Thursday, January 7, 2016

State Agency Fraud

I represent a 60 year old with orthopedic and cardiovascular problems who worked for 46 years, including over three decades as a media salesperson, where he earned a large six figure income. His application for Social Security Disability (“SSD”) benefits was initially denied by the State agency. 

Common sense dictates that a claimant does not misrepresent or exaggerate his disability in order to trick the government into paying SSD benefits that are a tenth of his past income. Nonetheless, despite having submitted Residual Functional Capacity (“RFC”) assessments from his orthopedist, cardiologist, and internist, the claimant was compelled to attend a hearing before his SSD benefits were approved today. Compelling a hearing was particularly appalling in light of fraudulent misrepresentations that the State agency in connection with a report that DDS Disability Adjudicator/Examiner V. Kumar prepared in connection with the claimant’s application. 

Kumar wrote that the claimant’s doctors refused to perform a consultative examination (“CE”) for the state approved vendor fee. Neither Kumar nor anybody else from the DDS ever spoke with 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. The official Social Security folder showed that the DDS never even contacted any of the claimant’s doctors by mail about anything. 

What made Kumar’s fraudulent misrepresentation especially appalling is that I had sent a letter that 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."

The second fraudulent assertion that Kumar made was that the CE was needed because there was insufficient evidence to evaluate the claim. The file contained over a hundred pages of treatment records, functionality opinions, and diagnostic testing. Proof that the evidence was sufficient is that the judge only asked a couple of questions at the hearing. Moreover, I had 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.” As discussed above, the folder contained three RFC assessments. In fact, the RFC from the claimant’s orthopedist appears in the eFolder twice. 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 such RFC assessment existed in the folder. 

The most egregious fraud committed was Kumar’s writing that the claimant missed two CE appointments. The claim folder included a form DDD-4184, entitled CE Appointment Notice History. The form DDD-4184 stated that the claimant did not keep the appointment for the CE. Whoever prepared the form DDD-4184 committed fraud because the claimant has photographs of him entering the IMA offices for the CE. The claimant also videotaped him inside the IMA offices, and being told to leave by IMA

Although I asked the judge what steps he would take to address the fraudulent misconduct by the State agency and/or IMA, I never received a response.

No comments: