Tennessee doctors earn big money denying disability claims
tennessean.com
tennessean.com
"Staff doctors take more time. The state employed a small number of staff doctors whose compensation is not tied to the number of cases they review. These doctors reviewed cases at a rate that is in line with federal recommendations. They typically earned less than $150,000 annually, according to the state’s salary database. Beginning this year, however, the state is terminating all doctors on salary and relying only on contract physicians."
So essentially, salaried state doctors took their time to review cases, perhaps realizing that these are real people on the other end of the paper work. The state doctors were paid less than the private doctors and the state is going to lay them off to go full private despite the fact that some of the private doctors are clearly just plowing through the reviews to boost their income.
A whistle blower then called this out and was let go.
Seems like corporate lobbying is alive and well in TN. Don't worry about the individuals, there's money to be made.
"Like Thrush, some of these doctors work very fast.
Dr. Kanika Chaudhuri, a pediatrician, evaluated 3,872 cases last fiscal year, averaging more than four cases per hour when she worked. She earned $192,000 in fiscal 2018 and $1.1 million since 2013.
Out of all the cases Chaudhuri reviewed over the five years, 78 percent were denied, according to data provided by the state."
Is it really a safe assumption that all states have identical rates of fraud? Different states have very different economic and social situations that could pressure somebody into committing fraud. Some states are suffering more than others with prescription drug abuse. Some states have industries that result in more disabilities than other states \cough{coal mines...}
In West Virginia 8.9% of the working age population receives disability, while in Hawaii only 2.8% do. In Tennessee, 6.5% of the working age population is on disability. The national average is 4.6%
"Look how shitty government is, elect me to fix it"
The guy who's shooting dogs for the ATF might thing the DEA is scum and the guy who's shooting dogs for the DEA might think the ATF is a waste but they both believe in the mission of their organization (or at least to the extent needed to do their jobs). They don't care or even realize that shooting dogs isn't their mission, it's just what the incentive structure tells them to do.
These doctors are shooting all the dogs (metaphorically speaking of course) but they're shooting all the dogs because the organization they work within has incentivized that behavior. It's not a top down policy to shoot (metaphorical) dogs. It just so happens that if your top down policy is to suck at everything then there's no motivation to stop the people at the leafs of the organizational tree from shooting dogs (denying disability wrongly as a matter of standard) practice. I think this is incompetence, not malice. The people actually misbehaving are too far removed from policy for this to be malice.
It's curious that you can see how incentives shape the behavior of some people, but not that of other people.
It’s not about people at the top responding differently it’s about the flow of influence. If 20% of the people at the bottom behave poorly the other people at the bottom have little influence. That changes at the top as it’s easyer to monitor a small group of people and their actions are more documented.
Ex: A cashier can fail to scan items for their friends at checkout and without any form of paper trail. The CFO can do more harm, but it’s harder for them to act in secret.
That's simply not true. Go to DC and you will meet a lot of dedicated and highly qualified people working at agencies. And they stay around. The real problem is Congress and some of the media that just scream "government bad" and "deep state" instead of doing their job which is to give the agencies guidance and fixing problems.
Who, exactly, are you referring to?
It's not like the stuff the article covers started in January of 2017. Who, exactly, in the chain of command here "hates government"?
In 2019, we are living in a world where one of the two parties made bad government a cornerstone of their party's policy, ~35 years ago. We are now reaping the wages of that decision.
The state government is controlled by Republicans and though not all Republicans "hate" every aspect of the government, a large contingent of party could be accurately described as hating government involvement in areas they don't agree with--like welfare, disability, healthcare etc...
The leader of the party has explicitly advocated for allowing and encouraging the current healthcare system (the ACA) to implode, so that he can replace it with something else. He also placed people in charge of departments who explicitly stated that such departments shouldn't exist.
Where is the corporate lobbying in this case? There are no corporations mentioned in connection with this story.
There is almost certainly a prime contractor who owns the relationship, who then hires independent contractors as subs. They probably collect a percentage or fixed fee for each piecework task completed.
Some organizations are looking for a paper trail to indicate they've done something - anything - to remedy the issue. Others try to get the full story and fix the rot.
I think we just don't hear about situations where the whistleblowers do a tremendous amount of good, because those are situations in which the problem has successfully been contained and thus aren't newsworthy.
This is in no way meant to justify the absolutely insane process outlined in the Tennesseean article. I just see a lot of people questioning why disability claims would be up when unemployment is down. This is a decades-long trend.
https://www.theatlantic.com/business/archive/2013/03/disabil...
Administrative law judges make judgements based on individual and regional considerations. Someone who may not meet the standard in NYC for disability may qualify in Tennessee, due to the makeup of the employment environment.
The fact that the state is so aggressive about denials is interesting, as it is probably increasing costs to the state due to increased litigation.
This could be a case of one department making their metrics look better at the expense of other departments.
There is even a consulting company whose job it is to recommend people who are on welfare that could be on disability, and then help them fill out the forms and get Dr. consent. This company gets paid 2k+ for each person they switch over..
I think rconti means unemployment insurance/assistance in this case. (if anybody else is a bit confused like i was)
End of the day, the reality is that states that are aggressive about these costs for idealogical reasons are most aggressive about medicaid (cost is split with state), "temporary assistance" (cash payments to individuals and familyies, shared with state).
Usually states make money on disability, WIC, and food stamps. (The Feds fund administrative costs.) Opposing these things is weird, particularly since the alternatives to these programs (jail, ER visits) cost something like 5-10x more!
From https://www.newsweek.com/dollar-stores-general-tree-america-...
> “Essentially what the dollar stores are betting on in a large way is that we are going to have a permanent underclass in America,” real estate analyst Garrick Brown told Bloomberg in 2017.
> Dollar General CEO Todd Vasos agreed, telling The Wall Street Journal, “The economy is continuing to create more of our core customers.” In other words, the more lower-income Americans struggle, the better dollar stores do.
Jobs Polarization is a fairly well researched and discussed topic in economics, but I'm yet to hear anything about it in the mainstream. Income inequality is a hot topic but I think this deserves more attention since it's part of that feedback loop and IMO what people feel directly.
https://www.stlouisfed.org/~/media/files/pdfs/publications/p...
People talk about robots stealing our jobs, but I think we've already kickstarted this process with things that produce similar effects like outsourcing. It's hard to say there's a causual relationship between the two, but disability benefit claims start rising around the same time as the recession in the early 90's.
There's an article from the National Bureau of Economic Research that suggests when firms are pressured they look to invest in automation or outsourcing. Then, when the economy recovers those jobs remain automated or outsourced, thus resulting in the 'Jobless Recoveries' we've been seeing in recent cycles.
https://www.nber.org/papers/w18334.pdf
If you're one of those people, then due to jobs polarization you're likely either looking at a lower paid job or training to find a higher paid one. Re-training has capital costs (not just money, but time and social capital to a point) that not everyone can afford.
Add in the hollowing out of many small towns and I think at least one cause of the rise in disability benefits starts to come into focus.
I don't think this is true for everyone by any means, but I do think it's a trend worth investigating. Right now, politically we're trying to tackle outsourcing, which IMO is kinda moot as automation is rising and produces similar effects.
People talk about automation as if it's something that's coming, but I think we're already seeing what that future looks like.
Increasing the minimum wage does nothing to increase the quality of life on the bottom, but does VERY WELL increase the cost of living (which rises to meet the new 'market will bear' level) and decrease everyone who pays rent rather than "earns" rent.
I feel that real world observation can confirm that raising the minimum wage mostly has the effects I describe above and that there are different approaches which should be tried (probably in combination).
* Actually tax the super-rich *1
* Tax passive income higher than "active" (work for living) income (maybe 2-3x rate?).
* Land Value based tax (re-development) on a trend (20 year median?) basis.
* Define "poverty" as 1.2 * (rent + healthy food + healthcare + other typical costs) per area.
* Supply side price controls.
* Anyone in poverty or out of work should instead be eligible for the New New Deal*.
Supply side price controls, a baseline offer in critical services for the private sector to (try to) beat, for ALL core public infrastructure: security (mil/'peace officers'), roads, water, sewer, education, healthcare, electricity, communications. Yes, this should focus on mostly covering natural monopolies and often provide a market framework for services on top of that infrastructure. Similar to how public roads enable many delivery services to compete.
New New Deal:
* free room/board/basic public food kitchen
* yearly aptitude assessment
* training for the job area of their choice out among aptitude matches/society needs
* arranged part time apprenticeship work with at least minimum wage per hourEvery man made system has fraud and abuse and yet reasonable people do not use these instances to attempt to discredit the entire system, no sensible person points to evidence of bank and corporate fraud to discredit the concept of banking and corporations? Even the church has fraud.
This article goes into great depth with documented evidence of serious problems, what is the connection to fraud in other regions covered in 2 articles covered way back in 2013 and how is it useful to this discussion?
The article vilifies the evil doctors who carelessly churn through disability claims, but it also notes that the doctor for the article's centerpiece was not provided any medical records indicating the patient's cancer was metastasized and inoperable. Absent that information, the determination may have been correct.
The doctor made $420k/yr for full time work processing claims. That puts him somewhere between dermatologists and urologists for doctor compensation, which is on the higher end of specialists. Is that too much? I have no idea, it seems like the job requires a great deal of breadth.
Sounds like the doctor screwed up.
That probably turns on "failed to obtain". The state collects and dumps case files onto the contract doctors. Is it the doctor's responsibility to search all sources of records for ones which were omitted and might be pertinent? Do privacy rules even allow this? I assume there is some waiver signed by the applicant to allow the state to request medical records, but is that then granted to the contract doctors?
If no indication of an admission to a hospital was made, then you have no reason to expect a discharge summary. However, I would imagine the radiology reports would have included the metastases...
The politicians have already decided the people in question do not matter, and they would like to kill them off as quickly and quietly as possible, preferably in such a way that blame is not attachable to them. They have been temporarily frustrated by the fact that their targets have found some other means to acquire the means to survive. The physician that denies the disability claim by default is thus serving a political interest, not a medical or humanitarian one. They are not being paid to advance the health interests of the community, but to protect the coffers of the states from those who may have a lawful claim on the money in them, in a manner that is technically conformant with the letter of the law.
The people dying while their disability denials are reviewed? That stems directly from the same political assumptions that mandate work requirements for welfare recipients. "Why should we give them money, if they're just going to die soon anyway, and they will never be able to pay it back?" It's the same premise businesses use to fire workers that are temporarily unproductive. "If you aren't making me money continuously, and especially right now, I have no further interest in you, so get out."
So if you have stage IV metastatic cancer, and are unable to walk, stand, or sit, and may have enough pain and/or pain-management medication to make concentration difficult, then I guess you had better make sure you fill out your complex bureaucratic forms correctly, as just one of the many things you have to juggle now in order to not die. You also have to trust that everyone else involved, none of whom have any direct stake in your outcome, will also fill out their forms correctly.
You can temporarily alleviate the symptom, but you cannot cure the disease without addressing its root cause: people who lack empathy for the infirm and the insolvent have acquired a large amount of power over both the government bureaucracy and the healthcare business.
Thus I suspect that the only phrase the review physician really needed to make a disability determination--"diagnosis: inoperable stage IV metastatic cancer"--was intentionally omitted from the review materials, because it was the only way to plausibly deny the application. A vital missing record can plausibly be explained as accidental, if you intentionally make the bureaucratic process onerous enough. Absent that vital datum, the whole dossier of review materials was absolutely useless. There is no point in employing an impartial administrative physician at all, if the medical record is incomplete. In that light, paying someone $0.5M every year for "garbage in, garbage out" processing is a lot more than the healthcare value provided to the patients. But paying someone $0.5M to paint a veneer of respectability, professional expertise, and due process over a system that would otherwise be paying out many millions in disability benefits is a lot less than the political value provided to the system. It's a lot cheaper to pay out $0.5M and let those sick people die, than to pay out those millions to keep them all alive just a little longer, at $800 apiece, every month until they kick off.
So the corrupt physicians working admin jobs under contract to the state aren't really at fault. Vote for government representation that believes "provide for the general welfare" is more of a mandate than an introductory rationale. Pay more to buy products from companies whom you know to be honorable with respect to their treatment of their workers. Try to treat people that you encounter in your job like people, rather than tasks or obstacles. You can't meaningfully change the outcome until you change the culture that produced it.
This is the key insight I took away as well. I have not applied for SSDI (nor made determinations for it); however, if the physician reviewing the records is not provided the information nor provided an opportunity to question to patient directly, you will of course have "garbage in, garbage out".
This is a systemic issue, and the system at fault is the local government.
If someone makes 400000 USD a year, shouldn't we expect him to actually check if he has all the required documents before making a decision?
Of course, then the doctor would need to actually review the case...
I was a happy fully sighted software developer up until a few years ago an eye disease started all of a sudden. Now I am blind. I applied for disability and got denied. I appealed and was denied again. In the end I hired a lawyer and won the case. Judge told me he was surprised that I had to go this far as my case seemed so clear to him.
To make things fair, I wasn't fully blind at the time when I applied for disagbility. My doctor thought I was blind enough to be considered disabled. Social security's doctor didn't think so.
Programming is a big part of my life, and I don't know what I'd do if I suddenly couldn't do it anymore. You're able to read and write posts on HN, so it seems that you're able to edit text again, albeit at a (significantly) reduced rate? Have you picked up programming as a hobby again? Or have you moved on to other things now that you don't have to?
People on disability skyrocketed after the turn of the century. It's very easy for the overweight to qualify for heart/breathing problems.
At first glance you would assume that $804/month is a low enough amount to keep people from applying. It won't even cover rent in many places. Even a $10/hr job will pay double that in gross pay in a month.
https://www.theatlantic.com/business/archive/2013/03/disabil...
https://www.bls.gov/cps/cps_htgm.htm#unemployed
Even people who no longer appear in the official U-3 unemployment statistic will often appear in U-4/U-5/U-6 depending on their exact circumstances.
Source?
Does this allow the doctors to get compensated again for the additional review or does it simply reopen the existing case? Already frustrating enough to have to re-apply... can't imagine the frustration of putting more money in the pockets of the people carelessly rushing your review.
Only 5-10% in step two get reversed, but 50% of those who pursue to step three (the judge) get approved. I suspect it's intentionally like this as a weeding out sort of thing.
Step three is best done with a lawyer, but they'll eat up $6k or so of the back-pay you get if it's approved.
https://thinkprogress.org/what-7-states-discovered-after-spe...
This is similar to the "New York marshals" involved in the debt-collections scheme articles that made the rounds on HN a short time ago. One person makes millions, solely because they have the bureaucratic rubber stamp that makes the grossly unethical business perfectly legal.
If you can put together a good racket, you can usually make a few hundred thousand dollars at it. That's just what sacrificing your own ethics is worth.
But now I wonder how much those docs pay for private security, to protect them from the terminally ill people, denied disability benefits, who may decide to go out with a suicidal attack on someone whom they could see as contributing to their doom.
I phrase this as a question because you seem to think it's simply a matter of getting 160 hours a month at $10 an hour.
So, that's the baseline to compare against for these welfare programs.
> Urban legend is that after the third time they just magically approve it.
The state you are in seems to make a big difference. My fiance applied three times in the state of Florida and were denied all three times. They were approved on their first application in Wisconsin.
Your medical situation also seems to make a big difference. In Florida, my fiance's doctors were spread around, requiring several trips to get paperwork. In Wisconsin, they are all at a single hospital, so requesting records was simple, and the medical records department sent all of them at once from all of their doctors with a single request.
> There's a whole group of lawyers that specialize in getting people approved for disability benefits.
Many of them work on contingency, taking a cut of the back pay that you get when a previously rejected application is ultimately approved. I understand that lawyers need to be paid, but taking a cut of someone's disability benefits seems pretty low to me. (That said, there are firms that work on a pro-bono, sliding scale, or a fee-for-service basis where they do not take a cut of your back payment.)
> It's very easy for the overweight to qualify for heart/breathing problems.
I wish this myth would die. The morbidly obese very rarely qualify for disability.
> [Y]ou would assume that $804/month is a low enough amount to keep people from applying. It won't even cover rent in many places.
Many places have supplemental rent assistance and other benefits that you become eligible for once you are on disability, which mitigates some of that.
https://www.washingtonpost.com/sf/local/2017/03/30/disabled-...
Poverty tends to be a very unhealthy situation - it leads to a poor diet, you skip medical treatment for initially small issues, jobs available are more likely to be of the sort that cause back and joint pain.
Now add in the fact that disabled folks need to live in cheaper, low cost-of-living areas, and you'll get big concentrations.
They do when they get evicted.
Uninsured rates are down, but a lot of Boomers are now in the decade before retirement where abused bodies tend to break down more and more.
I can tell you that does not happen magically. I went through the entire process and still got denied.
You first apply for SSDI and they keep asking for records. Then they have some doctor look at you (at least in my case). The doctor actually got upset with me for taking too long to answer his questions. They also had a psychologist ask me some questions too. Finally they deny you the first time (which is actually to be expected).
You then have your case re-reviewed (your first appeal), and get to see the same exact doctor yet once again. They ask for the newest records from your doctor and you have to fill out some of the same forms again. After that I got denied again. Apparently this part differs from state to state, and some just skip this re-review and go straight to see a judge.
Finally you get to have the portion where you sit with a judge (your second appeal in many states). I even had a lawyer for this part (the law firm wouldn't even help me prior to my first denial). There is an expert in the room to say if you are able to work or not. The expert actually said everything in my favor, and told the judge I was unable to work at any job. This judge still denied me.
After this you can try to fight it in federal court essentially saying that the judge was wrong, but you only have a 1% chance of winning. At this point you just have to reapply and start the whole process over.
The problem is, when you have an actual chronic illness and are seeing one of the top doctors in the country for it with loads of evidence, it doesn't matter to social security. I would rather be able to work than go through this process. Trying to navigate the process of what to do and what not to do to please the social security gods is especially hard with little energy and high brain fog some days. I was so exhausted initially, I didn't do much research and just filled out everything the best I could, which apparently was not in my favor.
LAWSUIT
If all of the patients who are being denied file one, then it will make denying these claims so expensive that no doctor will want to touch them with a 10 foot pole.
This word can be applied to all kinds of ills plaguing us in these times. I'm amazed that lawtech isn't right up there with biotech and fintech, but I'm guessing that as messed up as things are right now, law is ripe for disruption.
I'm pretty sure you can sue anyone for anything, and then the judge throws it out if the case doesn't have merit. But if enough people do it, somebody somewhere has to make a decision about whether to keep hearing cases or change the law to make filing illegal somehow. That's the point where people get seriously pissed off and protests form and somebody stands to lose an election.
I saw a documentary along similar lines where a town didn't want a pig farm (due to smell etc). The county wanted to force them to do it, so they said no and sued the county. Then the state said no so they sued the state. I think it went all the way to the supreme court. They worked their way up the ladder until finally the law was changed so that towns had their own say in whether they wanted to smell like a pig farm (which no town does).
This technique works well for environmental laws and when corporations poison neighborhoods with pollution, things of that nature.
Edit: I went to find the case but there are so many that I think the results stand on their own:
You can file almost anything you want, but it costs money to do so, and in some cases you can be forced to pay the defendant's legal fees. Lawyers can also face disciplinary action for filing suit that they know will be dismissed.
Assuming you learn how to file on your own, and you continue filing meritless lawsuits, you can be declared a vexatious litigant, and the court will bar you from taking further legal action without prior approval by a judge.
I agree that this feels like a market misalignment that could be corrected and make someone a boatload of money in the process, but between the above issue and the general slowness of the legal market I'm not sure that that's actually the case.
This is already done. There are law firms that specialize in disability cases on contingency - they take their payment as a cut of what your back pay would be if they win and nothing if they lose.
Libor, No Child Left Behind policy that ties test scores to school funding are some of the other examples that have similar issues.
If they know they've been rejected, they'll behave differently for the 'redundant' review.
If they don't know they've been rejected, they'll be annoyed at being asked to attend identical meetings that are in their view unnecessary.
Did someone code up an AI model for him?
while read app; echo "DENIED" >> ${app}; doneclaimstatus = rejected
randomvalue = GetRandomValue(1,100)
If (randomvalue <= 20), Then claimstatus = approved
return claimstatus
Doesn't even have to read the application. Well, maybe the name or app number just so it can reference it in the official response. That might be another application, though, with this one being the review application.
The article seems to tie denying disability with receiving more pay...but that's not even how it works. It doesn't matter if you are denying or approving, what matters is speed of your review. So, while I do view this as a problem, the headline is highly misleading. They aren't getting "big money" for denying disability. They are getting big money from reviewing fast, period. Approval or denial.
That's because if your errors tend toward approving claims that should have been denied, your are going to have a higher than normal fraud rate among your approvals, which might raise suspicion that you are in cahoots with the fraudsters maybe taking bribes to approve them.
Denying claims that should have been approved, on the other hand, probably has little risk of getting you personally is trouble.
Hence, there is an incentive when rushed toward denial of claims.
Sure, a good doctor goes through more claims than a bad doctor... but if you take away the ultimately outcome goal of helping patients, you can go through a lot more a lot faster. "My goal is to close tickets... anything I can do to reject a claim gets me to a closed ticket and gets me a bonus."
Multi-dimensional KPIs can help, but any time you have a raw number metric you'll need to sanity check on them. When dealing with customers, including customer satisfaction scores is a no-brainer. A lot of companies, Amazon comes to mind, have a "how's my driving" link in their email signatures.
This also seems like a good job for machine learning eventually.
I'm not sure what "this" you mean (testing the doctors or testing the patients), but I'd argue the opposite. ML is great at performing tests we understand, and is terrible at determining things we aren't sure how to determine.
In this case, either you are checking to see if someone is truly disabled (which we don't have a good test for other than doctors, and see how that's working out) or you are checking to see if a doctor is being wrong in their evaluation, and if you can't perform the evaluation, figuring out if the doctor is skimping won't be easier.
And of course, even if you develop a perfect test, because of the incentives people will find a way to abuse it, and machines aren't likely to notice that they are now being played.
What are the economic incentives to bias the decision one way or another?
It is also possible that there is some form of administrative punishment that makes false positives more burdensome than false negatives. If you are fined $1 for each false positive, and $0 for each false negative, you deny by default. If approvals are flagged for automatic recheck by the computer, and denials are only rechecked if an appeal is filed, you deny by default and let the real work fall to the appeals doctor. If the system branches in any way based on the APPROVE/DENY bit, that may affect how the bit is evaluated in the first place.
It's broken all the way down to the foundations. The state government in Tennessee is controlled by the state politics. And the state politics is very far from liberal democratic socialism. This is the state that had to have a literal gun battle in order to fight local government corruption [0], and is is equally important to note that shooting live rounds at the bastards didn't even get them to behave for an entire year. The veterans' coalition assembled to vote out the corruption was itself co-opted and re-corrupted almost immediately.
[0] https://en.wikipedia.org/wiki/Battle_of_Athens_%281946%29
What does this mean? Is it 80% of "average" cases? Or is it simply 80% of all cases and the "On average" part of the sentence just sloppy writing?
- Of the cases he reviewed since 2013, approximately 80% were denied. This would, as you note, be better phrased as "80 percent of the cases he reviewed were denied".
- Each year since 2013, he reviewed an unknown number of cases, and a certain percentage of those cases were denied. The arithmetic mean of those 6 yearly percentages is approximately 80%.
In the second case, the 80% figure is meaningless, but it's a calculation people often perform despite that fact.
Correspondingly, their licenses should be on the line, as well as liability for malpractice.
Let regulation and tort law take a few of them out. See what happens, then. Maybe even criminal law, as inevitably some patients will die due to lack of proper care.
So if they made a bad determination, I see no reason why the doctors can't be sued directly. Surely Social Security knows who reviewed it, so the records can be produced by FOIA.
Sure, these docs made .5M$ . But when these things are brought to light, have a way to make them much more painful and costly. Fraud by "rich people" usually isn't looked highly upon at jury trials.
My wife is a physician and the stories you hear are unbelievably sad but most people don't fit the definition of disability by social security. Most people are able to perform another job, however, their training and personality limits them in being reintroduced to the labor markets.
The problem isn't a simple one but there are other solutions such as retraining