SOCIAL SECURITY ADMINISTRATION

COMPASSIONATE ALLOWANCE
INITIATIVE

August 2010

A-01-10-21080

AUDIT REPORT

Mission

By conducting independent and objective audits, evaluations and investigations, we inspire public confidence in the integrity and security of SSA's programs and operations and protect them against fraud, waste and abuse. We provide timely, useful and reliable information and advice to Administration officials, 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:

Conduct and supervise independent and objective audits and investigations relating to agency programs and operations.
Promote economy, effectiveness, and efficiency within the agency.
Prevent and detect fraud, waste, and abuse in agency programs and operations.
Review and make recommendations regarding existing and proposed legislation and regulations relating to agency programs and operations.
Keep the agency head and the Congress fully and currently informed of problems in agency programs and operations.

To ensure objectivity, the IG Act empowers the IG with:

Independence to determine what reviews to perform.
Access to all information necessary for the reviews.
Authority to publish findings and recommendations based on the reviews.

Vision

We strive for continual improvement in SSA's programs, operations and management by proactively seeking new ways to prevent and deter fraud, waste and abuse. We commit to integrity and excellence by supporting an environment that provides a valuable public service while encouraging employee development and retention and fostering diversity and innovation.

MEMORANDUM

Date: August 6, 2010

To: The Commissioner

From: Inspector General

Subject: Compassionate Allowance Initiative (A-01-10-21080)

OBJECTIVE

The objective of our review was to assess the Social Security Administration's (SSA) efforts to expedite disability decisions under its Compassionate Allowance (CAL) initiative.

BACKGROUND

In October 2008, SSA implemented the CAL initiative to expedite the processing of disability claims for applicants whose medical conditions are so severe that their conditions clearly meet SSA's definition of disability. The initiative allows SSA to electronically target and make speedy decisions for the most obviously disabled individuals.

SSA's systems were originally designed to automatically identify disability claims for CAL if the claimant alleged 1 of the 50 conditions-25 rare diseases and 25 cancers-identified as CAL conditions. The initial list of CAL conditions was developed as a result of information received at public outreach hearings as well as comments from the public, SSA and disability determination services (DDS) personnel, and medical and scientific experts. (See Appendix B for a list of CAL conditions in effect when we selected our audit population.) Beginning March 1, 2010, SSA expanded the list of CAL conditions to include 38 more-for a total of 88 conditions.

According to SSA's policy, cases selected under the CAL initiative receive expedited processing within the context of the existing disability determination process. While the DDSs assess medical evidence to determine whether the claimant is disabled under the Social Security Act, SSA field office staff assesses the non-medical factors of eligibility, such as evaluating work activity or developing proof of age. If a claim is selected for CAL processing, the SSA field office is required to complete all necessary non-medical development immediately.

The CAL initiative is similar to the Quick Disability Determination (QDD) process. CAL and QDD are linked under the fast-tracked Agency Strategic Plan and Agency Performance goals. Both programs use a predictive model to electronically select claims, but criteria for CAL are simpler than the criteria for QDD. Additionally, cases with a terminal illness (TERI) indicator must be handled in an expeditious manner because of their sensitivity. These cases are identified by SSA or DDS staff and flagged in the Agency's records. See Appendix E for more information on the predictive model.

To perform this review, we obtained a file of 41,524 initial disability claims selected for CAL processing between October 2008 and September 2009. We analyzed disability determination records, benefit records, and electronic disability folder information for a sample of 275 of these claims. Additionally, we obtained a file of 27,044 disability claims not selected for CAL processing between October 2008 and September 2009 that were approved because of 1 of the top 10 diagnosis codes under which CAL cases were allowed in our sample. We analyzed electronic disability folder information for a sample of 50 cases from each of the 10 diagnosis codes. (See Appendix C for additional information on our scope and methodology.)

RESULTS OF REVIEW

We found that SSA generally expedited claims selected for CAL processing. SSA processed most cases selected for CAL processing in fewer days than the national average processing time. However, we found that not all disability claims with alleged CAL conditions were selected for CAL processing. As a best practice, SSA continually monitors the CAL predictive model and makes enhancements when necessary.
SAMPLE RESULTS FOR CASES CODED AS CAL

In our sample of 275 cases with a CAL indicator, we found that SSA's systems and SSA and DDS staff appropriately identified 271 cases. Of the 275 sample cases, 262 cases remained in CAL processing, while 13 cases were removed from CAL processing. The Agency processed these 262 sample cases at the initial level in an average of 47 days. SSA's national average processing time was 101 days in Fiscal Year 2009; therefore, CAL cases were processed in less time than the national average. Chart 1 (below) shows the average CAL processing time for initial disability claims by component.

In our 275 sample cases selected for CAL processing,

256 (93 percent) were allowed for disability benefits at the initial level and

19 (7 percent) were not allowed for disability benefits at the initial level.

Table 1 shows the breakout of the 275 sample cases by SSA program-DI and/or SSI-and by Region. (See Appendix D for a breakout by State.)

Table 1: Summary of Sample CAL Cases by SSA Program and Region
Region
DI Only
SSI Only Both DI and SSI Total by Region
Allowed Not Allowed
Allowed Not Allowed
Allowed Not Allowed
1 Boston 13 0 1 2 1 0 17
2 New York 12 1 1 0 3 0 17
3 Philadelphia 20 1 4 0 0 1 26
4 Atlanta 39 3 9 1 9 0 61
5 Chicago 33 4 3 0 10 1 51
6 Dallas 22 0 7 1 5 1 36
7 Kansas City 12 0 2 0 3 0 17
8 Denver 7 0 0 0 0 0 7
9 San Francisco 17 2 5 0 5 0 29
10 Seattle 9 1 3 0 1 0 14

TOTAL 184 12 35 4 37 3 275

Of the 275 cases selected for CAL processing, 256 (93 percent) were initially allowed for disability benefits. The average processing time for all allowances was 15 days, ranging from 1 to 139 days from the date the claim was received until the medical determination was completed by the DDS or affirmed by a Federal quality reviewer.

We sorted the sample claims by diagnosis code and identified the 10 most common diagnoses. Of the 256 allowances in our sample, we found most (195 claimants) had 1 of 10 diagnosis codes (as shown in Table 2).

Table 2: Primary Diagnoses of Allowed Cases

Diagnosis Number of Cases
Percent**
Lung Cancer 49 19.1
Breast Cancer 26 10.2
Pancreatic Cancer 25 9.8
Colon Cancer 22 8.6
Liver Cancer 20 7.8
Leukemia 14 5.5
Esophageal Cancer 13 5.1
Brain Cancer 9 3.5
Kidney Cancer 9 3.5
Anterior Horn Cell Disease (including Amyotrophic Lateral Sclerosis, or ALS) 8 3.1
Total 195 76.2

**The percent is based on the 256 allowed claims in our sample.

For example, a woman filed for DI benefits on June 3, 2009 because of lung cancer. She provided medical evidence with her application, and the DDS was able to make a determination the following day. After SSA's Disability Quality Branch (DQB) reviewed the case and SSA processed the claim, she received her first check on June 9, 2009-6 days after she contacted SSA to file for disability benefits.

Of the 275 cases selected for CAL processing, 19 (7 percent) were not allowed for disability benefits. The average processing time for all claims not allowed was 75 days, ranging from 16 to 218 days from the date the DDS received the claim until the medical determination was completed by the DDS or affirmed by a Federal quality review. Although only 7 percent of cases selected for CAL were not medically allowed, we analyzed these 19 cases further since one of the factors considered when selecting a case for CAL processing is that the applicant's medical conditions are so severe that his or her condition clearly meets SSA's definition of disability. Table 3 summarizes why these 19 claimants were not allowed benefits.

Table 3: Reasons CAL Cases Were Not Allowed
Able to perform past work 4
Able to perform work other than past occupation 5
Impairment not expected to last 12 months 2
Impairment not severe 6
Insufficient evidence 1
Returned to work 1

Total 19

Based on our review of these cases, it appeared 17 of these 19 claims were appropriately selected for CAL processing, based on information the claimants initially provided SSA. The remaining two cases were incorrectly identified because the predictive model identified key words out of context. For example, in one of the two cases, the claimant alleged liver disease and cervical cancer, but the system mistakenly identified the CAL condition as liver cancer. Additionally, 9 of these 19 claims were removed from CAL processing before the determination was made.

For example, a woman applied for both DI and SSI benefits on June 2, 2009 because of Stage IV Colon Cancer. The DDS denied her claim on September 29, 2009 because, although she had cancer, her condition was not expected to remain severe enough to keep her from working for 12 months in a row. She filed a reconsideration claim on November 12, 2009 and was approved for benefits on December 1, 2009.

Of the 275 cases selected for CAL processing, 206 cases (75 percent) were also selected for another type of expedited processing. Since these 206 cases were selected for another type of expedited processing, they would have been expedited whether or not they were selected for CAL processing. SSA has separate sets of policies and procedures for adjudicating each type of expedited processing initiative. Of the 206 cases

94 cases were also selected for QDD processing, and a determination was made in an average of 11 days;
28 cases were also selected for TERI processing, and a determination was made in an average of 28 days; and
84 cases were also selected for both QDD and TERI processing and a determination was made in an average of 9 days.

Cases may be removed from CAL processing if the medical evidence does not confirm the CAL condition or if the system mistakenly identified the condition as CAL. Of our 275 sample cases, 13 were removed from CAL processing. Most of these cases were removed because the claimant did not actually have the alleged medical condition. Additionally, it appeared that four cases should have been removed from CAL processing but were not. Three of these cases should have been removed because the claimant did not actually have the CAL condition alleged and one did not allege a CAL condition.

For example, in one case, a man from Massachusetts applied for SSI payments. He alleged pancreatic cancer as his disabling condition and his claim was selected for CAL processing. The DDS denied his claim, and the medical evidence showed that he did not have pancreatic cancer but had pancreatitis. This claim should have been removed from CAL processing so further appeals would not be expedited.

A CAL indicator is automatically added to the disability folder if the predictive model determines the case qualifies for CAL processing. Also, DDS and DQB have the capability to manually add cases to CAL processing if an alleged or existing condition that would allow CAL processing is identified. Of our 275 sample cases, 10 were not automatically selected for CAL processing. In these 10 cases, a CAL indicator was manually added on average 20 days after the claim was sent to the DDS, ranging from 4 to 38 days. Additionally, these claims were processed in an average of 23 days from the date the DDS received the claim until the medical determination was completed by the DDS or affirmed by a Federal quality review.

For example, a man filed for disability benefits in May 2009. He alleged lung and bone cancer as his disabling conditions. This claim was not automatically selected for CAL processing, but a CAL indicator was added when the claim was affirmed by a Federal quality review-37 days after the DDS received the claim.

SAMPLE RESULTS FOR CASES NOT IDENTIFIED FOR CAL PROCESSING

We reviewed a sample of 500 cases that were allowed and not processed as CAL, but they had a diagnosis code that matched 1 of the top 10 diagnosis codes of CAL cases in our sample. With SSA's assistance, we determined

303 (60 percent) appeared to have a CAL condition but did not provide enough detail for SSA's systems to automatically identify them as CAL;
60 (12 percent) had a CAL condition but applied before the predictive model was improved;
54 (11 percent) were diagnosed with a CAL condition after the date of application;
45 (9 percent) did not have a CAL condition or applied before the implementation of the CAL initiative; and
38 (8 percent) should have been identified as CAL.

Of the 500 sample cases not coded as CAL, 303 had a CAL condition but did not provide enough detail or correct spelling for SSA's systems to automatically identify the cases as CAL. Therefore, it is reasonable that these cases were not automatically selected for CAL processing. However, DDS staff could have recognized that a CAL condition existed and manually selected the cases for CAL processing. The average processing time for these cases was 36 days, ranging from 1 to 247 days from the date the claim was received until the medical determination was completed by the DDS or affirmed by a Federal quality review. Additionally, 50 of these cases were coded as QDD cases, 76 were coded as TERI cases, and 37 were coded as both QDD and TERI cases.

For example, a 45 year old woman applied for disability benefits on October 31, 2008, and her claim was sent to the DDS on November 3, 2008. She alleged cancer but did not specify what type of cancer even though she was diagnosed with stage 4 urethral cancer in October 2008. Because the claimant only alleged "cancer," the predictive model did not select this case for CAL processing. The DDS allowed her claim in March 2009-123 days after the DDS received the claim. Had the SSA employee handling this case asked for the specific diagnosis and entered it into the computer system, this claim would have been selected for CAL processing and expedited. This case could have been manually selected for CAL processing.

Of the 500 sample cases not coded as CAL, 38 cases appeared to meet CAL criteria. The average processing time for these cases was 28 days, ranging from 1 to 95 days from the date the DDS received the claim until the medical determination was completed by the DDS or affirmed by a Federal quality review. Additionally, 5 of these cases were coded as QDD cases, 10 were coded as TERI cases, and 5 were coded as both QDD and TERI cases.

By not identifying claims as CAL, SSA may not have expedited claims that qualified under CAL criteria. For example, a 52-year-old woman applied for disability benefits on August 19, 2009 and her claim was sent to the DDS on September 3, 2009. She alleged "liver and bone cancer," but her claim was not selected for CAL processing. The DDS allowed her claim on October 1, 2009-29 days after receiving the claim. This case may have been expedited if it had been selected for CAL processing.

Of the 500 sample cases not coded as CAL, 54 were diagnosed with a CAL condition after the date of application, and therefore were not automatically selected for CAL processing. The average processing time for these cases was 81 days, ranging from 2 to 192 days from the date the claim was received until the medical determination was completed by the DDS or affirmed by a Federal quality review. The average processing time from the date SSA became aware of the CAL condition was 22 days. Additionally, seven of these cases were coded as TERI cases.

For example, a 61 year old man applied for disability benefits in January 2009. At that time, he alleged a crushed disc and pinched nerves in his back as his disabling condition. In April 2009, he was diagnosed with lung cancer, and the DDS approved his claim 5 days after becoming aware of his condition.

The Commissioner of SSA has held five CAL public outreach hearings to obtain the public's views about the advisability and possible methods of identifying and implementing new CAL conditions. The hearings were on rare diseases, cancers, traumatic brain injury and stroke, early-onset Alzheimer's disease and related dementias, and schizophrenia.

Additionally, as a best practice, SSA continually monitors the CAL predictive model and makes enhancements when necessary. For example, the Agency identified some issues and made systems enhancements in March, May, and August 2009.

CONCLUSION AND RECOMMENDATIONS

Generally, we found SSA's efforts to expedite disability decisions under its CAL initiative were successful. SSA processed cases identified as CAL in an average of 47 days-faster than the national average of 101 days in Fiscal Year 2009. However, many of these claims would have been expedited even if not selected under CAL, since they were also selected under other expedited procedures. Also, the Agency did not identify all cases that qualified for CAL processing.

We recommend that SSA

1. Continue the best practice of reviewing the CAL predictive model periodically and identify enhancements, such as a medical spell check program, to ensure it is working at its optimal level.

2. Assess whether policies and procedures for adjudicating all claims identified for expedited processing should be combined and simplified for the claims adjudication process.

AGENCY COMMENTS

SSA agreed with our recommendations. See Appendix F for the Agency's comments.

Patrick P. O'Carroll, Jr.Appendices

APPENDIX A - Acronyms

APPENDIX B - Compassionate Allowance Conditions

APPENDIX C - Scope and Methodology

APPENDIX D - Sample Cases by Region and State

APPENDIX E - Predictive Model Software

APPENDIX F - Agency Comments

APPENDIX G - OIG Contacts and Staff Acknowledgments

Appendix A
Acronyms
CAL Compassionate Allowance
C.F.R. Code of Federal Regulations
DDS Disability Determination Services
DI Disability Insurance
DQB Disability Quality Branch
OIG Office of the Inspector General
PM Predictive Model
POMS Program Operations Manual System
QDD Quick Disability Determination
SSA Social Security Administration
SSI Supplemental Security Income
TERI Terminal Illness
U.S.C. United States Code

Appendix B
Compassionate Allowance Conditions

Table B-1 shows the Compassionate Allowance (CAL) condition alleged for each of our 275 sample cases and the average elapsed processing time, which is the number of days between the date the claim was received by the disability determination services (DDS) until the date the claim was completed by the DDS or affirmed by a Federal quality reviewer. Table B-2 shows a list of the remaining CAL conditions.

Table B-1: Alleged Impairment for 275 Sample Cases
Diagnosis Number of Cases Elapsed Processing Time
Acute Leukemia 16 12 days
Amyotrophic Lateral Sclerosis 11 16 days
Astrocytoma 1 5 days
Bladder Cancer 1 2 days
Bone Cancer 8 7 days
Breast Cancer 26 28 days
Esophageal Cancer 12 7 days
Friedreichs Ataxia 4 23 days
Frontotemporal Dementia, Picks Disease 4 41 days
Gallbladder Cancer 4 14 days
Gliblastoma Multiforme (Brain Tumor) 13 13 days
Head and Neck Cancers 10 20 days
Kidney Cancer 7 11 days
Large Intestine Cancer 22 22 days
Liver Cancer 35 25 days
Mantle Cell Lymphoma 1 143 days
Non-Small Cell Lung Cancer 33 12 days
Ornithine Transcarbamylase Deficiency 1 38 days
Ovarian Cancer 7 9 days
Pancreatic Cancer 31 21 days
Small Cell Cancer of the Large Intestine, Ovary, Prostate, or Uterus 5 21 days
Small Cell Lung Cancer 14 11 days
Small Intestine Cancer 1 4 days
Stomach Cancer 3 15 days
Thyroid Cancer 1 4 days
Not a Compassionate Allowance Condition 4 61 days
Total 275 19 days

Table B-2: CAL Conditions Not in Sample
Adrenal Cancer
Alexander Disease
Anaplastic Adrenal Cancer
Canavan Disease
Cerebro Oculo Facio Skeletal Syndrome
Chronic Myelogenous Leukemia
Creutzfeldt-Jakob Disease
Ependymoblastoma
Farber's Disease
Gaucher Disease
Infantile Neuroaxonal Dystrophy
Inflammatory Breast Cancer
Krabbe Disease
Lesch-Nyhan Syndrome
Metachromatic Leukodystrophy
Niemann-Pick Disease
Osteogensis Imperfecta
Peritoneal Mesothelioma
Pleural Mesothelioma
Pompe Disease
Rett Syndrome
Salivary Tumors
Sandhoff Disease
Spinal Muscular Atrophy
Ureter Cancer

Appendix C
Scope and Methodology
To accomplish our objective, we:

Reviewed applicable sections of the Social Security Act and the Social Security Administration's (SSA) regulations, rules, policies, and procedures.

Reviewed SSA's Fiscal Year 2009 Performance and Accountability Report showing the average processing time for all initial disability claims.

Obtained a file of 41,524 claims selected for Compassionate Allowance (CAL) processing between October 24, 2008 and September 30, 2009. From this population, we selected a sample of 275 claims for detailed review. For each claim, we:

o Reviewed SSA's systems, including the Disability Determination Services Query, Master Beneficiary Record, Supplemental Security Record, and electronic disability folder.

o Determined whether the claim was appropriately selected for CAL processing and whether the claim should have remained in CAL processing.

o Calculated the number of days to complete the medical determination (including quality reviews) after the application date.

o Calculated the number of days to complete all actions to process the claim.

Obtained a file of 27,044 disability claims not selected for CAL processing between October 24, 2008 and September 30, 2009 that were approved with 1 of the top 10 diagnosis codes under which CAL cases were allowed in our sample. From this population, we selected a sample of 50 cases from each of the 10 diagnosis codes for detailed review. For each claim, we:

o Reviewed the electronic disability folder.

o Determined, with assistance from SSA, whether the case should have been selected for CAL processing.

o Calculated the number of days to complete the medical determination (including quality reviews) after the claim was received by the DDS.

We conducted our audit between January and April 2010 in Boston, Massachusetts. The entities audited were the Offices of Disability Programs under the Deputy Commissioner for Retirement and Disability and Disability Determinations under the Deputy Commissioner for Operations. We conducted this performance audit in accordance with generally accepted government auditing standards. Those 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 tested the data obtained for our audit and determined them to be sufficiently reliable to meet our objective. We believe the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix D
Sample Cases by Region and State

Tables D-1 through D-10 show the breakout of the 275 sample cases selected for Compassionate Allowance (CAL) processing by Disability Insurance (DI) and/or Supplemental Security Income (SSI) program and by Region and State.

Table D-1: Summary of Sample CAL Cases in Region 1 - Boston
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Connecticut 3 0 0 0 0 0 3
Maine 2 0 0 0 0 0 2
Massachusetts 6 0 0 2 0 0 8
New Hampshire 1 0 0 0 1 0 2
Rhode Island 1 0 0 0 0 0 1
Vermont 0 0 1 0 0 0 1

TOTAL 13 0 1 2 1 0 17

Table D-2: Summary of Sample CAL Cases in Region 2 - New York
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
New York 8 0 1 0 1 0 10
New Jersey 3 0 0 0 2 0 5
Puerto Rico 1 1 0 0 0 0 2

TOTAL 12 1 1 0 3 0 17

Table D-3: Summary of Sample CAL Cases in Region 3 - Philadelphia
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Delaware 1 0 0 0 0 0 1
Maryland 4 0 1 0 0 0 5
Pennsylvania 7 0 2 0 0 0 9
Virginia 5 0 1 0 0 1 7
West Virginia 3 1 0 0 0 0 4

TOTAL 20 1 4 0 0 1 26

Table D-4: Summary of Sample CAL Cases in Region 4 - Atlanta
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Alabama 5 1 1 0 2 0 9
Florida 9 0 3 1 1 0 14
Georgia 11 0 1 0 3 0 15
Kentucky 0 0 0 0 1 0 1
Mississippi 1 1 1 0 1 0 4
North Carolina 7 1 2 0 1 0 11
South Carolina 4 0 1 0 0 0 5
Tennessee 2 0 0 0 0 0 2

TOTAL 39 3 9 1 9 0 61

Table D-5: Summary of Sample CAL Cases in Region 5 - Chicago
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Illinois 5 0 0 0 2 0 7
Indiana 6 0 0 0 0 0 6
Michigan 8 3 0 0 4 0 15
Minnesota 5 0 2 0 0 0 7
Ohio 3 1 1 0 2 1 8
Wisconsin 6 0 0 0 2 0 8

TOTAL 33 4 3 0 10 1 51

Table D-6: Summary of Sample CAL Cases in Region 6 - Dallas
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Arkansas 1 0 0 0 1 0 2
Louisiana 2 0 0 0 1 0 3
New Mexico 0 0 0 0 0 0 0
Oklahoma 2 0 1 1 1 0 5
Texas 17 0 6 0 2 1 26

TOTAL 22 0 7 1 5 1 36

Table D-7: Summary of Sample CAL Cases in Region 7 - Kansas City
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Iowa 4 0 0 0 0 0 4
Kansas 2 0 2 0 1 0 5
Missouri 5 0 0 0 2 0 7
Nebraska 1 0 0 0 0 0 1

TOTAL 12 0 2 0 3 0 17

Table D-8: Summary of Sample CAL Cases in Region 8 - Denver
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Colorado 2 0 0 0 0 0 2
Montana 1 0 0 0 0 0 1
North Dakota 0 0 0 0 0 0 0
South Dakota 0 0 0 0 0 0 0
Utah 2 0 0 0 0 0 2
Wyoming 2 0 0 0 0 0 2

TOTAL 7 0 0 0 0 0 7

Table D-9: Summary of Sample CAL Cases in Region 9 - San Francisco
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Arizona 1 0 0 0 1 0 2
California 14 1 5 0 3 0 23
Hawaii 2 0 0 0 1 0 3
Nevada 0 1 0 0 0 0 1

TOTAL 17 2 5 0 5 0 29

Table D-10: Summary of Sample CAL Cases in Region 10 - Seattle
State DI Only SSI Only Both DI and SSI Total by State
Allowed Not Allowed Allowed Not Allowed Allowed Not Allowed
Alaska 0 0 0 0 0 0 0
Idaho 1 0 0 0 0 0 1
Oregon 2 1 2 0 0 0 5
Washington 6 0 1 0 1 0 8

TOTAL 9 1 3 0 1 0 14

Appendix E
Predictive Model Software

The Social Security Administration (SSA) provided the following information, which describes the predictive model (PM) used to select Compassionate Allowance (CAL) and Quick Disability Determination (QDD) cases.

The PM software was originally designed by International Business Machines Corporation for the QDD process. It is a statistical modeling program that generates a score to identify initial cases that have a high degree of probability that the claimant is disabled, evidence of the claimant's allegations can be easily and quickly obtained, and the case can be processed quickly in the Disability Determination Services (DDS).

The CAL initiative leveraged the PM software for a different purpose. Each CAL condition (for example acute leukemia) was given a unique identification number. The conditions and their short descriptors-including alternative names and abbreviations-are contained in two global reference tables. These tables work with the PM to support its ability to appropriately identify cases by the named condition and allow SSA to facilitate rapid changes to improve the accuracy of the PM. The CAL PM uses both tables to scan and compare what is entered for allegations in SSA's disability case processing system.

Cases determined to be CAL can also meet the criteria for QDD and would be designated both QDD and CAL. Also, cases can be manually added as CAL at all adjudicative levels. CAL cases receive priority processing at all levels of adjudication.

The PM software enables automated identification of both QDD and CAL cases at the moment the initial disability application is transmitted from the field office to the DDS for a medical determination. The CAL initiative relies not only on the electronic process, but also on the experience of adjudicators, to identify cases for expedited adjudication.

Appendix F
Agency Comments

MEMORANDUM

Date: July 28, 2010

To: Patrick P. O'Carroll, Jr.
Inspector General

From: James A. Winn /s/
Executive Counselor to the Commissioner

Subject: Office of the Inspector General (OIG) Draft Report, "Compassionate Allowance Initiative" (A 01 10 21080)-INFORMATION

Thank you for the opportunity to review and comment on the draft report. We appreciate OIG's efforts in conducting this review. Attached is our response to the report recommendations.

Please let me know if we can be of further assistance. Please direct staff inquiries to
Candace Skurnik, Director, Audit Management and Liaison Staff, at (410) 965-4636.

COMMENTS ON THE OFFICE OF THE INSPECTOR GENERAL DRAFT REPORT, "COMPASSIONATE ALLOWANCE INITIATIVE" (A-01-10-21080)

We appreciate that you recognize our efforts to expedite processing of disability claims under the compassionate allowance (CAL) initiative. We also appreciated your cooperation during the audit.
You present an accurate description of the CAL initiative. We offer the following responses to your recommendations.
Recommendation 1
Continue the best practice of reviewing the CAL predictive model periodically and identify enhancements, such as a medical spell check program, to ensure it is working at its optimal level.
Comment
We agree and will review the CAL predictive model periodically and improve it if necessary to make sure it operates at an optimal level.
Recommendation 2
Assess whether policies and procedures for adjudicating all claims identified for expedited processing should be combined and simplified for the claims adjudication process.
Comment
We agree and will assess whether we can combine or simplify policies and procedures for expedited claims processing to enhance further the claims adjudication process.

Appendix G
OIG Contacts and Staff Acknowledgments
OIG Contacts

Judith Oliveira, Director, Boston Audit Division
Phillip Hanvy, Audit Manager
Acknowledgments
In addition to those named above:
Katie Greenwood, Auditor
Kevin Joyce, IT Specialist
Katie Toli, Auditor

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 Staff Assistant at (410) 965-4518. Refer to Common Identification Number A-01-10-21080.

Overview of the Office of the Inspector General
The Office of the Inspector General (OIG) is comprised of an Office of Audit (OA), Office of Investigations (OI), Office of the Counsel to the Inspector General (OCIG), Office of External Relations (OER), and Office of Technology and Resource Management (OTRM). To ensure compliance with policies and procedures, internal controls, and professional standards, the OIG also has a comprehensive Professional Responsibility and Quality Assurance program.

Office of Audit
OA conducts 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 reviews and program evaluations on issues of concern to SSA, Congress, and the general public.

Office of Investigations
OI conducts investigations 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 liaison to the Department of Justice on all matters relating to the investigation of SSA programs and personnel. OI also conducts joint investigations with other Federal, State, and local law enforcement agencies.

Office of the Counsel to the Inspector General
OCIG provides independent legal advice and counsel to the IG on various matters, including statutes, regulations, legislation, and policy directives. OCIG 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. Also, OCIG administers the Civil Monetary Penalty program.

Office of External Relations
OER manages OIG's external and public affairs programs, and serves as the principal advisor on news releases and in providing information to the various news reporting services. OER develops OIG's media and public information policies, directs OIG's external and public affairs programs, and serves as the primary contact for those seeking information about OIG. OER prepares OIG publications, speeches, and presentations to internal and external organizations, and responds to Congressional correspondence.

Office of Technology and Resource Management
OTRM supports OIG by providing information management and systems security. OTRM also coordinates OIG's budget, procurement, telecommunications, facilities, and human resources. In addition, OTRM is the focal point for OIG's strategic planning function, and the development and monitoring of performance measures. In addition, OTRM receives and assigns for action allegations of criminal and administrative violations of Social Security laws, identifies fugitives receiving benefit payments from SSA, and provides technological assistance to investigations.