Social Security Disability: Reviews of Beneficiaries' Disability 
Status Require Continued Attention to Achieve Timeliness and	 
Cost-Effectiveness (24-JUL-03, GAO-03-662).			 
                                                                 
The Social Security Administration (SSA) has had difficulty in	 
conducting timely reviews of beneficiaries' cases to ensure they 
are still eligible for disability benefits. SSA has been taking  
steps to improve the cost-effectiveness of its review process.	 
SSA has linked the review process to eligibility for a new	 
benefit that provides return-to-work services. This report looks 
at SSA's ability to stay current with future reviews, identifies 
potential improvements to the review process, and assesses the	 
review process--return-to-work link.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-662 					        
    ACCNO:   A07647						        
  TITLE:     Social Security Disability: Reviews of Beneficiaries'    
Disability Status Require Continued Attention to Achieve	 
Timeliness and Cost-Effectiveness				 
     DATE:   07/24/2003 
  SUBJECT:   Beneficiaries					 
	     Cost effectiveness analysis			 
	     Disability benefits				 
	     Eligibility criteria				 
	     Eligibility determinations 			 
	     Federal social security programs			 
	     Social security benefits				 
	     Workfare						 
	     SSA Disability Insurance Program			 
	     Supplemental Security Income  Program		 

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GAO-03-662

Report to the Chairman, Subcommittee on Social Security, Committee on Ways
and Means, House of Representatives

United States General Accounting Office

GAO

July 2003 SOCIAL SECURITY DISABILITY

Reviews of Beneficiaries* Disability Status Require Continued Attention to
Achieve Timeliness and CostEffectiveness

GAO- 03- 662

SSA will likely face a backlog of about 200,000 continuing disability
review (CDR) cases by the end of fiscal year 2003. SSA officials attribute
the pending backlog to its decision to reduce the number of cases reviewed
as a result of the delay in obtaining fiscal year 2003 funding. In
addition, the pending backlog resulted from putting more emphasis on
initial applications over CDRs. To ensure CDRs receive adequate attention,
SSA has requested some fiscal year 2004 funds be *earmarked* for these
reviews. Given SSA*s ability to eliminate its previous CDR backlog using
targeted funds, this maneuver could help SSA. Over the next 5 years, SSA
has estimated that 8.5 million CDRs, costing about $4 billion, are needed
to stay current. If SSA

generates another backlog, cost savings and program integrity may be
compromised by paying benefits to disability beneficiaries who are no
longer eligible to receive them. SSA is not making the best use of
available information when conducting its

CDRs, leaving opportunities for improvement. First, SSA*s decisions on the
timing of CDRs are not based on systematic analysis of available
information. Second, SSA*s process for determining which CDR method to

use is not always based on the best available information. For example,
SSA requires an in- depth review for all beneficiaries who, upon entering
the program, are expected to medically improve even if current information
on certain of those beneficiaries indicates that improvement is unlikely
and that the review would be better handled through a shorter, less
expensive method. Third, SSA has not fully pursued medical treatment data
available from the Medicare and Medicaid programs despite their potential
to improve SSA*s decisions regarding which review method to use. Fourth,
SSA*s CDRs continue to be hampered by missing or incomplete information on
beneficiaries* case history. SSA delays the provision of new return- to-
work benefits to beneficiaries

expected to medically improve based on the assumption that such
beneficiaries are least likely to need them. However, according to SSA
data, about 94 percent of such beneficiaries are not found to have
medically improved upon completion of a disability review. As a result,
some individuals who might benefit from return- to- work services are
initially denied access to them. SSA is reviewing this policy and while
doing so, will need to consider how to best balance its financial
stewardship and return- to- work goals. The Social Security Administration
(SSA) has had difficulty in

conducting timely reviews of beneficiaries* cases to ensure they are still
eligible for disability benefits. SSA has been taking steps to improve the
costeffectiveness of its review process. SSA has linked the review process
to eligibility for a new benefit that provides return- to- work services.

This report looks at SSA*s ability to stay current with future reviews,
identifies potential improvements

to the review process, and assesses the review process* return- to- work
link.

GAO recommends that the Commissioner of SSA

pursue a more comprehensive, data- driven approach to the method it uses
to decide when to assess individuals for ongoing eligibility;

rely more readily on current assessments of beneficiary information rather
than on assessments made at time of program entry when deciding which
review method to use;

and

study, and incorporate if costeffective, the more comprehensive use of
Medicare/ Medicaid data into

SSA*s decisions about the review method to use. In its comments on a draft
of this

report, SSA generally agreed with GAO*s recommendations.

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 662. To view the full product,
including the scope and methodology, click on the link above. For more
information, contact Robert E. Robertson at (202) 512- 7215 or RobertsonR@
gao. gov. Highlights of GAO- 03- 662, a report to the

Chairman, Subcommittee on Social Security, Committee on Ways and Means,
House of Representatives July 2003

SOCIAL SECURITY DISABILITY

Reviews of Beneficiaries' Disability Status Require Continued Attention to
Achieve Timeliness and CostEffectiveness

Page i GAO- 03- 662 Social Security Disability Letter 1 Results in Brief 3
Background 5 End of Targeted Funding and Other Issues Could Contribute to
Another Backlog, Threatening Cost Savings 10 Further Opportunities Exist
for SSA to Improve CDR CostEffectiveness

17 SSA*s Rationale for Postponing Return- to- Work Services to Some
Beneficiaries Is Not Well- Supported by Program Experience 24 Conclusions
27 Recommendations to the Commissioner of SSA 28 Agency Comments and Our
Evaluation 29 Appendix I Scope and Methodology 32

Appendix II Comments from the Social Security Administration 34

Appendix III GAO Contacts and Staff Acknowledgments 38 GAO Contacts 38
Staff Acknowledgments 38 Tables

Table 1: Estimated CDR Activities, Fiscal Years 2004- 08 13 Table 2: DDS
Directors* Reported Likelihood, If Any, of Experiencing an Event That
Jeopardizes Meeting CDR Workload During Fiscal Years 2004 and 2005 14
Table 3: Extent That DDSs Have a Strategy to Manage Anticipated

Events and Likelihood That Events Will Have Negative Impact on Workload
Processing During Fiscal Year 2004 and 2005 15 Table 4: Summary of SSA*s
CDR Activities During Special Funding

Period, Fiscal Years 1996- 2002 16 Contents

Page ii GAO- 03- 662 Social Security Disability Abbreviations

CDR continuing disability reviews CMS Center for Medicare and Medicaid
Services DDS Disability Determination Services DI Disability Insurance EF
Disability Electronic Folder MIE medical improvement expected MINE medical
improvement not expected MIP medical improvement possible SGA substantial
gainful activity SSA Social Security Administration SSI Supplemental
Security Income

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Page 1 GAO- 03- 662 Social Security Disability July 24, 2003 The Honorable
E. Clay Shaw, Jr. Chairman, Subcommittee on Social Security

Committee on Ways and Means House of Representatives

Dear Mr. Chairman: The Disability Insurance (DI) and Supplemental Security
Income (SSI) programs are the largest federal income programs for disabled
individuals, paying about $86 billion to about 10 million disabled
beneficiaries in 2002. These programs have been growing in recent years
and are poised to grow further as the baby boom generation ages. To help
ensure that only eligible

beneficiaries remain on the rolls, the Social Security Administration
(SSA) is required by law to conduct continuing disability reviews (CDR)
for all DI beneficiaries and some SSI disability recipients to determine
whether they continue to meet the disability requirements of the law. In
addition, to assist beneficiaries who want to return to work and leave the
disability

rolls, SSA began implementing the Ticket to Work and Self- Sufficiency
Program in 2002. Under this program, beneficiaries are issued a *ticket,*
or voucher, which they can use to obtain vocational rehabilitation,
employment, or other return- to- work services from an approved provider
of their choice.

Through much of the 1980s and 1990s, the Congress and GAO, among others,
emphasized the importance of CDRs for maintaining DI and SSI program
integrity and, consequently, the critical need for SSA to conduct CDRs
when they are due and in a cost- effective manner. However, SSA had
difficulty completing all required CDRs when they were due, which resulted
in the development of an enormous backlog of 4.3 million cases. In 1996,
the Congress, in response to these difficulties, authorized funding

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 03- 662 Social Security Disability targeted exclusively for
CDRs from fiscal year 1996 through 2002 to eliminate the CDR backlog and
conduct new CDRs as they became due. 1 At the time beneficiaries enter the
DI or SSI programs or continue their

benefits following a CDR, state- based Disability Determination Services
(DDS) determine beneficiaries* due date for a CDR based on their potential
for medical improvement. Beneficiaries classified as *medical improvement
expected* are generally scheduled for a CDR within 6 to 18 months,
beneficiaries classified as *medical improvement possible* are scheduled
once every 3 years, and beneficiaries classified as *medical improvement
not expected* are scheduled once every 5 to 7 years. Once the date for a
review arrives, SSA compiles information such as age, length of time on
the rolls, and qualifying medical condition to determine if it would be
cost- effective to complete the CDR based on information reported by the
beneficiary on a mailed- out questionnaire (* mailer*). In instances where
SSA determines it is best to examine the beneficiary in person, SSA sends
the beneficiaries* case file to the DDS for a full medical

review. To reduce work disincentives and address some beneficiaries* fear
that any work activity could result in the termination of their benefits
through a CDR, the Ticket to Work and Self- Sufficiency Program prohibits
SSA from conducting CDRs for beneficiaries who are using a ticket.
However, SSA has decided that it will not issue a ticket to beneficiaries
who are

expected to medically improve until their first CDR is completed. SSA
believes these beneficiaries do not require assistance to return to work.
But some disability advocates and policy experts believe that
beneficiaries expected to medically improve could benefit from early
ticket services and, therefore, should not be subject to restrictions on
ticket issuance.

1 The Balanced Budget and Emergency Deficit Control Act of 1985, as
amended, established statutory limits on federal government spending for
fiscal year 1991 through 2002. The act created, among other provisions,
annual adjustable dollar limits (spending caps) on

discretionary spending funded through the regular appropriations process.
The act, as amended, also required that SSA*s discretionary spending caps
that existed through fiscal year 2002 be adjusted upward to account for
appropriations targeted for CDRs. The Contract with America Advancement
Act of 1996 authorized about $4.1 billion to be paid from the Old- Age and
Survivors Insurance Trust Fund and the Disability Insurance Trust Fund to
process CDRs in fiscal year 1996 through 2002. Hereafter, in this report,
we refer to this funding mechanism authorized by the Balanced Budget and
Emergency Deficit Control

Act of 1985 as *CDR- targeted funding.*

Page 3 GAO- 03- 662 Social Security Disability Given the importance of
CDRs in ensuring program integrity and determining beneficiary eligibility
for assistance under the ticket program,

the Chairman of the Subcommittee on Social Security, House Committee on
Ways and Means requested that we review the CDR process. In response, this
report discusses: (1) what impact the expiration of targeted funding for
CDR processing would have on SSA*s ability to remain current with the CDR
caseload, and what level of funding would be needed over the next 5 years
to keep the workload current; (2) what opportunities exist for SSA to
improve the cost- effectiveness of the CDR process; and (3) whether SSA*s
rationale for delaying return- to- work and vocational services under the
ticket program for beneficiaries who are expected to medically improve is
adequately supported by program experience. To answer these questions, we
reviewed SSA documents, including the agency*s budget request and
estimates of the cost and savings from conducting CDRs. Also, we surveyed
52 DDS directors to assess the potential effect of the expiration of CDR-
targeted funding on DDS operations. Moreover, we analyzed SSA data on CDR
outcomes, reviewed SSA- contracted studies of the CDR process, examined
legislation, regulations, and SSA policy guidance related to CDRs and the
ticket program, and interviewed SSA officials. We performed our work in
accordance with generally accepted government auditing standards between
August 2002 and May 2003. See appendix I for a more detailed description
of our scope and methodology.

With the expiration of CDR- targeted funds at the end of fiscal year 2002,
SSA is at risk of generating another CDR backlog; based on SSA*s cost and
workload projections, it would cost a total of about $4 billion or more
over the next 5 years to complete its CDR workload. However, most of the
backlog expected to appear by the end of fiscal year 2003 will likely
consist of SSI CDRs and, according to SSA officials, this makes the
backlog less problematic than if it consisted mostly of DI cases. The
expected shortfall is attributable to several factors. One factor was
SSA*s decision to reduce the number of CDRs it processed pending fiscal
year 2003 funding decisions. Other factors relate to workload capacity and
the lower priority given to CDRs relative to initial claims. In the years
ahead, a CDR backlog could grow due to an expected increase in the number
of initial claims as well as DDS* potential difficulty with replacing the
disability examiners who leave through retirement or attrition. If another
large CDR backlog is generated, SSA is at risk of foregoing cost savings
and compromising the integrity of its disability programs by paying
benefits to disability beneficiaries who are no longer eligible to receive
them. Results in Brief

Page 4 GAO- 03- 662 Social Security Disability While SSA has taken a
number of actions over the past decade to significantly improve the cost-
effectiveness of the CDR process,

opportunities remain for SSA to better use information in CDR decision
making. In particular, SSA*s process for deciding when beneficiaries
should undergo a CDR is not based on systematic analysis of available
information, and likely results in some CDRs not being conducted at the
optimal time. Also, SSA*s process for determining which method to use in
conducting a CDR* mailer or full medical review* is not always based on
the best available information. For example, SSA requires a full medical
review for all beneficiaries who, upon entering the program, are expected
to medically improve even if current information on certain of those
beneficiaries indicates that improvement is unlikely and that the CDR
would be better handled through a much less expensive mailer. In addition,
SSA has not fully studied and pursued the use of medical treatment data on
beneficiaries available from the Medicare and Medicaid programs despite
the potential of these data to improve SSA*s decisions

regarding whether to use a mailer or full medical review to complete a
CDR. Finally, SSA continues to be hampered in its CDR decisions by missing
or incomplete information on beneficiaries* case history. While the exact
magnitude of this problem is unknown, 72 percent of DDSs

reported that missing or incomplete information hinders their ability to
determine whether medical improvement has occurred, thereby making it
difficult for SSA to cease benefits for some individuals who no longer
meet

eligibility standards. SSA*s rationale for delaying issuance of a ticket
to beneficiaries expected to medically improve, based on the premise that
they will regain their capacity to return to work without SSA assistance,
is not well- supported by program experience. The majority of these
beneficiaries* about 94 percent* are not found to have medically improved
upon completion of a CDR. As a result, some beneficiaries who might
otherwise benefit from potentially valuable return- to- work assistance
have to wait up to 3 years to access services through the ticket program.
SSA has acknowledged the need to reexamine this policy, and agency
officials have informed us that they are in the process of doing so. As
SSA reexamines this policy, it will need to consider alternatives that
better balance the agency*s program stewardship and return- to- work
goals.

This report contains recommendations for further improving the
costeffectiveness of SSA*s CDR process. In its comments on a draft of this
report, SSA agreed with our recommendations and said that our review
represents a comprehensive and accurate assessment of SSA*s
accomplishments in improving the CDR process as well as opportunities

Page 5 GAO- 03- 662 Social Security Disability to improve the process. SSA
also provided a number of technical comments, which we incorporated where
appropriate.

The DI and SSI programs are the two largest federal programs providing
cash assistance to people with disabilities. Established in 1956, DI is an
insurance program that provides monthly cash benefits to workers who are
unable to work because of severe long- term disability. Workers who have
worked long enough and recently enough are insured for coverage under the
DI program. In addition to cash assistance, DI beneficiaries receive
Medicare coverage after they have received cash benefits for 24 months. In
2002, SSA paid about $60 billion to 5.5 million disabled workers, with
average monthly cash benefits amounting to $834 per person. 2 DI cash
benefits are paid from the Federal Disability Insurance Trust Fund. 3 SSI,
created in 1972, is a means- tested income assistance program that

provides a financial safety net for disabled, blind, or aged individuals
who have low income and limited resources. Unlike the DI program, SSI has
no prior work requirement and no waiting period for cash or medical
benefits. Eligible SSI applicants generally begin receiving cash benefits
immediately upon entitlement and, in most cases, receipt of cash benefits
makes them eligible for Medicaid benefits. In 2002, about 5.5 million
people with disabilities received SSI benefits. 4 In the same year,
federal SSI cash benefits paid to SSI beneficiaries with disabilities
equaled $26 billion, 2 Included among these 5.5 million beneficiaries are
about 1.2 million beneficiaries who

were dually eligible for SSI benefits because of the low level of their
income and resources. In 2002, the DI program also paid about $6 billion
in cash benefits to about 1.7 million spouses and children of disabled
workers. 3 Most disabled Social Security beneficiaries are disabled
insured workers who receive

benefits through the DI program based on their own earnings record.
However, as of 2002, about 952,000 Social Security disability
beneficiaries were disabled surviving spouses and disabled adult children
who qualified for disability benefits based on the earnings record of an
insured spouse or parent. Many of these disabled surviving spouses and
adult children receive their disability benefits through the Social
Security Old- Age and Survivors Insurance (OASI) program, not the DI
program. OASI disability benefits for disabled surviving spouses and
disabled adult children are paid from the Old- Age and Survivors Trust
Fund. To receive OASI disability benefits, surviving spouses and adult
children must meet the DI program*s disability criteria, and they are also
subject to the requirement for

CDRs. For simplicity, our report refers to all disabled Social Security
beneficiaries (in both DI and OASI) as *DI beneficiaries.*

4 About 3.9 million of these individuals were working age adults aged 18
to 64. Background

Page 6 GAO- 03- 662 Social Security Disability and average monthly federal
SSI cash benefits amounted to about $398 per person. SSI cash benefits are
paid from general tax revenues. The DI and SSI programs use the same
statutory definition of disability. To

meet the definition of disability under these programs, an individual must
have a medically determinable physical or mental impairment that (1) has
lasted or is expected to last at least 1 year or to result in death and

(2) prevents the individual from engaging in substantial gainful activity
(SGA). Individuals are considered to be engaged in SGA if they have
countable earnings above a certain dollar level. 5 Moreover, for a person
to

be determined to be disabled, the impairment must be of such severity that
the person not only is unable to do his or her previous work but,
considering his or her age, education, and work experience, is unable to
do any other kind of substantial work that exists in the national economy.
SSA contracts with state DDS agencies to determine whether applicants are
disabled. To help ensure that only eligible beneficiaries remain on the
rolls, SSA is

required by law to conduct CDRs for all DI beneficiaries and some SSI
disability recipients to determine whether they continue to meet the
disability requirements of the law. In 1980, because of concerns about the
effectiveness of the CDR process and growing disability rolls, the
Congress enacted a law requiring that CDRs be conducted at least once
every 3 years for all DI beneficiaries whose disabilities are not
considered permanent and at intervals determined appropriate by SSA for DI

beneficiaries whose impairments are considered permanent. SSA issued
regulations in 1986 stating its policy of conducting CDRs for SSI
disability beneficiaries with the same frequency as it conducts CDRs for
DI beneficiaries. In 1994, the Congress established the first statutory
requirement for SSI CDRs, requiring that CDRs be conducted for a
relatively small proportion of SSI beneficiaries. Welfare reform
legislation enacted in August 1996 focused on CDRs for SSI children. 6
This legislation required that SSA (1) conduct CDRs at least once every 3
years for SSI children under age 18 if their impairments are not
considered permanent and for infants during their first year of life if
they are receiving SSI benefits due to low birth weight and (2) review the
cases of all SSI

5 For 2003, SSA considers countable earnings above $800 a month to be
substantial gainful activity for persons who are not blind and above
$1,330 a month for persons who are blind. 6 Personal Responsibility and
Work Opportunity Reconciliation Act of 1996 (Pub. L. No. 104- 193).

Page 7 GAO- 03- 662 Social Security Disability children beginning on their
18th birthdays to determine whether they are eligible for disability
benefits under adult disability criteria. The

redeterminations for 18- year- olds are considered part of the CDR
workload.

At the time beneficiaries enter the DI or SSI programs, DDSs determine
when beneficiaries will be due for CDRs on the basis of their potential
for medical improvement. Based on SSA regulations, DDSs classify
individuals into one of three medical improvement categories, called
*diary categories*: *medical improvement expected* (MIE), *medical
improvement possible* (MIP), or *medical improvement not expected* (MINE).
Based on the diary categories, DDSs select a *diary date* for each
beneficiary, which is the date that the beneficiary is scheduled to have a
CDR. The diary date is generally within 6 to 18 months if the beneficiary
is classified as MIE; 7 once every 3 years if classified as MIP; and once
every 5 to 7 years if classified as MINE. Upon completion of a CDR, DDSs

reassess the medical improvement potential of beneficiaries who remain
eligible for benefits to determine the most appropriate medical
improvement category and time frame for conducting the next CDR.
Beneficiaries classified as MIE are not eligible to receive Ticket to Work
services until either the completion of their first CDR, or until they
have received benefits for 3 years.

While SSA uses diary categories to determine the timing of CDRs, it has
developed another method, called profiling, to determine the most
costeffective method of conducting a CDR. Profiling involves the
application of statistical formulas that use data on beneficiary
characteristics contained in SSA*s computerized records* such as age,
impairment type, length of time on disability rolls, previous CDR
activity, and reported earnings* to predict the likelihood of medical
improvement and, therefore, of benefit cessation. For example, SSA found
that the longer an individual is on the disability rolls, the less likely
he or she is to have

benefits terminated. In addition, once an individual undergoes a CDR, the
chance that a new CDR will result in benefit termination is reduced
substantially. Reported earnings, on the other hand, greatly increase the
likelihood of termination.

7 Although SSA*s policy guidance indicates that CDRs for MIE beneficiaries
should generally be scheduled at intervals of 6 to 18 months, the guidance
provides DDS personnel with flexibility to establish a diary date for any
time period between 6 and 36 months. CDR Process

Page 8 GAO- 03- 662 Social Security Disability Through its profiling
formulas, SSA assigns a *score* to beneficiaries indicating whether there
is a high, medium, or low likelihood of medical

improvement. In general, beneficiaries with a high score are referred for
full medical reviews* an in- depth assessment of a beneficiaries* medical
and vocational status* while beneficiaries with lower scores are, at least
initially, sent a questionnaire, known as a *mailer.* 8 The mailer
consists of a short list of questions asking beneficiaries to report
information on their medical conditions, treatments, and work activities.
If beneficiaries*

responses to a mailer indicate possible improvement in medical condition
or vocational status, SSA may refer these individuals for a full medical
review. However, in most cases, SSA decides that a full medical review is
not warranted and that benefits should be continued.

In contrast to mailers, full medical reviews are labor intensive and
expensive. These reviews generally involve the following steps: (1) SSA
headquarters personnel determine that a CDR is due and notify the SSA
processing center; (2) personnel at the processing center locate the
beneficiary*s file and send it to the appropriate SSA field office; (3)
field office personnel contact the beneficiary, conduct a lengthy
interview, and send the file to the appropriate DDS; (4) the DDS requests
medical records

from the beneficiary*s physicians and other medical sources and, if these
sources cannot provide sufficient evidence, schedules medical or
psychological examinations with consulting physicians outside the DDS; and
(5) a DDS team, consisting of a disability examiner and a physician or
psychologist, determines whether the beneficiary continues to meet SSA
disability criteria.

As of fiscal year 1996, about 4.3 million CDRs were due or overdue. In
response, SSA and the Congress focused on providing funding to conduct
overdue CDRs and new CDRs as they became due. SSA developed a plan for a
7- year initiative to conduct about 8.2 million CDRs during fiscal years
1996 through 2002. In the Contract with America Advancement Act of 1996
(Pub. L. No. 104- 121), the Congress authorized a total of about $4.1
billion to fund the 7- year CDR plan. 9 In addition, The Personal

8 While SSA uses mailers primarily for beneficiaries with low profile
scores, the agency has recently expanded its use of mailers to some
beneficiaries with medium and high profile scores. 9 The act also required
that SSA report to the Congress annually for fiscal years 1996 - 2002 on
its CDR activities, including the estimated savings resulting from CDRs.
CDR Backlog

Page 9 GAO- 03- 662 Social Security Disability Responsibility and Work
Opportunity Reconciliation Act of 1996 (Pub. L. No. 104- 193) required SSA
to conduct CDRs on several beneficiary groups, such as low birth weight
babies and authorized an additional $250 million

for CDRs in fiscal years 1997 and 1998. The actual amount appropriated
during the 7- year period, about $3.68 billion, was less than the amount
authorized in 1996.

SSA reported to the Congress in its fiscal year 2000 CDR report that in
that year, the agency became current with the backlog of CDRs for all DI
beneficiaries. SSA officials indicated to us that although they are in the
midst of preparing the final statistics for its fiscal year 2002 CDR
report, it became current with the backlog of CDRs for all SSI
beneficiaries by the end of fiscal year 2002.

Since first implementing the profiling and mailer processes in the early
1990s, SSA has continued its efforts to improve the cost- effectiveness of
the CDR process. Most notably, SSA has refined the statistical formulas
used in profiling to identify which method* mailer or full medical review*
should be used to conduct the CDR. According to SSA officials and studies
of the profiling process, these improvements have led to some
beneficiaries receiving a mailer who otherwise would have received a full
medical review, thereby allowing SSA to reduce the overall cost of the CDR
process. Conversely, by improving SSA*s ability to identify beneficiaries
who are likely to medically improve, these refinements have also helped
the agency better ensure that it is conducting full medical

reviews* and ceasing benefits* when appropriate. 10 In addition to
improvements in its profiling process, SSA has also implemented other CDR
process improvements such as introducing an automated review of mailers.

10 According to SSA*s study of its profiling model, the agency*s recent
improvements in statistical profiling have resulted in hundreds of
millions of dollars in annual savings from being better able to identify
and cease the benefits of individuals who have a relatively high
likelihood of medical improvement. CDR Cost- Effectiveness

Page 10 GAO- 03- 662 Social Security Disability In the midst of its first
year following the cessation of CDR- targeted funds, SSA appears to be
developing another CDR backlog; the agency estimates it will cost several
billion dollars in total over the next 5 years to keep its

workload current. By the end of fiscal year 2003, on the basis of SSA*s
current projections, the agency will likely face a backlog of 200,000
CDRs, though the characteristics of the backlog may mitigate its negative
effects. SSA attributes the mounting backlog to the management decisions
it made at the beginning of the fiscal year during budget deliberations,
as well as

the need to process a larger than expected workload of initial disability
applications. SSA has estimated that it will need a total of about $4
billion to process its projected CDR workload over the next 5 years.
However, SSA*s updated estimate, expected to be available later this year,
will likely show a higher cost as the disability rolls continue to expand.
Aside from funding issues, DDSs reported that challenges associated with
processing initial disability applications and maintaining enough
disability examiners could jeopardize their ability to stay current with
the CDR workload over the next few years. If another large CDR backlog is
generated, SSA is at risk of foregoing cost- savings, thereby compromising
the integrity of its disability programs as a result of paying benefits to
disability beneficiaries who are no longer eligible to receive them.

At the end of March 2003* six months after the expiration of separate
authorized CDR funding* SSA was on a pace to generate a CDR backlog by the
end of the current fiscal year. However, most of the backlogged claims
will consist of SSI CDRs, which may make the backlog less problematic than
it otherwise would have been because, among other reasons, SSI CDRs have
lower long- term savings than DI CDRs. In its fiscal year 2003 budget
justification, SSA indicated that it needed to process about 1.38 million
CDRs during fiscal year 2003 to stay current with its CDR workload. Yet,
SSA expects to process a total of 1.18 million CDRs, if not more, by the
end of the fiscal year. 11 By the end of March 2003* the midpoint of the
fiscal year* SSA had processed about 539,000 CDRs. To reach the 1.18
million end- year revised total, SSA will need to process CDRs during the
second half of the fiscal year at a pace similar to that

11 On May 14, 2003, SSA released its revised final performance plan for
fiscal year 2003. The plan projects that SSA will process 1,129,000 CDRs
during fiscal year 2003. SSA also expects to process an additional 20,000
CDRs initiated for reasons other than maturation of the scheduled diary
date (e. g., a third party reports that the individual may no longer be
disabled). End of Targeted

Funding and Other Issues Could Contribute to Another Backlog, Threatening
Cost Savings

CDR Backlog Likely to Reemerge, Though Its Characteristics May Minimize
Negative Effects

Page 11 GAO- 03- 662 Social Security Disability achieved during the first
6 months of the fiscal year. 12 Nevertheless, while it appears that SSA
should be able to achieve this outcome, by the end of fiscal year 2003, it
will have accumulated a backlog of 200,000 CDRs.

SSA officials attributed the delay in obtaining a fiscal year 2003 budget
as the main factor in hampering their ability to conduct all of the
planned CDRs for the fiscal year. 13 Because of the uncertainty
surrounding the agency*s funding level, SSA reduced the number of CDRs it
sent to DDS officials for processing as well as froze DDS hiring and
overtime pay. SSA officials told us that they took these actions because
they were concerned that the fiscal year 2003 appropriations would not
support CDR activity at

the fiscal year 2002 level. SSA officials recognize that a hiring freeze
can have a longer- term impact because it disrupts the normal replacement
of disability examiners lost through attrition. SSA officials explained
that disability examiners generally do not increase overall productivity
when first hired. In fact, new disability examiners could initially
decrease productivity because experienced examiners may devote some of
their time to training these new examiners. SSA officials noted that it
generally takes 1 to 2 years before disability examiners become
proficient.

SSA*s management strategy to cut back on the number of CDRs it processed
during the delays to the extended fiscal year 2003 budget process reflects
the agency*s higher priority for processing of initial applications for
disability benefits. Specifically, while SSA cut back on the number of
CDRs, no similar action was reported with DI and SSI initial eligibility
decision making. SSA officials indicated that the application rate for
disability benefits increased during the beginning months of fiscal year
2003, further affecting its ability to stay current with CDRs. SSA
officials told us that although SSA sets a goal to process all CDRs and
initial applications, initial eligibility decisions are given the highest
priority. Officials said that, due to political pressure, getting
disability benefits to people in a timely manner is emphasized over
reviewing whether current beneficiaries remain eligible for benefits.
DDSs, likewise, place a greater priority on processing initial
applications. Three- fourths (75 percent) of

12 SSA indicated that 710,000 CDRs had been processed nearing the end of
April 2003. This year- to- date completion rate positions SSA to complete
all 1. 18 million CDRs. 13 The federal government had operated under a
series of continuing resolutions from the beginning of the fiscal year
through February 20, 2003. A continuing resolution is legislation

that may be enacted to provide budget authority for agencies to continue
in operation when the Congress and the President have not completed action
on appropriations by the beginning of the fiscal year.

Page 12 GAO- 03- 662 Social Security Disability directors said processing
initial disability claims were a top priority relative to CDRs, whereas
far fewer directors (23 percent) said that

processing initial claims and CDRs were equal priorities. SSA has recently
proposed an approach to avoid this competition between CDRs and initial
claims. Specifically, in SSA*s fiscal year 2004 budget request, the
Commissioner requested that almost $1.5 billion be earmarked for three
activities that could provide a return on investment* CDRs, SSI

nondisability redeterminations, 14 and overpayment workloads. While we did
not review the sufficiency of the level of this request, the earmarking of
funds for activities such as CDRs could help SSA keep current with these
activities. For example, if the number of initial applications for
disability benefits continues to increase over the next several years,
holding apart the necessary funds for CDRs could be a prudent measure.

SSA has indicated in its annual CDR reports, as well as in its performance
and accountability report, that its ability to complete all CDRs as they
become due in the future is dependent upon adequate funding. In 2000, SSA
estimated that a total of about $4 billion was needed to process the CDR
workload during the 5- year period between fiscal year 2004 and 2008 (see
table 1). SSA based these *rough estimates* on cost and workload
projections available at that time. SSA expects to release updated
workload and cost projections in the summer of 2003. While the estimates
made in 2000 are not inconsistent with recent years* authorized CDR
funding levels, they rely upon assumptions that may change in the years
ahead. For instance, the updated numbers for the fiscal year 2004 to 2008
period will likely be higher than the past estimate for this time period

because of the recent growth in the disability rolls. 14 To determine
whether beneficiaries remain financially eligible for SSI benefits after
the initial assessment, SSA conducts nondisability redeterminations to
verify eligibility factors such as income, resources, and living
arrangements. Beneficiaries are reviewed at least once every 6 years, but
reviews may be more frequent if SSA determines that changes in eligibility
are likely.

Page 13 GAO- 03- 662 Social Security Disability Table 1: Estimated CDR
Activities, Fiscal Years 2004- 08 Fiscal year CDRs to be

processed during year (in thousands) CDR expenses (dollars in millions)
Cessations a

(in thousands)

2004 1,637 $716 61 2005 1,682 $729 59 2006 1,632 $787 61 2007 1,769 $896
65 2008 1,793 $857 62 Source: SSA*s Office of the Chief Actuary, May 2000
estimates. a Estimated ultimate cessations after all appeals.

Despite the likely reemergence of a CDR backlog, the characteristics of
the backlog may mitigate its negative consequences. During fiscal year
2003, SSA has focused on DI CDRs. SSA officials cite four reasons for
this: (1) cessations of beneficiaries receiving DI benefits lead to higher
savings than cessations of recipients receiving SSI benefits, (2) SSA
desires to protect the DI trust fund, (3) legislation sets out a clearer
mandate to complete CDRs on beneficiaries receiving DI benefits than for
adult beneficiaries receiving SSI benefits, and (4) external auditors cite
SSA for noncompliance with the law when SSA does not complete the required
CDRs for DI beneficiaries.

As a result, most of the backlog that is expected to reemerge by the end
of fiscal year 2003 will likely consist of SSI CDRs and, according to SSA
officials, this makes the backlog less problematic than if the backlog
consisted of mostly DI cases. SSA maintains that not only do SSI adult
CDRs result in lower long- term savings, but also the legislative mandate
for conducting SSI CDRs is less prescriptive. Therefore, the negative
effects of falling behind on SSI CDRs are less severe.

Several of the issues that have contributed to the pending fiscal year
2003 CDR backlog will also appear, in the views of DDS directors, in the
future. First, nearly all directors expect to process a higher number of
initial disability claims than in the past. Most DDS directors have a
strategy in place to deal with this rising initial claims workload, but
still expect increased initial claims to negatively affect their ability
to process their CDR workload. Second, most directors expect to experience
difficulties in maintaining an adequate level of staffing, caused by many
examiners leaving and difficulties finding replacements. Most DDSs who
anticipate facing these staffing challenges reported that they have DDS
Directors Expressed

Concerns about Their Ability to Meet Future CDR Workload

Page 14 GAO- 03- 662 Social Security Disability strategies in place to
manage them. Nevertheless, nearly all believe that these staffing issues
will negatively impact their ability to stay current with

their expected CDR workloads. Tables 2 and 3 provide more specific
results.

Table 2: DDS Directors* Reported Likelihood, If Any, of Experiencing an
Event That Jeopardizes Meeting CDR Workload During Fiscal Years 2004 and
2005

Numbers in percent

Event Not at all likely Somewhat

likely Very likely

Higher number of initial disability claims than in past (n= 51) 2 35 63

State budget shortfalls causing constraints (e. g., personnel
restrictions) (n= 49) 25 29 47

Difficulties hiring disability examiners (n= 51) 28 31 41 High turnover of
disability examiners due to reasons other than retirement (n= 51) 35 51 14

Large number of disability examiner retirements (n= 51) 39 39 22

Source: GAO survey of DDS directors, February 2003.

Page 15 GAO- 03- 662 Social Security Disability Table 3: Extent That DDSs
Have a Strategy to Manage Anticipated Events and Likelihood That Events
Will Have Negative Impact on Workload Processing During Fiscal Year 2004
and 2005

Likelihood event will reportedly have a negative impact on staying current
with projected CDR workloads in fiscal year 2004 and 2005, even with

a strategy (in percentage) Event

Percentage of DDSs anticipating event that

have a strategy currently in place Not at all likely or not sure Somewhat
likely

or very likely

Higher number of initial disability claims than in past (n= 50) 78 8 92

State budget shortfalls causing constraints (e. g., personnel
restrictions) (n= 37) 57 17 a 83 a

Difficulties hiring disability Examiners (n= 37) 70 8 92 High turnover of
disability examiners due to reasons other than retirement (n= 33) 79 3 97

Large number of disability examiner retirements (n= 31) 81 3 97

Source: GAO survey of DDS directors, February 2003. a Percentage based on
35 responses (2 of the 37 DDS directors did not indicate a response about
the

likelihood of the event having a negative impact on CDR workload).

To the extent that funding, staffing, and other issues limit SSA*s ability
to process its CDR workload, the full realization of CDR cost savings
could be in jeopardy. SSA maintains that the return on investment from CDR
activities is high. In fact, SSA*s most recent annual CDR report to the
Congress summarizes its average CDR cost- effectiveness during fiscal year
1996 to 2000 at about $11 returned for every $1 spent on CDRs. 15 SSA has

noted, however, that such rates of return are unlikely to be maintained
because as SSA works down the backlog and beneficiaries come up for their
second and third CDRs, the agency does not expect as many cessations and,
therefore, the cost- benefit ratio could decline. 15 SSA calculated its
annual cost- effectiveness ratios by dividing the estimated present value

of total lifetime benefits saved with respect to CDR cessations (including
Old- Age, Survivors, and Disability Insurance, SSI, Medicare, and Medicaid
savings) by the dollar amount spent on periodic CDRs in a given year. SSA
points out that the ratios should be considered an approximation because,
for example, costs do not include the costs of appeals processed after the
end of a given year. However, SSA officials also noted that the
administrative costs for CDRs in a given year include the costs of appeals
of CDR cessations in prior years which are processed in that year. Cost
Savings and Program

Integrity Could Be Jeopardized If CDR Backlog Grows Again

Page 16 GAO- 03- 662 Social Security Disability Since the Congress*
provision of dedicated CDR funding starting in fiscal year 1996, SSA has
reported completing millions of CDRs that resulted in

substantial long- term savings. Table 4 shows the number of CDRs processed
annually between fiscal year 1996 and 2001, which ranged from about
500,000 to over 1.8 million. SSA has reported that these annual CDRs

will lead to long- term savings ranging from about $2 billion to $5.2
billion. 16 Table 4: Summary of SSA*s CDR Activities During Special
Funding Period, Fiscal Years 1996- 2002

Fiscal year Number of

CDRs processed Estimated

cessations a CDR Costs (dollars in

millions) 10- year

estimated savings b (dollars in millions)

1996 498,400 26,500 $208 $2,040 1997 690,478 49,700 $330 $3,555 1998
1,391,889 70,300 $462 $4,435 1999 1,703,414 87,300 $547 $5,185 2000
1,836,510 76,000 $609 $5,060 2001 1,730,572 63,600 $603 $4,245 2002 SSA
expects to report these data to the Congress in fall, 2003 Source: SSA*s
annual CDR reports submitted to the Congress, fiscal year 1996- 2001. The
law that authorized dedicated CDR funding for SSA between fiscal year 1996
and 2002 (Pub. L. No. 104- 121) required SSA to report to Congress for
each of those fiscal years specific information such as the amount spent
on CDRs and the estimated savings that would result from the cessation of
benefits.

a Estimated ultimate cessations after all appeals. b Estimates of the
reductions in benefit payments for the following programs: the Old- Age,
Survivors, and Disability Insurance program; the SSI program; the two
Medicare programs, Hospital Insurance and Supplemental Medical Insurance;
and the Medicaid program.

In addition to a favorable return on investment, SSA*s CDR activities help
protect DI and SSI program integrity. Keeping current with the CDR
workload can help build and retain public confidence that only qualified

16 Although we did not independently verify these savings estimates, we
discussed how SSA made its calculations and believe its approach is
reasonable. To estimate long- term savings, SSA calculated the value of
the reduction in both cash and medical insurance coverage that otherwise
would have been provided to individuals whose benefits were ceased
following the completion of a CDR. SSA factored in the effect of appealed
cases: SSA did not count savings from those beneficiaries who were
initially found ineligible for continued benefits but whose cessations
were later successfully appealed. Moreover, SSA officials told us that

to estimate savings over 10 years, they took into account the likelihood
that some individuals whose benefits were ceased through a CDR would
likely have left the disability rolls through death, retirement, and other
reasons pertaining to eligibility.

Page 17 GAO- 03- 662 Social Security Disability individuals are receiving
disability benefits. In addition, it helps protect the programs* fiscal
integrity and allows SSA to meet its financial stewardship

responsibilities. To the extent the agency falls behind in conducting
CDRs, a CDR backlog undermines these positive outcomes.

While SSA has taken a number of actions over the past decade to
significantly improve the cost- effectiveness of the CDR process,
opportunities remain for SSA to better use program information in CDR
decision making. While DDS personnel study available information on
beneficiaries to decide when they should undergo a CDR, they do not
conduct a systematic analysis of this information. As a result, CDRs may
not be conducted at the optimal time. Also, SSA*s process for determining
what method to use for a CDR* mailer or full medical review* is not always
based on the best information available. In addition, SSA has not fully
studied and pursued the use of medical treatment data on beneficiaries
available from the Medicare and Medicaid programs despite

the potential of these data to improve SSA*s selection of the most
appropriate CDR method. Finally, SSA continues to be hampered in its CDR
decisions by missing or incomplete information on beneficiaries* case
history, which may prevent SSA from ceasing benefits for some individuals
who no longer meet eligibility standards.

While DDS personnel review available information on beneficiaries to
establish a diary date indicating when beneficiaries should undergo a CDR,
they do not conduct a systematic analysis of this information. Diary
decisions are inherently complex because DDS personnel must assess a
beneficiary*s likelihood of medical improvement and how such medical
improvement will affect that person*s ability to work. Based on these
judgments, beneficiaries are placed in a diary category indicating either
that medical improvement is *expected,* *possible,* or *not expected.* DDS
personnel then assign a diary date that corresponds with the diary
category; the more likely a beneficiary is to medically improve, the
earlier the diary date.

Although SSA has established guidance for DDS personnel on diary date
decisions, SSA officials told us that, ultimately, such decisions are
difficult to make and are based on the judgment of the DDS staff. An SSA
contracted study of the diary process found that this process is often
subjective and that the setting of diary categories and dates is *almost
an afterthought* once the case file is developed and a disability
determination has been made. SSA*s study identified shortcomings in the
diary date process. For example, most beneficiaries assigned to the diary
category Further Opportunities

Exist for SSA to Improve CDR CostEffectiveness

Decisions on Timing of CDRs Are Not Based on Systematic Analysis of
Available Information

Page 18 GAO- 03- 662 Social Security Disability indicating they are
expected to medically improve are not found to have improved when a CDR is
conducted. Our analysis of SSA data indicates that between 1998 and 2002,
only about 5 percent of beneficiaries in the

MIE category 17 were found to have medically improved to the point of
being able to work again.

SSA*s diary process study indicated that diary predictions of medical
improvement could be substantially improved through the use of statistical
modeling techniques similar to those used in the CDR profiling process
that SSA uses to determine whether a mailer or a full medical review is
needed. The study noted that this systematic, quantitative approach to
assigning diary categories and dates would likely enhance disability
program efficiency by reducing the number of CDRs that do not result in
benefit cessation. 18 Another benefit derived from a more systematic
approach to diary categorization, according to SSA*s study, is improved
integrity of the diary process. Such integrity improvements will result
from more timely CDRs and from actual medical improvement rates that more
closely correlate with the diary categories that SSA assigns to
beneficiaries. For example, SSA*s study indicates that the actual medical
improvement rate for beneficiaries assigned to the MIE diary category
would increase to about 29 percent under this improved process.

SSA officials told us that, in response to the diary study
recommendations, the agency has begun to revise its diary process to
introduce a more systematic approach to selecting a CDR date. In
particular, SSA is developing a process that will use beneficiary data
collected at the time of benefit application, such as impairment type and
age, in a statistical formula to help determine when a CDR should be
conducted. While this change is likely to result in some improvements in
the timing of CDRs, the fundamental diary categorization process used by
DDSs will remain the same. Despite the study*s findings and
recommendations, SSA officials told us that they will not replace SSA*s
current process for assigning diary categories with a statistical process
because of what they believe would be significant costs involved in
changing this system across DDSs. However, SSA*s study acknowledged the
potential cost of implementing a new

17 This figure includes all MIE beneficiaries* those who have already
undergone a CDR as well as those who have not yet had a CDR. 18 The study
recommended that DDSs continue to assign diary categories because this
process is useful for indicating the severity of an impairment. The
statistical formula would then factor in this DDS diary category in
developing an ultimate diary determination.

Page 19 GAO- 03- 662 Social Security Disability process in DDSs, and
instead recommended that a revised diary process be centrally administered
in order to avoid such high costs. The officials

also said that such fundamental changes in the diary process would require
a change in regulations.

SSA*s process for determining what method to use for a CDR is not always
based on the best information available. In the 1990s, SSA introduced a
system that develops a *profile score* for each beneficiary. The profile
score indicates the beneficiary*s likelihood for medical improvement based
on a statistical analysis of beneficiary data. The purpose of the profile
score is to allow SSA to determine whether it is more cost- effective to
send a mailer or to conduct a full medical review. SSA*s own contracted
studies indicate that profiling results provide the best available
indication of whether a beneficiary is likely to medically improve.
Nevertheless, for some beneficiaries, SSA continues to use the diary
category that was judgmentally assigned by DDS personnel as the basis for
their decision about whether to send a mailer or conduct a full medical
review.

SSA requires a full medical review for all beneficiaries whose diary
category indicates that medical improvement is expected (MIE) and who have
not yet undergone a CDR. 19 This is the case even when the profile score
indicates that improvement is unlikely. In fiscal year 2002, about 14
percent of beneficiaries in the MIE diary category were assigned to the
*low* profile category, which indicates that medical improvement is not
likely. SSA officials acknowledged that their policy requiring full
medical reviews for all beneficiaries in this diary category departs from
their usual practice of using mailers for beneficiaries in the low profile
category, but they believe that this policy is reasonable given that these
beneficiaries are more likely to medically improve than those assigned to
other diary categories. However, SSA*s data from 1998 to 2002 shows that
most beneficiaries in this category* about 94 percent* do not medically
improve to the point of being able to work.

19 SSA applies a different process for MIE beneficiaries who have
undergone one or more CDRs. These beneficiaries may receive a mailer if
their CDR profile score indicates that they have a low likelihood of
medical improvement. However, most beneficiaries assigned to the MIE
category have not yet undergone a CDR; in fiscal year 2002, about 88
percent of all beneficiaries in this diary category had not had a CDR.
When referring to MIE beneficiaries in the remainder of our discussion in
this section, we are describing only those beneficiaries who have not yet
had a CDR. SSA*s Process for

Determining CDR Method Not Always Based on Best Information Available

Page 20 GAO- 03- 662 Social Security Disability For other CDR cases, SSA
may require that a mailer be sent even when the profile score indicates
that conducting a full medical review would be

most cost- effective. Specifically, SSA*s policy is to send a mailer to
all beneficiaries who were assigned a diary category that indicates
medical improvement is not expected (MINE), 20 even if the profile score
indicates a relatively high likelihood of medical improvement. 21 Whether
or not these

beneficiaries subsequently receive a full medical review will be based on
the results of their mailer. SSA officials said that MINE beneficiaries
with a high profile score are more likely to receive a full medical review
based on their mailer responses because SSA conducts a more stringent
review of their mailer responses. 22 However, it is not clear that sending
mailers to beneficiaries in the high profile category is the most cost-
effective approach. SSA studies of the mailer process have indicated that,
while this process is effective, it does not provide the same assurance as
full medical reviews that medical improvement will be identified. As a
result, the use of

mailers for beneficiaries whose profile scores indicate a high likelihood
of improvement could result in SSA identifying fewer benefit cessations.
23 SSA has not fully studied and pursued the use of medical treatment data

on beneficiaries available from the Medicare and Medicaid programs despite
the potential of these data to improve SSA*s decisions regarding whether
to use a mailer or full medical review to complete a CDR. In

2000, an SSA contracted study found that the use of Medicare data from the
Center for Medicare and Medicaid Services (CMS)* such as data on hospital
admissions and medical treatments* resulted in a significant improvement
in SSA*s ability to assess potential medical improvement through CDR
profiling. Based on these results, SSA, in fiscal year 2003,

20 SSA officials told us that while it is their intention to do mailers
for all MINE beneficiaries, they may be unable in some years to send
mailers to all of these beneficiaries if their overall funding for mailers
is insufficient.

21 In addition to sending mailers to high profile beneficiaries in the
MINE diary category, SSA has recently begun to send mailers to some high
profile beneficiaries in the MIP diary category.

22 SSA also sends mailers to medium profile beneficiaries in the MINE
diary category. However, SSA has some evidence from its profiling studies
indicating that issuing mailers to medium profile beneficiaries is likely
to be cost- effective. No similar evidence exists regarding high profile
beneficiaries. 23 Although a relatively small proportion of beneficiaries
have their benefits ceased based

on a CDR, the savings from these benefit cessations are substantial, as
noted earlier in this report. SSA Has Not Fully Studied

and Pursued the Use of Medical Treatment Data from Medicare and Medicaid

Page 21 GAO- 03- 662 Social Security Disability implemented a process that
uses CMS Medicare data in CDR profiling to determine if DI beneficiaries
who are initially identified as candidates to

receive a full medical review should instead receive mailers. 24 SSA
expects that this will result in administrative savings due to the reduced
number of full medical reviews the agency must conduct. SSA has also
initiated a study to assess whether CMS Medicaid data can be used in the
same way to decide if SSI beneficiaries, scheduled to receive full medical
reviews, could instead be sent mailers.

But SSA*s efforts to obtain and use CMS Medicare or Medicaid data are
incomplete because the data will only be used to reclassify full medical
reviews to mailers but not to reclassify mailers to full medical reviews.
SSA officials told us that they have no plans to pursue this additional
use of the data because they believe their current profiling system is
sufficient for identifying beneficiaries who have a low likelihood of
medical improvement. While they agreed that the CMS data could potentially
be useful for reclassifying mailers to full medical reviews, they noted
that

they would need to first study this particular use of the data and would
need to develop another interagency agreement with CMS to authorize and
obtain data for this purpose. Also, they said that any action to
reclassify mailers to full medical reviews would require SSA to publish a
Federal Register notice describing this action.

SSA could potentially achieve substantial program savings from conducting
additional full medical reviews in cases where CMS data indicate that
beneficiaries originally identified as mailer candidates have a relatively
high likelihood of medical improvement. Using CMS Medicare

data for this purpose would be consistent with the results of an SSA study
that recommended that these data be used whenever it improves the agency*s
ability to accurately predict medical improvement. For example, the study
noted that the CMS data would be useful for enhancing SSA*s profiling of
beneficiaries with mental impairments, including those with a low
likelihood of medical improvement for whom SSA would usually send a
mailer. To the extent that CMS data improves SSA*s ability to identify
beneficiaries for full medical review, the program savings from reduced

24 SSA is using CMS Medicare data to reassess the prospects of medical
improvement for beneficiaries who, based on their initial CDR profiling
results, are considered to have a high or medium likelihood of medical
improvement. Typically, SSA would conduct full medical reviews for these
beneficiaries. However, SSA*s reassessment may indicate that some of these
beneficiaries instead have a low likelihood of medical improvement and

therefore should receive mailers.

Page 22 GAO- 03- 662 Social Security Disability lifetime benefit payments
to those beneficiaries whose benefits are ceased could easily exceed any
increased administrative costs resulting from additional full medical
reviews.

SSA continues to be hampered in its CDR decisions by missing or incomplete
information on beneficiaries* case history, which may prevent SSA from
ceasing benefits for some individuals who no longer qualify for

benefits. To cease benefits based on a CDR, SSA must determine if the
beneficiary has improved by comparing information about the beneficiary*s
current condition to information from the agency*s previous decision
regarding the beneficiary*s medical condition. This previous decision and
the evidence supporting it are recorded by SSA and maintained in case
folders that are usually stored in SSA records storage facilities.
However, in conducting CDRs, DDSs sometimes have difficulty retrieving the
case folders or the key medical evidence that is maintained in these
folders.

Without the information contained in case folders, DDSs cannot establish a
comparison and, therefore, cannot determine if medical improvement has
occurred. As a result, SSA is legally required to keep the beneficiary on
the disability rolls even though the beneficiary may have been judged to
no longer qualify for benefits had the DDS been able to establish a
comparison. SSA*s inability to cease benefits in cases where folders are
missing or incomplete could result in a substantial cost to the federal
government arising from continued payments of benefits* cash and medical*
to people who no longer meet eligibility standards. 25 Our discussions
with SSA officials, survey of DDSs, and review of SSA

studies indicate that missing or incomplete folders present an obstacle to
effective processing of CDRs. However, evidence on the extent of this
problem is mixed. In responding to our survey on CDRs, about 72 percent of
DDSs informed us that missing or incomplete information from case folders
negatively impacted the quality or timing of CDR decisions to a moderate
or great extent. An August 2002 study of missing or incomplete folders
conducted by SSA*s Office of the Inspector General reported that DDSs, as
well as other SSA components such as field offices, complained

25 Missing or incomplete case folders may also result in additional
administrative costs to the extent that SSA and DDS personnel spend time
attempting to locate or reconstruct missing information. Missing or
Incomplete

Case Folders May Result in Fewer Benefit Cessations

Page 23 GAO- 03- 662 Social Security Disability that a large proportion of
cases were missing information. 26 This study found that case folder
retrieval is a significant problem for SSA. Among

the problems identified were untimely receipt of case folders, nonreceipt
of requested folders, and folders provided without necessary medical
evidence. The report questioned SSA*s oversight of folder inventory and
retrieval processes and recommended that SSA take various actions, such as
independent quality assurance reviews, to improve management of case

folders. A study contracted by SSA also identified problems with
disability case folder management, such as misrouted or missing folders.
The study noted that *inefficient folder management increases
administrative and program costs and risks data integrity* and recommended
that SSA

*analyze the reasons for missing folders and provide recommendations for
process and systems improvements.*

SSA headquarters officials we spoke with said that SSA has examined the
incidence of missing or incomplete case folders and found that the problem
is not as significant as claimed by DDSs. For example, in fiscal year
2000, SSA investigated allegations of substantial numbers of missing case
folders in two DDSs. SSA officials told us that they were able to locate
many of the folders that had been reported as missing. The officials
attribute the discrepancy between their findings and the allegations of
DDSs, in part, to staff shortages and workload pressures at field offices,
which result in a failure of these offices to take further steps to look
for folders. However, our survey of DDSs indicates that regardless of
SSA*s ability to locate many case folders upon further investigation, DDSs
are still having difficulty obtaining the information they need to make
CDR decisions.

In a 2002 memorandum to SSA*s Inspector General, the SSA Commissioner
acknowledged that missing or incomplete case folders are a problem in the
CDR process, but noted that the problem had been overstated. The
memorandum cited data indicating a lost folder rate of about 0.5 percent
for DI CDRs and about 3 percent for SSI CDRs. 27 The Commissioner also
said that SSA had taken a number of actions in recent years to reduce the
incidence of lost folders, such as issuance of additional guidance and
training on this issue. In addition, the Commissioner noted that the
agency

26 Office of the Inspector General, Social Security Administration, Case
Folder Storage and Retrieval at the Social Security Administration*s
Megasite Records Center, A- 04- 99- 62006 (Washington, D. C., 2002). 27
Data are based on CDRs conducted from 1997 to 2001.

Page 24 GAO- 03- 662 Social Security Disability was committed to building
a system of electronic folders 28 that will *virtually eliminate the
incidences of lost folders.* While electronic folders

may be a key initiative in resolving SSA*s problems with missing or
incomplete case folders, SSA does not plan to fully implement this system
until mid- 2005. 29 In addition, these electronic folders will be
established only for new disability cases; cases established prior to
implementation of electronic folders will remain in a paper format.
Therefore, problems in handling these older case folders will likely
continue.

SSA*s rationale for postponing issuance of a ticket to beneficiaries
expected to medically improve* those who are assigned an MIE diary
category* is not well- supported by program experience. In issuing
regulations implementing the ticket act, SSA decided to postpone issuance
of tickets to MIE beneficiaries who have not yet had a CDR based on the
premise that these beneficiaries could be expected to regain their
capacity to work without SSA assistance. 30 However, our analysis of SSA
data indicates that the vast majority of MIE beneficiaries in the DI and
SSI programs* about 94 percent* are not found to have medically improved
upon completion of a CDR. As a result, some beneficiaries who might
otherwise benefit from potentially valuable return- to- work assistance
must wait up to 3 years to access services through the ticket program. 31
Some disability advocacy groups and SSA*s own Ticket to Work and Work

Incentives Advisory Panel have questioned SSA*s policy of delaying the 28
SSA is currently developing a Disability Electronic Folder (EF) which,
when completed, will be the repository of all information used in the
disability process and should eventually replace the paper folders. As a
result, processing components should not have to rely on a paper folder to
take adjudicative actions. The EF is planned to be linked to all existing
and

future systems that support the disability case process. Information will
be captured electronically during the case intake process and transmitted
to the EF. Documentation and forms received from external sources (e. g.,
claimants, medical providers, third parties, etc.) will be converted to an
electronic format (e. g., scanning and imaging) and added to

the EF. Electronic documents received from medical providers will be
indexed and added to the EF.

29 SSA plans to begin rollout of electronic disability folders in January
2004 and plans to achieve national implementation over an 18- month
period. 30 The Ticket to Work Act gave the SSA Commissioner authority to
determine which disabled beneficiaries would be eligible to participate in
the ticket program. 31 SSA*s policy on ticket eligibility states that any
MIE beneficiary who has been on the disability rolls for at least 3 years
will be eligible for a ticket, even if they have not yet had a CDR. SSA*s
Rationale for

Postponing Return- toWork Services to Some Beneficiaries Is Not Well-
Supported by Program Experience

Page 25 GAO- 03- 662 Social Security Disability issuance of tickets to MIE
beneficiaries. In particular, they have commented that delaying tickets to
all MIE beneficiaries when only a

small proportion of these beneficiaries return to work underscores the
inherent weakness of relying upon the MIE category as a basis for granting
access to ticket services. Furthermore, the ticket panel cited research
indicating that the sooner a person with recent work history receives
employment services, the more likely the person will be to return to work.
In our prior work examining DI and SSI return- to- work policies, we also
noted that delays in the provision of vocational rehabilitation services
can diminish the effectiveness of such return- to- work efforts. 32
Delaying services to some disability beneficiaries, therefore, undermines
SSA*s recent efforts to increase its emphasis on helping these
beneficiaries return to work.

In publishing its final regulations implementing the ticket program, 33
SSA wrote that many commenters on the draft regulations had indicated that
the agency should provide tickets to all beneficiaries, regardless of
their diary category. The commenters also referred to the MIE diary
category as an *administrative convenience* that is *not a sufficiently
precise tool to

deny beneficiaries immediate access to a ticket.* In responding to these
comments, SSA wrote that use of the MIE category to identify which
beneficiaries should receive tickets *is the most administratively
feasible approach currently available to us.* SSA acknowledged that it
might be possible to improve the system for identifying such beneficiaries
and wrote that it planned to conduct an evaluation to identify possible
improvements.

SSA officials told us that they are examining the current policy of
issuing tickets to MIE beneficiaries to identify possible alternatives but
they are not sure when this assessment will be completed. 34 However, they
noted that their policy of limiting ticket issuance reflects congressional
interests

in striking an appropriate balance between program stewardship and 32 U.
S. General Accounting Office, SSA Disability: Program Redesign Necessary
to Encourage Return to Work, GAO/ HEHS- 96- 62 (Washington, D. C.: Apr.
24, 1996). 33 66 Fed. Reg. 67370, Dec. 28, 2001.

34 In May 2003, SSA announced in the Federal Register (Social Security
Administration: Semiannual Regulatory Agenda, 68 Fed. Reg. 31240, May 27,
2003) that its long- term plans include a proposal to revise its rules to
allow the immediate issuance of tickets to MIE beneficiaries. However,
SSA*s Associate Commissioner responsible for reviewing the ticket

policy for MIEs told us that SSA has not made a final decision regarding
any changes to the current policy and that the agency*s review has not
been completed.

Page 26 GAO- 03- 662 Social Security Disability encouraging return to
work. Moreover, they explained that reversing the current policy would be
costly. SSA*s actuaries have estimated that issuing

tickets to all MIE beneficiaries would cost an additional $822 million
over 10 years because the ticket law prohibits SSA from conducting CDRs on
beneficiaries who are using a ticket. Therefore, SSA would continue to pay
DI and SSI benefits to some beneficiaries who might have otherwise had
their benefits terminated.

The drawbacks of SSA*s current policy of postponing issuance of tickets to
MIE beneficiaries and the potential costs associated with an alternative
policy that would allow immediate issuance of tickets to these
beneficiaries highlights the need for SSA, as part of its policy
reexamination, to consider other policy alternatives that might better
balance the agency*s program stewardship and return- to- work objectives.
While we did not conduct an in- depth assessment of potential alternatives
to SSA*s current policy, 35 our review of the CDR program and ticket
provisions indicate that other options may exist that would achieve a
better balance among SSA*s program objectives. For example, SSA could
develop a better means of identifying beneficiaries who are expected to
medically improve. Earlier in this report, we noted that an SSA-
contracted study of the diary process recommended implementation of an
improved system that, among other things, would better identify MIE
beneficiaries through statistical modeling of diary decisions. One effect
of such improved identification, according to the study, would be to
substantially reduce the proportion of beneficiaries with an MIE diary
category. For instance, the study found that although SSA, over the past
decade, has assigned the MIE diary category to about 9 percent of DI
beneficiaries, a statistically- based diary process would result in about
3 percent of DI beneficiaries being assigned to the MIE category. This
would potentially minimize the number of beneficiaries initially denied
tickets and may also provide more assurance, within and outside SSA, that
such beneficiaries

can truly be expected to improve. SSA might also consider an option that
provides for the issuance of tickets to all MIE beneficiaries while
allowing CDRs to be conducted as scheduled for these beneficiaries. This
policy would require a legislative change because, as we noted earlier,
the Ticket to Work Act currently prohibits

35 Given the recent implementation of the ticket program, insufficient
data were available during the period of our review to conduct the
analysis necessary to fully evaluate such alternatives.

Page 27 GAO- 03- 662 Social Security Disability SSA from conducting a CDR
while a person is using a ticket. 36 While the ticket program*s
prohibition on CDRs for ticket users was intended to

remove a potential disincentive for beneficiaries to return to work, MIE
beneficiaries currently get neither a ticket nor protection from a CDR. A
policy allowing CDRs to be conducted on these beneficiaries while they use
a ticket would at least give these beneficiaries immediate access to
return- to- work services offered under the ticket program. In addition,
SSA would still be able to achieve the cost savings that are derived from
CDRs

for beneficiaries that it considers most likely to medically improve.
Failure to cost effectively process CDRs as they become due could
negatively affect DI and SSI program integrity. SSA and DDSs are to be
commended for bringing the CDR workload current as of the end of 2002. SSA
is also to be commended for the improvements it has made in the CDR
process. However, a confluence of events, such as the expiration of
targeted CDR funding and an increase in initial applications, is
increasing the chances of a CDR backlog recurring, which could result in
SSA paying out billions of dollars in the long term to beneficiaries who
no longer qualify for benefits. In its fiscal year 2004 budget request,
SSA has asked the Congress for targeted funding for several program
activities, including CDRs, that provide a return on investment. If
approved, the targeted funding could increase SSA*s chances of staying
current with its CDR workload because this workload would not have to
compete internally for funding with the initial determination workload.

While SSA has taken a number of steps to improve the CDR process, it has
not taken advantage of other opportunities that could further improve the
cost- effectiveness of this process and its ability to stay current. In
particular, although a more systematic and quantitative process for
assigning diary categories and dates would likely improve the timing of
CDRs, SSA does not intend to make comprehensive revisions to the diary
process based on this more rigorous approach. In addition, despite SSA*s
reliance on profiling formulas to improve the agency*s ability to predict
medical improvement and benefit cessation, SSA is ignoring or not giving
full consideration to information from these formulas in its decisions to

conduct mailers or full medical reviews for some beneficiaries. Also,
although SSA acknowledges that medical treatment data from Medicare and,
possibly, Medicaid improve the agency*s ability to determine when a

36 However, the prohibition on CDRs for all other ticket users could
remain in effect. Conclusions

Page 28 GAO- 03- 662 Social Security Disability mailer should be used, it
does not see a need to consider the use of these data to help determine
when a full medical review might be preferable.

Furthermore, despite long- standing concerns, SSA has not fully addressed
the problem of missing or incomplete case folders, which limits SSA*s
ability to achieve cost savings through the CDR process.

Finally, SSA*s initial assessments of which beneficiaries are most likely
to improve are not very accurate and, therefore, may not be the most
appropriate criteria to use for delaying beneficiary access to a ticket
for return- to- work services. The ticket program is relatively new so
little program information is available for SSA to draw upon in
reexamining its current policy on ticket access for beneficiaries most
likely to improve. SSA has the challenge of developing a policy that will
make return- to- work assistance available to beneficiaries at the
appropriate time while

providing adequate mechanisms for ensuring program integrity. To further
improve the cost- effectiveness of the CDR process, we recommend that the
Commissioner of SSA take the following actions:

 Pursue more comprehensive enhancements of the CDR diary process* beyond
those already being considered* to ensure that the full benefits of a more
systematic, quantitative approach to diary setting are attained. Among
such key enhancements would be the use of a statistical approach to
determine diary categories. Given the significant implications of such
changes for the DI and SSI programs, SSA could consider pilot testing the
revised diary process before fully implementing it.

 Given the cost- effectiveness of conducting mailers in cases where there
is a low likelihood for benefit cessation, revise SSA*s policy to allow
mailers to be sent whenever appropriate* as indicated by the profiling
scores* to beneficiaries with a diary category indicating that they are
expected to medically improve. For beneficiaries assigned to a diary
category

indicating that they are not expected to medically improve, SSA should
conduct a thorough analysis of its current policy, which allows mailers to
be used for all of these beneficiaries regardless of their profile scores.
SSA*s analysis should evaluate the overall cost- effectiveness of this
policy, taking into account both the potential reduction in administrative
costs from conducting fewer full medical reviews and the potential
increase in benefit payments from reduced cessations. If this analysis
indicates that the current policy results in higher overall costs for
SSA*s disability programs, SSA should revise the policy to make it
consistent with the agency*s general profiling approach* which prescribes
the use of full Recommendations to

the Commissioner of SSA

Page 29 GAO- 03- 662 Social Security Disability medical reviews in cases
where profiling indicates that a beneficiary has a relatively high
likelihood of medical improvement.

 Study the use of Medicare and Medicaid data for the purpose of deciding
whether to use a full medical review in conducting a CDR for beneficiaries
who would otherwise receive a mailer. If found to be cost- effective, SSA
should incorporate Medicare and Medicaid data into its CDR process for
this purpose.

In commenting on a draft of this report, SSA agreed with our
recommendations. SSA noted that our review represents a comprehensive and
accurate assessment of SSA*s accomplishments in improving the CDR process
as well as opportunities to improve the process. While agreeing with each
of our recommendations, SSA supplied additional information describing its
current or planned actions and the basis for such actions.

With regard to our recommendation that SSA pursue more comprehensive
enhancements of its diary process, SSA said that it is currently studying
recommendations made by its contractor regarding the establishment of a
statistically- based diary process and that SSA staff will be meeting in
the near future to explore implementation options. However, SSA noted it
has not yet made a decision regarding implementation.

Regarding our recommendation that SSA revise its policies for determining
what method to use for a CDR* mailer or full medical review* SSA said that
while it generally agreed with our recommendation, it believes we were
overly harsh in stating that it is not making the best use of available
information. SSA noted that its policy for allowing mailers to be used for
all MINE beneficiaries supplements information produced through profiling,
thereby improving the process for selecting a CDR

method. SSA said that this policy is based on evaluation and analysis of
several thousand similar cases and noted that it will verify the
costeffectiveness of this policy through its ongoing integrity reviews. We
continue to believe that any departure from SSA*s analytically- based
process for using profiling scores to select a CDR method should be based
on sound analysis indicating that an alternative process would result in
improved cost- effectiveness. We, therefore, are encouraged by SSA*s plans
to evaluate the cost- effectiveness of its current policy. However, it is
not Agency Comments

and Our Evaluation

Page 30 GAO- 03- 662 Social Security Disability clear that SSA*s integrity
reviews 37 will be adequate for assessing the costeffectiveness of the
agency*s mailer policy for MINE beneficiaries due to

the potential limitations of these reviews. For example, an SSA-
contracted study identified several problems with the integrity reviews
that SSA conducts for beneficiaries in the low profile category, such as
the drawing of integrity samples that are not consistently representative
of the mailer population. To the extent that such problems remain
unresolved, SSA may need to develop an alternative means of evaluating its
mailer policy for MINE beneficiaries.

With regard to our recommendation on the use of Medicare and Medicaid data
for deciding whether to use a full medical review for beneficiaries who
would have otherwise received a mailer, SSA said that it intends to
contract for such a study in fiscal year 2004 if funding is available. SSA
noted that if the concept is found to be feasible, it will develop a pilot
for this approach.

SSA also provided additional comments intended to update or clarify some
information we provide in this report. In particular, SSA noted that, due
to its efforts to keep as current as possible, it believes its CDR backlog
by the

end of fiscal year 2003 will be significantly less than the potential
backlog of 200,000 CDRs that we cited. While there is always a certain
degree of imprecision associated with any projection, our backlog figure
is based on the best information that was available during our review. We
developed

our potential backlog figure based on extensive discussions with SSA
officials and reviews of SSA*s CDR workload and budget projections. SSA
did not provide us with any revised official estimates or analyses that
would have led us to revise the CDR backlog figure we report.

In addition, SSA said that our report implies that it does not take
seriously the shortfall in completing CDRs for the SSI program. SSA is
apparently referring to our discussion of the CDR backlog where we note
that most of the backlog that is expected to develop by the end of fiscal
year 2003 will consist of SSI CDRs, which may make the backlog less
problematic than it otherwise would have been because, among other
reasons, SSI CDR

cessations have lower long- term savings than DI CDR cessations. We did
not intend to imply that SSA does not take the SSI backlog seriously.

37 Each year, SSA conducts integrity reviews in which it selects samples
of beneficiaries to whom mailers were sent and sends these cases to DDSs
for full medical reviews. The results of these full medical reviews are
intended to provide a basis for assessing the reliability of using results
from profiling formulas to identify appropriate mailer recipients.

Page 31 GAO- 03- 662 Social Security Disability Rather, we included this
information to more accurately characterize the nature of the potential
backlog because that could provide important

insights as to how to deal with it. Finally, SSA said that although our
survey of DDS directors indicates that attrition among disability
examiners is an issue for DDSs, SSA and DDSs are accustomed to dealing
with such issues and DDSs are still able to complete their workloads.
Although we are aware that DDSs regularly confront multiple challenges to
completing their disability program workloads, we cannot ignore the clear
implications of DDS directors* answers to our survey questions. Given that
a clear majority of DDS directors indicated that disability examiner
attrition is somewhat or very likely to jeopardize their ability to
complete their CDR workload, we believe that it is important for us to
identify this issue as a potentially significant factor in the possible
development of a CDR backlog in the years ahead. SSA*s comments appear in
appendix II. SSA also provided additional

technical comments that we have incorporated in the report, as
appropriate. Copies of this report are being sent to the Commissioner of
SSA,

appropriate congressional committees, and other interested parties. The
report is also available at no charge on GAO*s Web site at http:// www.
gao. gov. If you have any questions about this report, please contact me
at (202) 512- 7215. Other contacts and staff acknowledgments are listed in
appendix III.

Sincerely yours, Robert E. Robertson Director, Education, Workforce,

and Income Security Issues

Appendix I: Scope and Methodology Page 32 GAO- 03- 662 Social Security
Disability To evaluate the impact of the expiration of separate funding
for continuing disability review (CDR) processing and the level of funding
needed to remain current with the CDR caseload, we interviewed Social
Security

Administration (SSA) officials from the Office of Budget, the Office of
the Chief Actuary, the Office of Disability and Income Security Programs
at SSA headquarters in Baltimore. We also reviewed SSA documents,
including the agency*s budget request and estimates of the cost and
savings from conducting CDRs. In addition, we surveyed Disability
Determination Services (DDS) directors to assess the potential effect of
the expiration of special CDR funding on DDS operations. To develop the
survey, we identified information that would help us address the research
questions. We generated specific survey items by reviewing SSA CDR

reports submitted annually to the Congress and drawing upon interviews we
conducted early in the assignment with SSA officials and the National
Association of Disability Examiners. We validated our survey instrument by
obtaining feedback from SSA officials and pretesting it with several
current DDS directors.

In consultation with SSA, we excluded 2 of the 54 DDSs from our survey as
well as the federal DDS. The two DDSs excluded were Guam and South
Carolina*s DDS serving persons who are blind* both relatively small DDSs
that are run by one person. We excluded the federal DDS because responses
from this site might skew results as the site (1) is a federal entity and
as such it is *different* than other DDSs, (2) is used to process the
overflow of CDRs, and (3) serves as SSA*s test unit. The remaining 52 DDSs
(essentially 1 for each of the 50 states, plus the District of Columbia
and Puerto Rico) comprised the study universe. All 52 of these DDSs
responded to our survey.

To assess the opportunities for SSA to improve CDR cost- effectiveness and
to examine SSA*s rationale for delaying return- to- work services to some
beneficiaries under the ticket to work program, we interviewed SSA
officials from the Office of Disability and Income Security Programs and
the Office of the Chief Actuary at SSA headquarters in Baltimore. We also
reviewed legislation, regulations, and SSA policy guidance related to the
CDR and the ticket programs. In addition, we examined various studies

and reports on the CDR and ticket to work programs, including reports from
SSA*s Office of the Inspector General and a wide range of
contractorproduced reports analyzing the cost- effectiveness of the CDR
process. Finally, we analyzed data from SSA on the number of adult DI and
SSI beneficiaries, aged 19- 64, assigned to various CDR diary and
profiling categories and the CDR outcomes* cessation or continuance* for
these beneficiaries. These data were derived from SSA administrative data
sets Appendix I: Scope and Methodology

Appendix I: Scope and Methodology Page 33 GAO- 03- 662 Social Security
Disability used by the agency to select cases for review and to track the
results of CDRs. We did not independently verify these data, but based on
comparison to SSA*s previously published data, and discussion of minor

discrepancies with SSA officials, we determined that they were
sufficiently reliable for our purposes. We performed our work in
accordance with generally accepted government auditing standards between
August 2002 and May 2003.

Appendix II: Comments from the Social Security Administration Page 34 GAO-
03- 662 Social Security Disability Appendix II: Comments from the Social
Security Administration

Appendix II: Comments from the Social Security Administration Page 35 GAO-
03- 662 Social Security Disability

Appendix II: Comments from the Social Security Administration Page 36 GAO-
03- 662 Social Security Disability

Appendix II: Comments from the Social Security Administration Page 37 GAO-
03- 662 Social Security Disability

Appendix III: GAO Contacts and Staff Acknowledgments

Page 38 GAO- 03- 662 Social Security Disability Shelia D. Drake, Assistant
Director (202) 512- 7172 Brett S. Fallavollita, Analyst- in- Charge (202)
512- 8507 The following individuals also made important contributions to
this report:

Mark Trapani, Melinda L. Cordero, and Corinna A. Nicolaou. Appendix III:
GAO Contacts and Staff

Acknowledgments GAO Contacts Staff Acknowledgments

(130194)

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