Tuesday, July 14, 2015

Report IMA & DDS Fraud To Inspector General

When a Social Security hearing office receives a disability appeal, it sends the claimant form HA-L2, which is a Request for Hearing Acknowledgment Letter. At the bottom of the first page of Form HA-L2 in bold face type is the (800) 269-0271 telephone number for the Inspector General’s Fraud Hotline, in case you “Suspect Social Security Fraud.” Presumably, that warning is designed to intimidate claimants. 

In all my years representing Social Security Disability (“SSD”) claimants, I can think of only one instance of a claimant attempting to perpetrate a fraud. On the other hand, on a seemingly weekly basis, I find the Disability Determination Services (“DDS”) and its contractor, IMA, committing fraud. Claimants and their advocates should call the Inspector General’s Fraud Hotline when DDS or IMA fraud is suspected. 

One of my client’s eFolder became accessible today. A review of the eFolder revealed several instances of fraud by the DDS and IMA. 

First, a DDS examiner named V. Kumar wrote that the claimant’s doctors refused to perform a consultative examination (“CE”) for the state approved vendor fee. That was a lie. Neither Kumar nor anybody else from the DDS ever contacted any of the claimant’s doctors to ask them if they would perform a CE, let alone ask them if they would perform a CE for any particular fee. What makes Kumar’s fraudulent misrepresentation especially appalling is that I had sent a letter about the CE, which stated: 

"the treating physicians are ready, willing, and able to perform a CE, but you have not asked them to perform a CE. I have spoken with the claimant who has agreed to pay any difference between what you are willing to pay and the amount the treating doctor would charge. Therefore, do not falsely claim that a treating source refused to do the CE because of the fee involved."

If you have a case that is pending at a hearing office, I would suggest reviewing the eCAT report to see what the DDS examiner wrote.

The second fraudulent assertion that Kumar made was that the CE was needed because there was insufficient evidence to evaluate the claim. The file contains over a hundred pages of treatment records, functionality opinions, and diagnostic testing. To compound matters, I sent a detailed seven page single spaced letter to the DDS, asking them to identify any additional medical evidence that they claimed was needed to evaluate the claim. As always, instead of specifying a single piece of medical evidence they purportedly needed, the DDS simply sent a second CE notice, despite my having sent them that detailed letter, which among other things stated: 

"In order for me to have the chance to obtain the information that you claim you need, you need to clarify precisely what information you are seeking. Simply resending a notice with a new CE date fails to fulfill your responsibility to develop the record, and shows that you lack any valid reason for the CE."

Kumar’s third fraudulent misrepresentation was that stating “No RFC /MRFC assessments are associated with this claim.” Contrary to Kumar’s unambiguous statement, the eFolder contained, not one, but two, Residual Functional Capacity (“RFC”) assessments. In fact, the RFC from the claimant’s orthopedist appears in the eFolder twice. There was also an RFC from the claimant’s cardiologist. It was impossible for Kumar to have missed all three reports when reviewing the claimant’s file. Nonetheless, Kumar stated in no uncertain terms that no RFC assessment was in the eFolder. 

The fourth instance of fraud also concerns the CE. Kumar wrote that the claimant missed both CE appointments. As discussed below, that statement is demonstrably false. However, giving Kumar the benefit of the doubt, it is possible that Kumar was provided with the false information by IMA. 

In the eFolder is form DDD-4184, entitled CE Appointment Notice History. The form DDD-4184 states that the claimant did not keep the appointment for the CE. It is unclear who prepared form DDD-4184, but it is clear that whoever did so, committed fraud. The claimant has photographs of him entering the IMA offices. The claimant also has videotape of him inside the IMA offices, being told to leave by IMA. It is a blatant and undeniable lie that the claimant did not keep the appointment. 

As stated in prior posts, I would advise claimants to videotape their CE. There is nothing in the Social Security statute, regulations, POMS, HALLEX, or case law that precludes videotaping a CE. Furthermore, I secured a copy of the contract that IMA has with the DDS, and there is nothing in it that prohibits videotaping a CE.

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