TN 4 (10-15)

Citations:

20 CFR §§ 404.1503a,

416.903a,

404.1519q,

416.919q

The Social Security Administration (SSA) is responsible for ensuring the integrity of its programs. We expect all Federal and State Disability Determination Services (DDSs) employees, contractors, medical consultants (MCs), psychological consultants (PCs), and consultative examination (CE) providers to comply with the standards of professional conduct, and to conduct all activities within the community and with government agencies in a professional and ethical manner.

A. Program integrity in SSA disability programs

SSA will not use any MC/PC, CE provider, or diagnostic test facility (except to provide existing medical evidence):

• who is currently excluded, suspended, or otherwise barred from participation in the Medicare or Medicaid programs or any other Federal or federally assisted program;

• whose license to provide health care services is currently revoked or suspended by any state licensing authority pursuant to adequate due process procedures for reasons bearing on professional competence, professional conduct, or financial integrity;

• who has surrendered such a license while formal disciplinary proceedings involving professional conduct are pending; or

• that has an expired license and it has not been renewed.

NOTE: The exclusion does not apply to the purchase of existing medical evidence of record from any medical source properly licensed at the time of service. Give such evidence normal consideration in the processing of the disability claim.

B. Program Integrity in the DDS

1. Program integrity reporting responsibilities

The DDS will:

• Work to ensure only eligible or entitled persons are receiving benefits.

• Report all alleged or suspected violations, whether by an applicant, recipient, employee, or contractor.

• Notify the regional office (RO) when the DDS discontinues using the services of an MC/PC, CE provider, or diagnostic test facility that has been suspended or found guilty of fraud in a state or local action.

NOTE: The RO notifies the DDS in all neighboring States, federal case processing units, and if appropriate, SSA’s Office of the Inspector General.

a. CE panel provider actions suggest potential fraud or conflict of Interest (COI)

If a CE panel provider’s actions suggest potential fraud or COI, or if the provider is not following SSA's policies regarding the CE process, the DDS will:

• Determine the degree of intervention necessary (e.g., training, suspension of services, etc.); and

• Document the actions taken to resolve the issue.

NOTE: For more information on COI see DI 39569.100 and Violations and Fraud in the Social Security Administration Programs and Operations see DI 39569.600.

b. Multi-state provider issues

The DDS should notify the RO and other appropriate DDSs if a multi-state provider or a provider near the border of a neighboring state is involved in irregular practices or unprofessional conduct. The RO notifies other affected ROs and federal case processing units.

NOTE: The regions may use their own discretion on whether its DDSs will notify other DDS locations or whether the RO will notify the other ROs affected and allow that RO to notify their own DDS.