely |
|
Population size |
48,097 |
Sample size |
275 |
Attribute Projections |
|
Sample cases |
32 |
Point estimate |
5,597 |
Projection lower limit |
4,138 |
Projection upper limit |
7,360 |
Note: All projections were calculated at the 90-percent confidence level.
Appendix C -- Continuing Disability Review Funding and Cost Effectiveness
In Fiscal Years (FY) 1996 through 2002, the Social Security Administration (SSA) received additional funding for conducting Continuing Disability Reviews (CDR). In its FY 2007 budget request, the Agency requested special funding for CDRs. The chart below shows SSA’s CDR workloads in FY 1996 through FY 2007.
FY |
Special Funding |
Cost of CDRs |
Number of CDRs |
Initial Cessations |
Estimated 10 year Savings |
$260 million |
$208 million |
498,400 |
41,910 |
$2.5 billion |
|
1997 |
$360 million |
$330 million |
637,874 |
81,283 |
$4.2 billion |
1998 |
$570 million |
$462 million |
1,356,353 |
113,315 |
$5.6 billion |
1999 |
$720 million |
$547 million |
1,703,414 |
131,531 |
$5.2 billion |
2000 |
$720 million |
$609 million |
1,746,882 |
116,513 |
$6.0 billion |
2001 |
$720 million |
$603 million |
1,730,572 |
100,233 |
$5.3 billion |
2002 |
$720 million |
$634 million |
1,502,944 |
120,790 |
$6.0 billion |
2003 |
$0 |
$551 million |
1,361,331 |
100,545 |
$5.3 billion |
2004 |
$0 |
$543 million |
1,592,010 |
96,934 |
$5.7 billion |
2005 |
$0 |
$493 million |
1,513,009 |
86,987 |
$5.4 billion |
2006* |
$0 |
- |
1,242,000 |
- |
- |
2007* |
- |
- |
1,558,000 |
- |
- |
*The numbers for FY 2006 and FY 2007 are estimates.
SSA's CDR process has consistently yielded a favorable ratio of savings to costs, averaging roughly $10.5 to $1 for FYs 1996-2005. This ratio was calculated by dividing the estimated amount of future benefits saved due to CDR cessations by the cost of CDRs conducted.
Appendix D -- Agency Comments
MEMORANDUM |
Date: |
December 11, 2006 Refer |
Refer To: S1J-3 |
To: |
Patrick P. O'Carroll, Jr. |
From: |
Larry W. Dye /s/ |
Subject: |
Office of the Inspector General (OIG) Draft
Report, “Childhood Continuing Disability Reviews and Age 18
Redeterminations” (A-01-06-21093) |
We appreciate OIG’s efforts in conducting this review. Our comments on the draft report content and recommendations are attached.
Let me know if we can be of further assistance. Staff inquiries may
be directed to
Ms. Candace Skurnik, Director, Audit Management and Liaison Staff, at extension
54636.
Attachment:
SSA Response
COMMENTS ON THE OFFICE OF THE INSPECTOR GENERAL (OIG) DRAFT REPORT, "CHILDHOOD CONTINUING DISABILITY REVIEWS AND AGE 18 REDETERMINATIONS" (A-01-06-21093) -- INFORMATION
Thank you for the opportunity to review and comment on the draft report. Although we have several reservations, we agree with the report's findings and its recommendations.
When resources permit, our primary objective is to manage the process so that all continuing disability reviews (CDR) and age 18 redeterminations that are eligible for review are released timely. We look forward to the time when adequate resources are made available to the Agency to perform all CDRs when due and hope that your audit report will help lead in that direction.
The first two recommendations contain the following parenthetical clause: "When the Agency chooses to use its budgetary resources for purposes other than conducting these reviews, it should publicly disclose these facts to Congress." This could be interpreted to mean that SSA has not informed Congress of this in the past. However, on page 6, the report quotes both the Commissioner's testimony to Congress on May 11, 2006, where she informed them that for FY 2006, SSA is processing fewer CDRs and is instead focusing on initial disability claims, due to budget restrictions, as well as the Agency's Performance Plan for Fiscal Year 2007. We recommend that the clause be revised in both recommendations to reflect the fact that SSA informed Congress in the past. The sentence could be revised as follows: "When the Agency chooses to use its budgetary resources for purposes other than conducting these reviews, it should continue to publicly disclose these facts to Congress."
On page 4 of the draft report, there is a reference to the Childhood CDR sample stating, “Of the 106 CDRs not completed timely, 55 were never initiated.” We are concerned that a third party, not having worked on nor followed this audit closely, may not understand that there are specific reasons for these 55 cases not being initiated. Most importantly, CDR cases may not be initiated timely when sufficient funding is unavailable to process the cases. In addition, all CDR cases requiring a full medical review are routinely examined on a monthly basis to determine if a condition exists (such as a recipient being in a non-pay status) that would cause the case to be temporarily screened out and a more productive one substituted in its place.
Our specific responses to the report's recommendations are provided below.
Recommendation 1
Conduct Childhood CDRs at least every 3 years for children under age 18 whose impairments are likely to improve in accordance with the Social Security Act provisions. (When the Agency chooses to use its budgetary resources for purposes other than conducting these reviews, it should publicly disclose these facts to the Congress.)
Response:
We agree. When we have been able to do so, our procedure is to initiate a case a few months before the review diary matures to facilitate timely processing.
Recommendation 2
Conduct Age 18 Redeterminations by the time recipients attain age 20. (When the Agency chooses to use its budgetary resources for purposes other than conducting these reviews, it should publicly disclose these facts to the Congress.)
Response:
We agree. As in our response to Recommendation 1, when we have been able to do so, our procedure is to initiate a case a few months before the review diary matures to facilitate timely processing.
Recommendation 3
Continue to seek special funding for CDR workloads.
Response:
We agree. However, while funding outside the discretionary spending limits was an effective funding mechanism previously, it is not the only way in which Congress could provide resources to fulfill the Agency's stewardship responsibilities.
Appendix E -- OIG Contacts and Staff Acknowledgments
Judith Oliveira, Director, Boston Audit Division, (617) 565-1765
David Mazzola, Audit Manager, (617) 565-1807
Acknowledgments
In addition to those named above:
Chad Burns, Auditor
Phillip Hanvy, Senior Program Analyst
Kevin Joyce, IT Specialist
Toni Paquette, Program Analyst
For additional copies of this report, please visit our web site at www.socialsecurity.gov/oig or
contact the Office of the Inspector General’s Public Affairs Specialist
at (410) 965-3218. Refer to Common Identification Number
A-01-06-21093.
DISTRIBUTION SCHEDULE
Commissioner of Social Security
Office of Management and Budget, Income Maintenance Branch
Chairman and Ranking Member, Committee on Ways and Means
Chief of Staff, Committee on Ways and Means
Chairman and Ranking Minority Member, Subcommittee on Social Security
Majority and Minority Staff Director, Subcommittee on Social Security
Chairman and Ranking Minority Member, Subcommittee on Human Resources
Chairman and Ranking Minority Member, Committee on Budget, House of Representatives
Chairman and Ranking Minority Member, Committee on Government Reform and Oversight
Chairman and Ranking Minority Member, Committee on Governmental Affairs
Chairman and Ranking Minority Member, Committee on Appropriations, House of Representatives
Chairman and Ranking Minority, Subcommittee on Labor, Health and Human Services,
Education and Related Agencies, Committee on Appropriations,
House of Representatives
Chairman and Ranking Minority Member, Committee on Appropriations, U.S. Senate
Chairman and Ranking Minority Member, Subcommittee on Labor, Health and Human
Services, Education and Related Agencies, Committee on Appropriations, U.S. Senate
Chairman and Ranking Minority Member, Committee on Finance
Chairman and Ranking Minority Member, Subcommittee on Social Security and Family
Policy
Chairman and Ranking Minority Member, Senate Special Committee on Aging
Social Security Advisory Board
-- FOOTNOTES FOLLOW --
A representative payee
is a person, agency, organization, or institution selected to receive and
manage benefits on behalf of a recipient who cannot manage or direct the
management of his or her finances because of age, mental, and/or physical
impairments. The Social Security Act §§ 205(j) and 1631(a),
42 U.S.C. §§ 405(j) and 1383(a), and 20 C.F.R. §§ 404.2001-2065
and 416.601-665.
The Social Security Act § 1614(a)(3)(H)(iii)(II) states Age 18 redeterminations are to be completed either during the 1-year period beginning on the individual's 18th birthday or, in lieu of a continuing disability review, whenever the Commissioner determines that an individual's case is subject to a redetermination.
SSA acknowledged that CDRs can take up to a year in our prior report, Review of the Effectiveness of SSA’s Low Birth Weight Baby Program (A-04-95-06015), July 1997.
In our July 2002 report, Continuing Disability Reviews for Supplemental Security Income Recipients Approved Based on Low Birth Weight (A-01-02-12031), we also defined CDRs as timely if completed within 12 months after the scheduled review date.
SSA stated this policy decision was made due to a number of projects implemented at that time to transition disabled childhood beneficiaries into adulthood.
We believe our definition of timeliness (within 1 year of the scheduled review date) was reasonable because the average and median number of days it took the Agency to complete Childhood CDRs for our sample cases were 314 and 238 days, respectively.
According to the SSI annual
report for FY 2005 (published May 2006), the lowest annual cessation rates
after all appeals between FYs 1999 through 2005 were 13.6 percent
for Childhood CDRs and 26.9 percent for Age 18 Redeterminations. Therefore,
throughout our report, we counted only 13.6 percent of the dollars related
to Childhood CDRs that were not completed and 26.9 percent of the dollars
related to Age 18 Redeterminations that were not completed. (See
Appendix B for details on our methodology.)
Of the 106 CDRs that were not completed timely, we did not count dollars for 41 cases—the 35 continuances, 3 cases where the scheduled medical review came due in October 2006, 2 of the cessations that were later overturned on appeal and 1 case where benefits were suspended. The remaining 65 recipients were paid from 1 month to almost 10 years (with a median of 13 months) after the Childhood CDRs should have been completed.
Overview of the Office
of the Inspector General
The Office of the Inspector General (OIG) is comprised of our Office of Investigations
(OI), Office of Audit (OA), Office of the Chief Counsel to the Inspector General
(OCCIG), and Office of Executive Operations (OEO). To ensure compliance with
policies and procedures, internal controls, and professional standards, we
also have a comprehensive Professional Responsibility and Quality Assurance
program.
Office of Audit
OA conducts and/or supervises financial and performance audits of the Social
Security Administration’s (SSA) programs and operations and makes recommendations
to ensure program objectives are achieved effectively and efficiently. Financial
audits assess whether SSA’s financial statements fairly present SSA’s
financial position, results of operations, and cash flow. Performance audits
review the economy, efficiency, and effectiveness of SSA’s programs and
operations. OA also conducts short-term management and program evaluations
and projects on issues of concern to SSA, Congress, and the general public.
Office of Investigations
OI conducts and coordinates investigative activity related to fraud, waste,
abuse, and mismanagement in SSA programs and operations. This includes wrongdoing
by applicants, beneficiaries, contractors, third parties, or SSA employees
performing their official duties. This office serves as OIG liaison to the
Department of Justice on all matters relating to the investigations of SSA
programs and personnel. OI also conducts joint investigations with other
Federal, State, and local law enforcement agencies.
Office of the Chief Counsel to the Inspector General
OCCIG provides independent legal advice and counsel to the IG on various matters,
including statutes, regulations, legislation, and policy directives. OCCIG
also advises the IG on investigative procedures and techniques, as well as
on legal implications and conclusions to be drawn from audit and investigative
material. Finally, OCCIG administers the Civil Monetary Penalty program.
Office of Executive Operations
OEO supports OIG by providing information resource management and systems security.
OEO also coordinates OIG’s budget, procurement, telecommunications, facilities,
and human resources. In addition, OEO is the focal point for OIG’s strategic
planning function and the development and implementation of performance measures
required by the Government Performance and Results Act of 1993.