Supplemental Security Income: Disability Program Vulnerable to Applicant
Fraud When Middlemen Are Used (Letter Report, 08/31/95, GAO/HEHS-95-116).

Pursuant to a congressional request, GAO reviewed fraudulent claims for
disability benefits under the Supplemental Security Income (SSI)
program, focusing on: (1) the extent of fraudulent applications
submitted by non-English speaking immigrants using middlemen; (2)
factors that contribute to SSI vulnerability to such fraudulent
applications; and (3) government initiatives to combat such fraudulent
activities.

GAO found that: (1) although the Social Security Administration (SSA)
has been aware of allegations of SSI fraud related to the use of
middlemen since 1990, the number of applicants who have obtained SSI
benefits illegally through the use of middlemen is unknown; (2) the
number of immigrants receiving SSI disability benefits rose from 45,000
in 1983 to 267,000 in 1993; (3) in California, about 6,000 potentially
fraudulent applications have been identified, of which about 30 percent
represent SSI claims currently being paid; (4) ineligible SSI recipients
can receive about $113,000 in SSI, Medicaid, and Food Stamp benefits by
the time they are 65 years old; and (5) SSA has established a task force
in California to combat fraudulent applications involving middlemen and
has terminated benefits for 207 recipients, as of April 1995. In
addition, GAO found that SSI is vulnerable to fraudulent applications
involving middlemen because SSA: (1) management practices and bilingual
staff shortages enable applicants to use middlemen; (2) has only limited
monitoring of middlemen; (3) has limited funds for investigations; (4)
has not coordinated its efforts to monitor middlemen with state Medicaid
agencies; and (5) needs a better strategy to keep ineligible applicants
from ever being accepted on SSI rolls.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-116
     TITLE:  Supplemental Security Income: Disability Program Vulnerable 
             to Applicant Fraud When Middlemen Are Used
      DATE:  08/31/95
   SUBJECT:  Supplemental security income program
             Disability benefits
             Social security benefits
             Fraud
             Program abuses
             Beneficiaries
             Immigrants
             Internal controls
             Data collection operations
             Data bases
IDENTIFIER:  Food Stamp Program
             AFDC
             Aid to Families with Dependent Children Program
             California
             Washington
             Medicare Program
             
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Cover
================================================================ COVER


Report to the Chairman, Special Committee on Aging, U.S.  Senate

August 1995

SUPPLEMENTAL SECURITY INCOME -
DISABILITY PROGRAM VULNERABLE TO
APPLICANT FRAUD WHEN MIDDLEMEN ARE
USED

GAO/HEHS-95-116

Disability Fraud Program


Abbreviations
=============================================================== ABBREV

  CDR - continuing disability review
  CE - consultative examination
  DDS - disability determination service
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  INS - Immigration and Naturalization Service
  MFCU - Medicaid Fraud Control Unit
  OIG - Office of Inspector General
  PRUCOL - permanently residing under color of law
  SSA - Social Security Administration
  SSI - Supplemental Security Income

Letter
=============================================================== LETTER


B-257888

August 31, 1995

The Honorable William S.  Cohen
Chairman, Special Committee on Aging
United States Senate

Dear Mr.  Chairman: 

Recent media reports and congressional hearings have focused
attention on allegedly fraudulent claims for disability benefits that
have been filed by legal immigrants under the Supplemental Security
Income (SSI) program.  Such fraudulent claims have been facilitated
by middlemen\1 who provided translation services and involved
themselves in the SSI application process of non-English-speaking
immigrants.  It has been alleged that middlemen have coached SSI
claimants on how to appear mentally disabled, have used dishonest
health care providers to submit false medical evidence to those
determining eligibility for benefits, and have provided false
information on claimants' medical and family histories.  As a result
of these allegedly fraudulent activities, people have obtained SSI
disability benefits to which they are not entitled. 

Given your concern about this issue, we agreed to (1) determine the
extent of fraudulent applications submitted by non-English-speaking
immigrants using middlemen, (2) describe factors that contribute to
the SSI program's vulnerability to such fraudulent applications, and
(3) describe federal and state initiatives to combat such fraudulent
activities. 

To meet our objectives, we interviewed officials from, and reviewed
available data provided by, Social Security Administration (SSA)
headquarters, regional offices, and several field offices, as well as
disability determination services (DDS) offices in three states.  We
also met with representatives from California's Medicaid Fraud
Control Unit and with officials in the U.S.  Attorney's Office in
Seattle, Washington.  We coordinated our study with then-Department
of Health and Human Services' (HHS) Office of Inspector General (OIG)
and discussed with them their efforts to investigate cases of
suspected fraud involving middlemen.  Our work was conducted from May
1994 through June 1995 in accordance with generally accepted
government auditing standards. 


--------------------
\1 In this report, "middleman" refers to a person or organization
that provides translation and/or other services for a fee, to help
individuals apply for SSI. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Although some ineligible non-English-speaking applicants have
obtained SSI benefits illegally by using middlemen, the actual number
of people who have done so is unknown.  We do know that the number of
immigrants receiving SSI disability benefits rose from 45,000 in 1983
to 267,000 in 1993.  Those immigrants unable to speak English needed
translating help to communicate with the SSI system.  By 1990, SSA
had become aware of allegations of SSI fraud related to the use of
middlemen.  For example, a Washington State middleman arrested for
fraud had helped at least 240 immigrants obtain $7 million in SSI
benefits by coaching them on which medical symptoms to claim and
providing false information on their medical conditions and family
histories.\2 In California, about 6,000 potentially fraudulent
applications have been identified.  Of these 6,000 applications,
about 30 percent represent SSI claims currently being paid.\3
Mistakes in accurately determining eligibility are costly:  We
estimate that a single ineligible SSI recipient can receive a total
of about $113,000 from SSI, Medicaid, and the Food Stamps program by
the time he or she is 65 years old.\4

SSI's vulnerability to fraudulent applications involving middlemen is
the product of a combination of factors.  First, SSA management
practices and bilingual staff shortages enable applicants to use
middlemen.  For example, under SSA regulations and SSA customer
service standards, applicants may apply for benefits at the field
office of their choice--SSA does not restrict applicants to offices
in which SSA has staff that speak their language.  In addition, the
unavailability of documentation for applicants' medical histories and
the applicants' need for translators at medical examinations enhance
SSI's vulnerability to fraud.  Furthermore, SSA's vulnerability to
fraud when middlemen are involved has been compounded by SSA's
limited monitoring of middlemen, HHS OIG's limited funds for
investigations, and the lack of coordination between the efforts of
SSA and state Medicaid agencies.  Finally, SSA needs a more
comprehensive, programwide strategy for keeping ineligible applicants
from ever being accepted on the SSI rolls. 

The Congress, SSA, and several states have initiated efforts to
prevent or detect fraudulent SSI claims involving middlemen.  Federal
legislation has made SSI fraud a felony and has given SSA access to
information from the Immigration and Naturalization Service (INS) and
the Centers for Disease Control.  SSA established a task force in
April 1993 to combat fraudulent applications involving middlemen that
has suggested initiatives such as developing and managing an
interpreter database.  Also as a result of the task force, SSA's San
Francisco regional office is conducting continuing disability reviews
of possibly fraudulent cases involving middlemen.  As of April 26,
1995, this effort had resulted in terminations of benefits for 207
recipients, although 60 percent of these terminations have been
appealed.  Because many of the task force initiatives are in the
planning stages or the early stages of implementation, it is too soon
to evaluate their effectiveness.  Several states are also attempting
to address the problem. 

While SSA has several planned or early-stage initiatives to prevent
or detect SSI fraud when middlemen are used, more could be done.  A
more aggressive, programwide strategy for improving the quality of
information obtained from applicants would increase SSA's ability to
make better disability determination decisions, thereby keeping
ineligible applicants from ever getting on the SSI rolls.  A
comprehensive strategy should include cost-benefit analyses of (1)
SSA's alternatives for addressing the problem as well as (2) SSA's
resource limitations and applicants' need for expedient and
convenient service.  Such a strategy should include components to
better manage SSA's resources to improve communication with
applicants.  SSA could require that its own bilingual staff or
contractors conduct interviews with non-English-speaking applicants
and explore the use of videoconferencing technology, which would
maximize the use of SSA bilingual staff.  SSA should also share among
its field offices information it has already gathered about
interpreters and middlemen, until the planned automated database is
established.  Also, SSA should institute a mechanism by which it
obtains regular access to investigative results of state Medicaid
agencies. 


--------------------
\2 The 240 cases are being reviewed by an intergovernmental task
force formed in 1992 to investigate middleman fraud in one county in
Washington. 

\3 About 1,800 of the 6,000 applications represent cases that could
be subject to continuing disability reviews.  SSA has completed about
400 of these reviews to date; more will be done as resources permit. 

\4 The actual total amount of $112,805 represents $50,688 from SSI,
$55,396 from Medicaid, and $6,721 from food stamps.  Some applicants
ineligible for SSI could still be eligible for Medicaid, food stamps,
or both. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Authorized in 1972 under title XVI of the Social Security Act, the
SSI program is administered by SSA.  Until recently, SSA was an
agency within HHS.  Effective March 31, 1995, it became an
independent agency.\5 SSI provides cash benefits to aged, blind, or
disabled individuals whose income and resources are below certain
levels.  Individuals seeking SSI benefits on the basis of disability
must meet financial eligibility requirements and disability criteria. 
SSI is federally funded, and most states provide recipients a
supplement.  SSA determines applicants' financial eligibility; DDS
offices, which are state agencies funded and overseen by SSA, make
the initial determination of applicants' medical eligibility.  In
1994, more than 6 million SSI recipients received nearly $22 billion
in federal benefits and $3 billion in state benefits.  The maximum
federal SSI monthly benefit in 1995 is $458 for an individual and
$687 for a couple if both spouses are eligible. 

To be eligible for SSI, individuals must be U.S.  citizens or legal
immigrants.\6 Also eligible for SSI benefits are certain other
immigrants, classified by public assistance programs as permanently
residing in the United States under color of law (PRUCOL).\7 Under
the SSI program, the PRUCOL category includes refugees, defined by
INS as people who are outside their country of nationality and unable
or unwilling to return to that country because of persecution or a
well-founded fear of persecution.  Refugees are eligible to become
lawful permanent residents after 1 year of continuous presence in the
United States, and most do. 

Most SSI recipients are also eligible for Medicaid and food stamps. 
Medicaid is a federal/state matching entitlement program administered
by HHS' Health Care Financing Administration (HCFA).  Medicaid
provides medical assistance to low-income aged, blind, or disabled
individuals; members of families with dependent children who receive
benefits from the Aid to Families With Dependent Children program;
and certain other children and pregnant women.  The Food Stamp
program, administered by the Department of Agriculture's Food and
Nutrition Service, is a federally funded entitlement program that
provides food stamp coupons to low-income families. 


--------------------
\5 Social Security Independence and Program Improvements Act of 1994
(P.L.  103-296). 

\6 Legal immigrants include those classified by INS as lawful
permanent residents--people lawfully accorded the privilege of
residing permanently in the United States. 

\7 SSI regulations define a PRUCOL immigrant as an alien residing in
the United States with the knowledge and permission of INS whose
departure INS does not contemplate enforcing (20 C.F.R.  416.1618). 


      APPLYING FOR SSI BENEFITS
---------------------------------------------------------- Letter :2.1

To apply for SSI disability benefits, an individual must generally
file a claim, in person, by telephone, or by mail, with an SSA field
office.  Usually, an SSA field office claims representative
interviews the claimant in person or by telephone to determine
whether the claimant's income and resources meet SSI financial
eligibility criteria and to obtain information about the claimant's
disability.  In the case of a non-English-speaking claimant, if the
claims representative does not speak the claimant's language, an
interpreter participates in the interview.  The SSA claims
representative is also available to help the claimant complete the
application form.  If the claimant is deemed financially eligible,
the SSA field office refers his or her claim to the state DDS for a
medical review. 

DDS decides whether a claimant's physical or mental impairment meets
SSI disability criteria.  To be considered disabled, a claimant must
be unable to engage in any substantial gainful activity because of a
physical or mental impairment that is expected to last at least 12
months or to result in death.  To make a determination, DDS obtains
and reviews medical evidence from health care providers who have
treated the claimant.  If DDS finds the medical evidence insufficient
or possibly fraudulent, it orders a medical consultative examination
(CE).  DDS is generally responsible for ensuring that there is no
language barrier between the claimant and the CE provider.  If the CE
provider does not speak the claimant's language, DDS can either
arrange for an interpreter or allow the claimant to use his or her
own interpreter.  If the claim is denied, an appeals process is
available. 

SSA conducts a redetermination on each case periodically to ensure
that recipients continue to be eligible for SSI according to
financial eligibility criteria.  The frequency of redeterminations
varies based on anticipated changes in income and other factors;
however, a redetermination is performed on every case at least once
every 6 years.  SSA has also been authorized to conduct periodic
continuing disability reviews (CDR) to ensure that people whose
medical condition has improved and who are no longer disabled leave
SSI's rolls.  We previously reported that SSA had conducted
relatively few CDRs for several years.\8

In 1994, to increase the number of CDRs that SSA conducted under the
SSI program (only 11,000 were conducted in 1994) the Congress
instituted a requirement that SSA conduct at least 100,000 CDRs on
SSI cases each year for the next 3 years, beginning with fiscal year
1996.  SSA is also required to conduct CDRs on at least one-third of
disabled SSI recipients who turn 18 years old in each of the next 3
years. 

If an SSA or DDS office suspects that a claim is fraudulent and the
CE does not refute that suspicion, that claim is referred to the OIG
for investigation.\9 Generally, the function of the OIG is to work
with SSA to develop evidence to establish potential violations of the
Social Security Act; decide whether suspected fraud cases meet
federal, state, or county guidelines for criminal or civil
prosecution; and formally prepare and present cases for prosecution
to the U.S.  Attorney or the District Attorney. 

The Congress is considering legislation that could have a significant
impact on both immigrants already receiving SSI benefits and those
applying for SSI benefits.  The House of Representatives passed H.R. 
4 in 1995, which includes a provision that would generally bar legal
immigrants, except for lawful permanent residents who are 75 years
old or older and who have lived in the United States for at least 5
years and refugees in the country fewer than 6 years, from receiving
certain welfare benefits, including SSI benefits.  The Senate is
considering a similar measure that would eliminate eligibility for
all noncitizens except for legal immigrants who have worked in the
United States long enough to qualify for Social Security disability
benefits--at least 10 years--and recent refugees and veterans. 


--------------------
\8 Social Security:  New Continuing Disability Review Process Could
Be Enhanced (GAO/HEHS-94-118, June 27, 1994). 

\9 Until March 31, 1995, cases of suspected fraud were referred to
the HHS OIG; the independent SSA now has its own OIG. 


   EXTENT OF FRAUDULENT
   APPLICATIONS BY
   NON-ENGLISH-SPEAKING IMMIGRANTS
   USING MIDDLEMEN IS UNKNOWN
------------------------------------------------------------ Letter :3

Although some ineligible non-English-speaking immigrants obtain SSI
benefits by using middlemen, the actual number of people who do so is
unknown.  During the past decade, the SSI immigrant caseload has
grown dramatically, as compared with the U.S.  citizen caseload.  To
serve those immigrants who do not speak English, interpreters were
introduced to the SSI application process.  By 1990, SSA was aware
that some non-English-speaking applicants were using middlemen to
defraud the SSI program and were collecting SSI benefits for which
they were ineligible.  Because SSI recipients generally remain on the
rolls for a long time, the cost of a single mistake in determining
eligibility is high:  We estimate that one ineligible recipient could
improperly receive a total of about $113,000 in federal benefits by
the time he or she is 65 years old. 

As mentioned previously, little is known about the actual number of
non-English-speaking immigrants receiving SSI as a result of
fraudulent applications made with the assistance of middlemen.  Most
of the suspected cases of middleman fraud identified so far have been
in California and Washington--about 6,500 cases.  In both states,
there has been a concerted effort to uncover fraudulent claims
facilitated by middlemen.  Washington's intergovernmental task force
on SSI middleman fraud, for instance, identified the following
case:\10 A Washington middleman who ran a business submitting
fraudulent SSI claims was convicted of fraud.  For a fee of between
$2,000 and $3,000 from each applicant, he had provided inaccurate
information on their SSA forms, coached them to feign mental
impairments, and provided false translations at their medical
examinations.  At least 500 of the more than 1,000 immigrants he had
coached qualified for benefits; as of November 1994, 95 of these
recipients had received about $3.2 million in benefits.  Three of the
500 have been convicted of fraud.  The SSI claims of these 500
recipients, as well as other potentially fraudulent claims that have
been identified, are subject to SSA reviews.  SSA has begun
implementing reviews of 460 suspected fraudulent claims in
Washington. 


--------------------
\10 In 1992, Washington formed an intergovernmental task force to
investigate middleman fraud in one county. 


      IMMIGRANT CASELOAD AND NEED
      FOR INTERPRETERS HAVE RISEN
      DRAMATICALLY
---------------------------------------------------------- Letter :3.1

During the past decade, the immigrant portion of the SSI disability
caseload rose much more rapidly than the U.S.  citizen portion of the
caseload.  Between 1983 and 1993, the number of U.S.  citizens
receiving SSI disability benefits rose from approximately 2.3 million
to 4.2 million--less than a twofold increase.  In comparison, during
the same period, the number of immigrants receiving SSI disability
benefits rose from 45,000 to 267,000-- approximately a sixfold
increase.\11 This increase is particularly dramatic when contrasted
with the increase in the number of immigrants admitted annually to
the United States in the past decade; that is, 628,132 were admitted
in 1983, compared with 1,000,630 in 1993.\12

The immigrant component of the SSI disability caseload is important
because it is different from the rest of the caseload in one obvious,
but significant, way:  Many immigrants do not speak or understand
English.  As a result, when they apply for SSI benefits, they need
someone to translate for them during their interactions with the
English-language SSI system.  SSA field offices often maintain
interpreters on staff for the languages that are prevalent in their
geographical areas, but sometimes field offices are unable to meet
the need for interpreters.  As a result, non-English-speaking
applicants have been free to involve their own interpreters in the
application process except where fraud is suspected. 


--------------------
\11 Charles Scott and Elsa Ponce, Aliens Who Receive SSI Payments,
SSA, Office of Supplemental Security Income (Mar.  1994).  Included
with disabled immigrant recipients are blind recipients, who
represent 1.4 percent of all SSI recipients. 

\12 Excluded from the 1993 figure are 24,278 former illegal
immigrants who were legalized under the Immigration Reform and
Control Act of 1986; included are an estimated 113,152 refugees.  In
view of the way in which the data were collected, this 1993 figure
may be overstated. 


      FRAUD PROBLEM HAD SURFACED
      BY 1990
---------------------------------------------------------- Letter :3.2

Many of the SSA and DDS offices we visited had recognized middleman
fraud as a problem by 1990.  Some middlemen were suspected of taking
advantage of non-English-speaking claimants' lack of sophistication
and apprehensions about being in a new country, thus leading
claimants to believe that middleman services were an essential
support in navigating the SSI system.  Middlemen were known to have
coached claimants to feign forms of mental impairment, such as
delayed stress syndrome or depression; controlled SSA interviews by
answering all questions asked of claimants; prepared applications for
numerous claimants using identical wording to describe the same
mental impairments; and established relationships with unscrupulous
doctors who helped them defraud the SSI program by submitting false
medical evidence. 

In 1990, for example, SSA's San Francisco regional office sent a
memorandum to SSA headquarters, describing trends in disability
claims involving suspected middleman fraud.  The memorandum
highlighted the following trends:  claimants often alleged mental
disorders; the same middleman represented many claimants at their SSA
field office interviews and at their CEs; and the same physician
provided essentially identical medical reports for many claimants. 
One California DDS branch office identified 176 claimants who had
used the same middleman, who was suspected of routinely providing
false information and coaching claimants, and the same treating
doctor, who allegedly provided "interchangeable" medical reports. 


      FRAUDULENT APPLICATIONS ARE
      COSTLY
---------------------------------------------------------- Letter :3.3

The result of such middleman involvement in the SSI application
process is that some non-English-speaking immigrants collect SSI
benefits to which they are not entitled.  This situation is
especially problematic because we estimate that each person
collecting illegal SSI benefits costs the program thousands of
dollars a year.  Moreover, once claimants are accepted into the SSI
program, it is likely that they will remain on the rolls for a long
time. 

On the basis of a recent study of the duration of stay on SSI
disability rolls, SSA reported that the expected mean lifetime
disability stay of new SSI recipients before they reach age 65 is
about 11 years.\13 Thus, given the average federal monthly SSI
benefit in December 1994 of $384, a recipient improperly admitted to
the program could collect about $51,000 in SSI benefits to which he
or she was not entitled.  Moreover, the cost to the government could
be higher than just the SSI payments, because in most states,
Medicaid benefits and food stamps are automatically provided to SSI
recipients.  As a result, the recipient could improperly receive
total federal benefits worth about $113,000.\14


--------------------
\13 Data are not available on the expected mean lifetime disability
stay of immigrants. 

\14 We estimate that an SSI recipient's annual Medicaid and Food
Stamp benefits are $5,036 and $611, respectively. 


   SEVERAL FACTORS CONTRIBUTE TO
   SSI'S VULNERABILITY TO
   APPLICANT FRAUD WHEN MIDDLEMEN
   ARE USED
------------------------------------------------------------ Letter :4

There are various reasons for which SSI is vulnerable to fraudulent
applications when middlemen are involved.  First, some SSA management
practices permit middleman involvement.  In addition, SSA has a
shortage of bilingual staff to handle non-English-speaking
applicants.  Third, unavailable documentation of applicants' medical
histories as well as translations provided by interpreters at
applicants' medical examinations make disability determinations
difficult.  Moreover, SSA's monitoring of middlemen remains limited
until SSA's planned interpreter database is developed and completed,
and HHS OIG investigations of cases of suspected fraud involving
middlemen were hampered by a lack of resources.  In addition, SSA has
no formalized procedures for regularly working with state Medicaid
agencies--a type of coordination that could help SSA identify cases
of suspected fraud.  Finally, SSA needs a more effective programwide
strategy for keeping ineligible SSI applicants off the rolls. 


      SOME SSA MANAGEMENT
      PRACTICES ENABLE APPLICANTS
      TO USE MIDDLEMEN
---------------------------------------------------------- Letter :4.1

Some of SSA's current management practices--in particular, certain
provisions of SSA guidance and procedures--enable
non-English-speaking applicants to use middlemen.  For example, SSA
guidance states that if an applicant does not have an interpreter,
SSA will provide one.  This practice places secondary responsibility
for providing translation services on SSA field offices.  The result
is that SSA field offices are not generally required to use their
bilingual staff for translating in interviews unless an applicant
does not provide his or her own interpreter.  When the applicant does
provide an interpreter, SSA will generally use the applicant's
interpreter as long as there is no reason to suspect that he or she
is unreliable.  SSA also allows applicants to use their relatives or
friends as interpreters, even though unscrupulous middlemen sometimes
pose as relatives or friends.  Moreover, SSA's broad definition of a
qualified or reliable interpreter enables an applicant to use almost
any interpreter he or she chooses.  Finally, SSA procedures allow
claimants to apply for SSI at any SSA field office, even though doing
so enables them to abuse the system.  When some middlemen or
claimants learn that a certain SSA field office has staff who can
speak the language of the claimant, they can go instead to a
different field office, where no employees speak the language,
thereby retaining control of the interview portion of the application
process. 


      SSA HAS A BILINGUAL STAFF
      SHORTAGE
---------------------------------------------------------- Letter :4.2

SSA's bilingual staffing problems exacerbate program vulnerabilities
that arise because of some of SSA's management practices.  HHS OIG
reported in 1990 that the number of bilingual SSA employees was
insufficient to provide adequate service to non-English-speaking
individuals.  As a result, SSA has hired more bilingual staff.\15
However, some SSA field offices remain without enough staff who can
speak the languages needed.  According to 1993 and 1994 SSA data, at
least 45 field offices at which non-English-speaking individuals
represented 10 percent or more of the workload needed additional
bilingual staff.  Furthermore, an SSA San Francisco regional office
study of 1,198 cases from 1992 and 1993 found that when an
interpreter was required, field office personnel were able to
interpret in less than an estimated 5 percent of the cases when the
language was other than Spanish.  One California field office we
visited had encountered 127 people speaking 19 languages in a single
day.  Because of the shortage of SSA staff who can speak the
necessary languages, there may be more instances of SSI applicants
using middlemen than would otherwise be necessary.\16


--------------------
\15 SSA reported that in fiscal year 1993, 266 of permanent field
office hires were bilingual; in fiscal year 1994, 481 of such hires
were bilingual. 

\16 Other federal agencies with bilingual staff shortages may have
similar problems with implementing their programs. 


      DIFFICULTIES IN OBTAINING
      ADEQUATE MEDICAL INFORMATION
      HEIGHTEN CHANCES FOR FRAUD
---------------------------------------------------------- Letter :4.3

SSI's vulnerability to fraud when middlemen are used is enhanced by
difficulties in obtaining adequate medical information and other
kinds of information useful to the disability determination process
of non-English-speaking claimants.  Documentation of the individual
claimant's medical history from the claimant's home country may be
limited or nonexistent.  As a result, there is little longitudinal
history of the claimant's health before his or her arrival in the
United States.  Furthermore, when a claimant undergoes a medical
examination in the United States with a provider who does not speak
his or her language, the claimant needs an interpreter. 

When claimants are allowed to provide their own interpreters at
medical examinations, SSI becomes more vulnerable to fraud.  If a
middleman provides a false translation of a claimant's symptoms or
coaches the claimant on how to behave during the examination, the
provider could make an incorrect medical assessment and submit
inaccurate medical evidence to the state DDS.  Moreover, some
middlemen bring claimants to dishonest providers who are willing to
submit false medical evidence to DDS. 

Although DDS can order a CE if the applicant's medical information is
inconclusive, the middleman may be able to manipulate this exam if
the provider does not speak the applicant's language or have his or
her own translator.  In addition, DDS may be hindered in collecting
essential information on the claimant's education and work
experience.  Taken together, these information deficits can seriously
impede the DDS as it attempts to accurately assess the claimant's
ability to work. 


      SSA MONITORING OF
      APPLICANTS' USE OF MIDDLEMEN
      IS LIMITED
---------------------------------------------------------- Letter :4.4

Despite recent changes in some SSA procedures, SSA's monitoring of
middlemen is limited.  Although data on interpreters are being
collected, they are not currently being incorporated into a central
database.  Rather, hard copy data are being maintained in the case
files of individual claimants.  SSA is beginning to design an
automated system for tracking middlemen.  However, it may not be
completed for several years, and SSA has no interim monitoring
procedures in place. 

As a result of congressional hearings in February 1994 and the Social
Security Independence and Program Improvements Act of 1994, SSA now
requires all non-SSA interpreters to complete and sign a form
containing their name, address, and relationship to the applicant. 
These forms are maintained in applicants' files, providing a
potentially valuable body of information.  But because the data
collected on these forms are not being entered into an automated
database, no central file exists to help SSA identify and track
middlemen suspected of fraud.  Thus, when an SSA field office
encounters a new interpreter, it has no easy means to determine his
or her reliability or whether he or she has a record with other field
offices. 

SSA recently began developing a nationwide database of interpreter
information that will identify reliable interpreters and flag
middlemen who are convicted or suspected of fraud.  According to SSA,
this database could be operational in 1996 or 1997.  But we believe
it could be some time after that before users will be able to
retrieve comprehensive interpreter data from this database, because
SSA will probably have to compile and input considerable information,
such as the signed interpreter forms previously discussed. 
Furthermore, work to develop the interpreter database has been
somewhat slow to date, according to one SSA official, because some
SSA automated systems are still being modernized. 

In the interim, SSA has no formal procedures in place to monitor
middlemen.  Two of the California field offices we visited maintained
their own lists of suspect middlemen, but these lists were not being
regularly shared with other SSA offices.  The California DDS also
maintains a list of suspect middlemen that it has submitted to the
SSA regional office, but that office has not distributed the list to
SSA field offices. 


      HHS OIG LACKED FUNDS FOR
      SUFFICIENT INVESTIGATIONS
---------------------------------------------------------- Letter :4.5

During the last several years that HHS OIG was responsible for
investigating SSI middleman fraud, it investigated very few cases.\17
In fact, SSA field offices said they had become hesitant to forward
suspect claims because of what they perceived as a lack of interest
by HHS OIG.  According to HHS OIG, it had too few resources to
perform more SSI investigations and was concentrating its resources
on cases with a larger payoff. 

HHS OIG, which was responsible for investigating fraudulent SSI
claims until March 31, 1995, completed 10 middleman fraud
investigations between 1987 and April 1995.  These investigations
resulted in the conviction of five middlemen.  HHS OIG also
participated with other federal and state investigators in some joint
investigations of middleman fraud. 

SSA field office staff told us they had become reluctant to refer
suspect claims to HHS OIG because they expected that little or no
action would be taken.  According to results of an informal SSA
survey, in February 1994, the San Francisco regional office had
referred at least 600 claims involving suspected middleman fraud to
the HHS OIG, and the Seattle regional office had referred between 200
and 300.  These numbers represent referrals made since October 1992. 
The California claims were subject to selection for the CDRs being
conducted currently on potentially fraudulent cases involving
middlemen.  The Washington claims will be examined by the
intergovernmental task force. 

Between 1990 and 1994, HHS OIG investigative resources declined about
17 percent--from 469 staff to 390.  In 1994, the HHS Inspector
General reported that a lack of resources--specifically, limited
federal investigative and prosecutive resources--posed an "obstacle"
to the pursuit of middleman fraud.  At that time, the HHS OIG was
also responsible for investigating fraud in the much larger Medicare
and Medicaid programs, as well as in the SSI program.  Furthermore,
some threats allegedly made by middlemen on SSA field staff may have
contributed to a lower number of referrals to the HHS OIG for
investigation of middleman fraud. 

Beginning March 31, 1995, SSA has had its own OIG solely dedicated to
SSA programs.  SSA is adding 50 positions in fiscal year 1996 to
augment the staff who transferred from the HHS OIG. 


--------------------
\17 Within the HHS OIG, the specific component responsible for
investigations is the Office of Investigations. 


      COORDINATION BETWEEN SSA AND
      STATE MEDICAID AGENCIES IS
      NOT ROUTINE
---------------------------------------------------------- Letter :4.6

One way for SSA to extend its resources would be to work more
regularly with state Medicaid agencies.  When one state shared
information during its Medicaid fraud investigations, SSA eventually
identified nearly 2,000 possibly fraudulent claims associated with
illegal middleman activity.  But coordination between SSA and state
Medicaid agencies is not a regular practice. 

At the federal level, HCFA, within HHS, funds and oversees the
Medicaid program.  Federal law requires that a single state agency be
charged with administration of the Medicaid program.  Each state's
own Medicaid agency is variously situated in departments such as
health, welfare, or human services.  The state Medicaid agency may
contract with other state entities to conduct some program functions. 

The state Medicaid agency is responsible for program integrity.  In a
case of health care provider abuse, the state Medicaid agency is
authorized to take certain administrative actions.  Where provider
fraud is suspected, the state Medicaid agency in most states refers
cases for investigation to Medicaid Fraud Control Units (MFCU). 
MFCUs investigate selected providers suspected of overbilling
Medicaid for the services they provide to eligible patients or for
billing for services that they never provided.  States report the
names of prosecuted or sanctioned providers to the HHS OIG so that
the OIG can take appropriate action to exclude these providers from
participation in other federal health programs, such as Medicare.  In
the course of their investigations of providers, it is possible for
states to obtain information that could be useful to SSA, such as the
lists of patients maintained by suspect providers, some of whom are
associated with middlemen. 

In California, for example, an investigation initiated by the state
and assisted by the HHS OIG yielded information that, when passed on
to SSA, led to SSA's identification of 1,981 SSI recipients
associated with potentially fraudulent claims involving middlemen. 
Routine coordination of efforts with state Medicaid agencies could
enhance SSA's ability to identify potentially fraudulent SSI claims. 
For example, state investigative information could be helpful to SSA
in meeting the 1994 congressional requirement that SSA conduct at
least 100,000 SSI CDRs each year for the next 3 years, beginning in
1996.  SSA could use state investigative information to help it
identify high-priority cases for these CDRs. 

To date, however, coordination between SSA and state Medicaid
agencies has been ad hoc.  When SSA was part of HHS, according to SSA
officials, SSA generally did not contact state Medicaid agencies on a
regular basis because Medicaid fell under the administrative
jurisdiction of HCFA.  Consequently, SSA did not establish--and has
not yet established since it became an independent agency in March
1995--formal coordination procedures for obtaining potentially
helpful information from state Medicaid agencies. 


      SSA NEEDS A MORE
      COMPREHENSIVE PROGRAMWIDE
      STRATEGY FOR KEEPING
      INELIGIBLE
      NON-ENGLISH-SPEAKING
      APPLICANTS OFF SSI
---------------------------------------------------------- Letter :4.7

SSA has tried a few approaches for handling some of the individual
factors that contribute to SSI's vulnerability to fraud, but needs to
develop and implement a more comprehensive, programwide strategy for
ensuring that only eligible applicants receive SSI benefits.  For
example, one SSA approach for limiting the extent to which
non-English-speaking applicants could use middlemen was to
disseminate its definition of a qualified interpreter to all field
staff.  Furthermore, SSA disseminated a program circular in May 1995
to clarify procedures for conducting interviews with
non-English-speaking claimants.  In addition, SSA's approach to the
bilingual staffing shortage has been to encourage field offices to
hire more staff, although, according to SSA, this has been difficult
for field offices to do because of recent constraints on hiring. 
Moreover, SSA's plan for tracking fraudulent middlemen may not be
fully implemented for several years; its OIG needs more resources to
perform investigations; and SSA does not routinely use state
investigative information to help identify fraudulent SSI
applications. 

A more comprehensive, programwide strategy for ensuring that only
eligible people receive SSI benefits could include, for example,
requiring that SSA's own bilingual staff or contractors conduct
interviews with non-English-speaking applicants and exploring the use
of videoconferencing technology, which would maximize the use of SSA
bilingual staff, if SSA determines that the benefits outweigh the
costs. 


   SOME INITIATIVES ADDRESS
   MIDDLEMAN FRAUD
------------------------------------------------------------ Letter :5

The Congress, SSA, and several states have initiated various efforts
to prevent or detect fraudulent SSI claims involving middlemen.  Some
of the efforts, such as passage of new legislation, have been
completed; others are in progress.  A discussion of some of these
initiatives follows.  (See app.  I for a detailed list of
initiatives.)


      CONGRESSIONAL INITIATIVES
---------------------------------------------------------- Letter :5.1

The legislation that established SSA as an independent agency, the
Social Security Independence and Program Improvements Act of 1994,
contained provisions for expanding SSA's authority to prevent,
detect, and terminate fraudulent claims for SSI benefits.  Some of
the law's provisions did the following:  changed the federal crime of
SSI fraud from a misdemeanor to a felony; gave SSA the authority to
impose civil penalties against any person or organization determined
to have knowingly caused a false statement to be made in connection
with an SSI claim; and gave SSA the authority to request immigrant
medical data and other information from INS and the Centers for
Disease Control for use in eligibility determinations.\18 The
provisions of the law that relate to SSI reflect legislative
recommendations that were made by the Subcommittee on Oversight and
the Subcommittee on Human Resources, House Committee on Ways and
Means, in May 1994.\19 The Subcommittees also made several
administrative recommendations to SSA.\20


--------------------
\18 Prospective immigrants must meet certain medical criteria
prescribed by the Centers for Disease Control. 

\19 The Subcommittees' recommendations were provided in a May 12,
1994, report, Reforms to Address Supplemental Security Income Fraud
and Abuse Involving Middlemen. 

\20 Administrative recommendations included that SSI establish a
quality assurance program to ensure accurate interpreter translations
and that the agency develop a database of interpreters who are
available to all SSA field offices by telephone. 


      SSA INITIATIVES
---------------------------------------------------------- Letter :5.2

SSA established a task force in April 1993 to combat middleman fraud. 
In large part as a result of the work of the task force, SSA has
initiated various efforts to detect and prevent middleman fraud. 
Because many of these initiatives are in the planning stages or the
early stages of implementation, however, it is too soon to evaluate
their effectiveness. 

One effort under way, as mentioned earlier, is the development of a
nationwide database to help SSA and DDS offices monitor middlemen. 
The database is expected to be useful in identifying reliable
interpreters and in identifying and tracking middlemen whose
activities are questionable.  Because all SSA and DDS offices are
expected to have access to the database, an office that encounters a
new interpreter will be able to determine from the database if other
offices have had experience with the same person. 

A second task force initiative, which resulted largely from February
1994 hearings on middleman fraud,\21 implements one of the provisions
in the legislation that established SSA as an independent agency.  As
of March 1994, SSA requires that all non-SSA interpreters fill out a
form on which they provide their name, address, and relationship to
the applicant and sign a statement that they are providing an
accurate translation.  These forms are being maintained in each
claimant's file, providing a potentially valuable body of
information.  SSA officials said that these files may eventually be
incorporated into the database. 

Another task force effort has resulted in SSA plans to review
possibly fraudulent cases involving middlemen for which benefits are
already being paid.  In California, SSA identified many potentially
fraudulent cases as a result of an ad hoc cooperative venture between
the state and SSA.  (See following section on state initiatives.) SSA
plans to conduct 600 CDRs in California.  As of April 26, 1995, 386
CDRs had been completed in California, resulting in 207 initial
benefit terminations.  These terminations are subject to appeal, and
thus far about 60 percent have been appealed.  In Washington,
potentially fraudulent cases were identified as a result of an
intergovernmental task force effort.  (See following section on state
initiatives.) SSA has begun to do 460 reviews in Washington, but none
have been completed yet. 

SSA also reported that its ultimate goal is to dramatically reduce
reliance on middlemen in developing the claims of
non-English-speaking applicants.  SSA is trying several approaches to
reduce the use of middlemen as interpreters.  First, SSA continues to
encourage bilingual hiring in its field offices to improve service
delivery to the non-English-speaking public.  SSA reported that in
fiscal year 1993, 266 of 533 permanent field office hires (50
percent) were bilingual; in fiscal year 1994, 481 of 1,099 such hires
(44 percent) were bilingual. 

In addition, in February 1995, SSA officials reported that a
statement of work was being prepared for a pilot contract to test the
feasibility of using contract interpreter services to supplement
SSA's own interpreter staff.  But the funding for the pilot has been
reduced to $100,000, so only a limited number of SSA offices will
receive contract services under the pilot.  SSA officials doubt that
a national contract for interpreter services is feasible, given
anticipated costs. 

Furthermore, in 1994, SSA expanded upon efforts of at least 2
regional offices by asking all 10 regional offices to establish
directories of bilingual employees who were available to help other
field offices by interpreting during telephone interviews.  Many of
the 13 SSA field offices we visited expressed a need for more
bilingual staff; only 1 reported having used a bilingual SSA employee
from another field office to interpret by telephone. 

Finally, individual field offices have also looked to external
sources, such as local advocacy groups, professional translation and
interpreter services, and community service centers, for interpreting
assistance.  At least two field offices have made arrangements with
universities and institutes for students to earn credits or serve
internships for performing interpreter services. 


--------------------
\21 On February 24, 1994, the Subcommittee on Oversight and the
Subcommittee on Human Resources, House Committee on Ways and Means,
held a joint hearing to review the problem of middleman fraud in the
SSI program and to consider possible legislative and administrative
solutions. 


      STATE INITIATIVES
---------------------------------------------------------- Letter :5.3

Several states have been active in seeking more effective fraud
prevention and detection approaches.  Again, many of these
initiatives are in the early stages of implementation, so it is too
soon to evaluate their success. 

One initiative involves the use of independent or state-certified
interpreters at CEs, a practice currently employed in Pennsylvania
and Minnesota.  In California, if fraud is suspected or if there is
reason to believe that the claimant's interpreter is not objective or
qualified, the state DDS pays for an independent interpreter for the
CE or uses someone from a community assistance group or other
reliable source.  Massachusetts and Connecticut DDS offices use paid
interpreters as much as possible and encourage CE providers to
require positive identification from the person being examined. 

In addition, California has initiated a pilot project to establish a
fraud investigation unit in one of its DDS offices.  With SSA
approval and assistance, the state plans to hire and train
investigators to pursue fraudulent SSI disability claims. 
Investigations will be based on suspected fraud referrals from DDS
staff. 

Also in California, an ad hoc cooperative venture between the state
Medicaid agency and SSA yielded useful information.  When the state
requested assistance from the HHS OIG on some of their Medicaid fraud
investigations, SSA had the opportunity to obtain the names of
patients of providers who had been arrested or convicted of Medicaid
fraud, as well as the names of clients of middlemen who used these
medical providers.  SSA then compared these names to those in their
database of current SSI claimants, to flag claimants who might have
been collecting benefits fraudulently.  Since July 1992, 6,062
potentially fraudulent claimants have been identified in California,
many as a result of the cooperation between the state, the HHS OIG,
and SSA.  Furthermore, during 1993 and 1994, California reported 22
arrests or convictions of providers, middlemen, and their assistants. 

Finally, Washington State formed an intergovernmental task force in
1992 in one county to investigate middlemen and others suspected of
fraud.\22 Under the direction of the U.S.  Attorney, the task force
has identified 460 suspected fraudulent claims involving middlemen. 
In 1994, three middlemen, three SSI recipients, and several others
were arrested or convicted. 


--------------------
\22 The task force has included investigators or staff from the
Federal Bureau of Investigation, Internal Revenue Service, Customs
Service, Postal Inspection Service, Department of Agriculture's OIG,
INS, Washington State Patrol, Pierce County Prosecutor's Office,
Tacoma Police Department, Pierce County Sheriff's Office, then-HHS
OIG, and SSA. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

SSA has awarded SSI benefits to unknown numbers of
non-English-speaking immigrants who are actually ineligible for SSI
benefits.  These awards are very costly to the government, accounting
in each case for thousands of dollars in improper payments over the
years.  Although individual SSA field offices have been creative in
developing their own approaches to dealing with the problem, SSA's
programwide efforts to ensure that only people who are eligible for
SSI benefits receive them have been limited.  SSA's responses to SSI
fraud have included publishing guidance for SSA interviews.  If the
interviewer believes that the interpreter may be providing inaccurate
information, the interview should be terminated until an interpreter
who meets SSA criteria for a qualified interpreter can be provided. 
SSA also plans to improve communication with and outreach efforts to
the non-English-speaking community, and it plans to develop a quality
assurance program for interpretations. 

A more effective programwide strategy for ensuring that only eligible
people obtain SSI benefits would require consistent, programwide
practices for obtaining more accurate applicant information,
maintaining and sharing information on interpreters and middlemen
among field offices, and using the work of other government agencies
to help identify potentially fraudulent cases.  A comprehensive
strategy should consider cost-benefit analyses of SSA's alternatives
for addressing the problem, SSA's limited resources, and applicants'
need for timely service.  Such a strategy could involve, for example,
SSA requiring that its own bilingual staff or contractors conduct
interviews with non-English-speaking applicants and exploring the use
of videoconferencing technology, which, as mentioned earlier, could
take best advantage of SSA bilingual staff.  These components of a
programwide strategy would further prevent claimants from using
middlemen to manipulate the system. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

We recommend that the Commissioner of Social Security develop a more
aggressive, programwide strategy for improving the quality of
information obtained from applicants, maintaining and sharing data
collected on interpreters and middlemen among field offices, and
using information that results from the work of other government
agencies--local, state, and federal--to pursue cases in which fraud
is suspected. 

Such a strategy should include developing improved ways to more
effectively manage SSA's resources to further facilitate
communications with applicants, possibly by requiring that SSA
bilingual staff or SSA contracted staff conduct the interviews and by
exploring videoconferencing technology. 

This strategy should also include

  instituting procedures for sharing, among field offices, the
     information SSA has already collected about interpreters and
     middlemen from its required forms and other sources, until the
     automated interpreter database is established, and

  establishing a mechanism to facilitate regular sharing of all state
     Medicaid agencies' investigative results with SSA. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :8

SSA agreed with the intent of our recommendations and stated that it
is exploring these recommendations as it continues its efforts to
minimize fraud in cases involving middlemen.  For example, SSA cited
a pilot currently under way in California wherein state investigators
are reviewing cases referred from DDS for possible prosecution under
state and local laws. 

SSA also suggested the following change to our report concerning
whether SSA's practices permit non-English-speaking applicants to use
middlemen:  "SSA officials explained that SSA is attempting to
address the fraud problem within the framework of its efforts to
provide all non-English-speaking claimants convenient, accessible,
and timely service in an environment of limited bilingual staff and
funding.  Experience suggests that the vast majority of
non-English-speaking claimants are not involved in fraudulent
activity.  Therefore, to meet customer service needs and save
resources, SSA does allow the non-English-speaking claimant the
option of providing his or her own interpreter as long as the
interpreter agrees to provide an exact interpretation of the
claimant's response and can function as a capable interpreter. 
However, if, during the course of the interview, the interviewer
believes that the interpreter is not acting in the claimant's best
interest or is not providing accurate information, the interview is
terminated.  The interview is then rescheduled for a later date when
another interpreter can be provided by SSA."

We believe that despite its staffing and funding constraints,
concerns with claim processing times, and current efforts to address
fraud, SSA can do more to reduce the SSI program's vulnerability to
fraudulent applications involving middlemen.  Given that each person
collecting illegal SSI benefits costs the program thousands of
dollars a year, SSA must aggressively pursue any available
opportunity such as those we have recommended to further minimize
unwarranted outlays of federal monies so that it can increase the
public's confidence in this important program. 

The agency also made other technical comments that we incorporated
throughout the report as appropriate.  (See app.  II.)


---------------------------------------------------------- Letter :8.1

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
from the date of this letter.  At that time, we will send copies to
the appropriate congressional committees and federal agencies. 
Copies also will be available to others on request. 

If you or your staff have any questions concerning this report,
please call me on (202) 512-7215.  Other GAO contacts and staff
acknowledgments are listed in appendix III. 

Sincerely yours,

Jane L.  Ross
Director, Income Security Issues


INITIATIVES FOR ADDRESSING
MIDDLEMAN FRAUD
=========================================================== Appendix I

INITIATIVES BY THE CONGRESS
(P.L.  103-296)

The federal crime of SSI fraud has been elevated from a misdemeanor
to a felony. 

SSA now has the authority to impose civil penalties against any
person or organization determined to have knowingly caused a false
statement to be made in connection with an SSI claim. 

Third-party translators are now required to certify under oath the
accuracy of the translation provided and the relationship between the
translator and the SSI applicant or recipient. 

SSA now has enhanced authority to redetermine eligibility and give
less weight to evidence of disability in those cases where SSA has a
reason to believe that fraud was involved and to expeditiously
terminate benefits in those cases where there is insufficient
reliable evidence of disability or other basis for eligibility. 

SSA now has the authority to request medical data and other
information from the Immigration and Naturalization Service and the
Centers for Disease Control for use in disability determination. 

The cognizant Office of Inspector General (OIG) is required to make
SSI recipient identifying information available to SSA as soon as OIG
has reason to believe that fraud is involved and an active
investigation will not be compromised. 

SSA is required to report annually to the House Committee on Ways and
Means and the Senate Committee on Finance the extent to which it has
used its authority to conduct reviews of SSI cases, including the
extent to which these cases involved probable fraud. 

INITIATIVES BY THE SOCIAL SECURITY
ADMINISTRATION

SSA plans to develop a nationwide database to help SSA and disability
determination services (DDS) offices monitor middlemen. 

SSA now requires that all non-SSA interpreters provide their name,
address, and relationship to the claimant and certify that they are
providing an accurate translation. 

SSA has implemented plans to conduct reviews of suspected fraudulent
claims of identified SSI recipients.  About 400 continuing disability
reviews have been completed in California, and 460 reviews are being
started in Washington.  Additional reviews will be started as
resources permit. 

Efforts to improve the availability of reliable interpreters include
encouraging the field offices to hire more bilingual staff, testing
the feasibility of contract interpreter services, developing
alternative sources of community interpreters, and establishing
regional directories of bilingual staff. 

SSA has published new guidance that includes criteria for identifying
qualified or reliable interpreters and terminating interviews with
suspect middlemen. 

SSA plans to develop a quality assurance program for interpretations,
to develop a better procedure for processing fraud referrals, and to
improve communication with and outreach efforts to the
non-English-speaking community. 

INITIATIVES BY THE STATES

DDS in California, Washington, Pennsylvania, Minnesota,
Massachusetts, and Connecticut have begun to use independent or
state-certified interpreters at consultative exams (CE). 

California has instituted a pilot project, funded by SSA, that
established an SSI fraud investigation unit in one of its DDS
offices. 

California shared information about some of its fraud investigations
of medical providers with SSA, which has used the information to
identify potentially fraudulent SSI claimants. 

Washington has created an intergovernmental task force to investigate
middlemen suspected of fraud. 

Massachusetts and Connecticut DDS offices encourage CE medical
providers to require positive identification from claimants. 

The Texas DDS tries to use bilingual CE providers. 




(See figure in printed edition.)Appendix II
COMMENTS FROM THE SOCIAL SECURITY
ADMINISTRATION
=========================================================== Appendix I



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


GAO CONTACTS AND ACKNOWLEDGMENTS
========================================================= Appendix III

GAO CONTACTS

Christopher C.  Crissman, Assistant Director, (202) 512-7051
Ann Lee, Evaluator-in-Charge, (415) 904-2027

ACKNOWLEDGMENTS

In addition to those named above, the following individuals also made
important contributions to this report:  Elizabeth A.  Olivarez,
Clarence Tull, Zachary R.  White, and Michael J.  Ross, Evaluators;
Eli Kuo, Intern;
Nancy L.  Crothers and Jonathan M.  Silverman, Communications
Analysts; James P.  Wright, Assistant Director (Study Design and Data
Analysis); and Stephen R.  Myerson, Assistant Director
(Investigations). 



RELATED GAO PRODUCTS
============================================================ Chapter 0

Supplemental Security Income:  Growth and Changes in Recipient
Population Call for Reexamining Program (GAO/HEHS-95-137, July 7,
1995). 

SSI Disability Issues (GAO/HEHS-95-154R, May 11, 1995). 

Social Security:  Federal Disability Programs Face Major Issues
(GAO/T-HEHS-95-97, Mar.  2, 1995). 

Welfare Reform:  Implications of Proposals on Legal Immigrants'
Benefits (GAO/HEHS-95-58, Feb.  2, 1995). 

Supplemental Security Income:  Recent Growth in the Rolls Raises
Fundamental Program Concerns (GAO/T-HEHS-95-67, Jan.  27, 1995). 

