
Tennessee doctors earn big money denying disability claims - howard941
https://www.tennessean.com/story/news/2019/01/06/tennessee-doctors-disability-claims/1077220002/
======
wonderwonder
This is everything that is wrong with health care in the US. From the article:

"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.

~~~
sharemywin
Seems like a simple 10X fine for screwing up would fix the problem. But the
government has run by people that hate government will never fix the problem.

~~~
jerf
"But the government has run by people that hate government will never fix the
problem."

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"?

~~~
vkou
This problem didn't start in 2017, it started with the Reagan presidency.

~~~
basementcat
This started long before Reagan. Even Andrew Jackson allowed the Charter of
the ancestor of the Federal Reserve to expire.

~~~
vkou
The consequences of which affect precisely nobody today.

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.

~~~
pnutjam
Yes, this is largely because disability has become the defacto welfare system.

------
rconti
A couple of great articles for those who aren't aware that disability is the
new welfare.

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...](https://www.theatlantic.com/business/archive/2013/03/disability-
insurance-americas-124-billion-secret-welfare-program/274302/)

[http://apps.npr.org/unfit-for-work/](http://apps.npr.org/unfit-for-work/)

~~~
Spooky23
The reason it is "the new welfare" is that states don't pay a share, it's a
purely Federal program paid for out of payroll taxes. Certain states make it
very difficult to get safety net benefits, and those who do can only get them
for a limited period of time. SSDI is the last stop.

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.

~~~
vonmoltke
> 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.

~~~
softawre
Yes, it goes into detail about this in the npr article linked by GP.

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..

------
jws
The centerpiece case for the story is an odd one to support the assertion.

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.

~~~
hangonhn
"In Chrisman’s case, Thrush failed to obtain one critical piece of evidence: a
discharge paper from a hospital that stated Chrisman’s cancer was inoperable
and had metastasized. The prognosis clearly qualified him for disability, even
under the complex rules set by the Social Security Administration. The mistake
was discovered only after Chrisman hired a lawyer."

Sounds like the doctor screwed up.

~~~
jws
_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?

~~~
lazyasciiart
It wouldn't have to be provided to the contract doctors, you'd just need a
process where the doctor says "this paperwork is missing a discharge document,
without that I can't make a determination" and the state/patient can get it.
(I'm not a doctor so I don't know if a discharge document is something you
would expect to see in a medical history)

~~~
warkdarrior
How would the doctor know that a document is missing?

~~~
lazyasciiart
That was the caveat in parentheses.

~~~
riahi
You would only know there was a discharge summary if there was a corresponding
admission history and physical.

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...

------
mltony
Here is my similar story from Washington state.

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.

~~~
jniedrauer
Maybe something you don't feel comfortable discussing, and feel free to
disregard if it is. But I've often thought about what I would do if this, or a
major injury to my hands, were to happen to me.

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?

~~~
mltony
It took me a few years to adjust, but I'm back in the workforce. I am working
in a big IT company now. Blind people can use screenreaders - assistive
software - to write code and leave comments on hacker news. If something
happens to your hands, I've heard of a software developer who is using
dictation software to write code. There are ways you can work around your
disabilities.

------
bluedino
You can have your case re-reviewed. Urban legend is that after the third time
they just magically approve it. There's a whole group of lawyers that
specialize in getting people approved for disability benefits.

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.

~~~
ohithereyou
Anecdata: My fiancee has lupus and a kidney transplant. There are days where
they are completely bedbound and days where they can walk around just fine,
depending on if they are in a lupus flare and what it is attacking. All of
their doctors (rheumatologist, nephrologist, and internist) have urged her to
apply for disability as they all consider them firmly in the permanently
disabled camp.

> 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.

~~~
adrr
There are some counties in the US where 1 out of 5 people are on disability. I
can't see how you get a rate that high unless it was easy to qualify for
disability.

[https://www.washingtonpost.com/sf/local/2017/03/30/disabled-...](https://www.washingtonpost.com/sf/local/2017/03/30/disabled-
or-just-desperate/?utm_term=.d0d902acedfe)

~~~
ceejayoz
> I can't see how you get a rate that high unless it was easy to qualify for
> disability.

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.

~~~
adrr
Poor people don't move because they lack funds to do so. It's one of the big
problems in the US that hits the fixed income people who live in high expense
areas. Access to healthcare for the poor is a lot better than in it was in
2005 because of Obamacare that expanded medicaid yet disability rate is at an
all-time high. Indicators for health care access like high cholesterol levels
and untreated cavities is at a 20 year low.

~~~
ceejayoz
> Poor people don't move because they lack funds to do so.

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.

------
zackmorris
The most powerful word in the American justice system is:

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.

~~~
wonderwonder
Issue is that most state and federal level organizations enjoy Sovereign
Immunity. Makes them immune to most forms of lawsuits. They can do what they
want without issue.

~~~
zackmorris
I'm not certain about this (maybe someone who knows for sure can chime in).

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:

[https://www.google.com/search?q=pig+farm+lawsuit](https://www.google.com/search?q=pig+farm+lawsuit)

~~~
learc83
>I'm pretty sure you can sue anyone for anything, and then the judge throws it
out if the case doesn't have merit.

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.

------
itissid
When ever you concentrate a large enough wad of cash(i.e. the incentive) to a
simple metric. Sooner or later that metric will be gamed. Metrics should be
more nuanced and well studied and flexible to change and behavioral study
needs to be incorporated into fraud detection and prevention.

Libor, No Child Left Behind policy that ties test scores to school funding are
some of the other examples that have similar issues.

~~~
snarf21
You are exactly right but you always get what you optimize for. In this case,
it worked _exactly_ as intended.

------
richard_todd
It seems they should just feed the reviewers some small percentage of
redundant claims, and use statistics to direct oversight and scrutiny. The
high-volume reviewers who statistically disagree with their peers would be
easy to spot.

~~~
jackvalentine
Are the reviews entirely based on paperwork? It seems like the human element
of the claimant would be a confounding variable.

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.

~~~
richard_todd
I think the article says some reviewers assess at a rate greater than 4 per
hour, so I assume they are largely if not entirely paperwork.

~~~
jackvalentine
Well then it's an obvious first step to take, I think. Good idea.

------
hindsightbias
"Thrush’s productivity has paid off. He earned $420,000 for reviewing the
applications of 9,088 Tennesseans applying for disability during the year
ending June 30. He has made more than $2.2 million since 2013."

Did someone code up an AI model for him?

~~~
newnewpdro

      while read app; echo "DENIED" >> ${app}; done

~~~
nathancahill
Needs more nested ifs to be truly AI.

~~~
nickpsecurity
It's just gotta pass the Turing Test. The doctor in question could be
represented by this pseudocode with no nesting:

claimstatus = 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.

------
partiallypro
This is purely anecdotal, but I am from Tennessee, grew up near a poorer
community...and it is seemingly normal for people to fraudulently claim
disability as a supplement for welfare. People even brag about it. There are
certainly perverse incentives for both doctors and people claiming disability
claims to cheat the system.

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.

~~~
mmaurizi
Something mentioned in the article - the social security administration is
required by law to double-check half of all approvals, but not denials. So the
incentive is definitely to deny as quickly as possible - if you approve
everyone you'll be caught, but if you deny everyone that's far less likely.

~~~
partiallypro
But it offers no data to support the general idea that this is the case (that
denials are through the roof, even if TN is a higher rate than the national
level, it is marginal. Also it leaves out the median which would be more
interesting, since a few states could greatly bring down the average.) The
approvals are reviewed because denials can be appealed. It's a safe guard
against fraud. I'm not saying there aren't perverse incentives, but "doctors
earn big money approving disability claims" has less of a moral outcry from
the reverse.

------
mnm1
Same story with worker's compensation in Washington State. It's really not
even worth applying without a lawyer and a few thousand dollars at least to
gamble that you can prove that the pain is caused by work. The word of your
actual doctors means nothing and only the five minute consultation by their
hacks determines your fate, a consultation whose result is known ahead of
time: denied. And this is a state run program allegedly ran for the benefits
of the workers paying into it. Yeah right. A bunch of bullshit we wouldn't
need to deal with if we had proper healthcare in this country. But instead,
this is the way America treats its workers. Why would we expect anything
better for disability?

------
dbg31415
This highlights the dangers of KPIs in general.

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.

------
ada1981
I wonder if putting a cap on the total annual payout, along with including
“dummy claims” that need to be approved / rejected to test the doctors and
keep them honest would be useful.

This also seems like a good job for machine learning eventually.

~~~
ergothus
> 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.

------
lordnacho
Why is there a focus on one type of error? Is there some reason why doctors
would be biased toward wrongly denying disability benefits, rather than
wrongly allowing?

What are the economic incentives to bias the decision one way or another?

~~~
dtech
The article does not go into detail, but I expect a doctor with a high false
positive rate to not get much applications his way in the future as it costs
the state a lot of money.

~~~
jfrankamp
This is a key point, and points to so many thing being broken at the same time
it hurts my head. The real smoking gun would be to find some sort of defacto
evidence that doctors got the hint that denial gets them more business. That
would sit in the next layer up, the assignment of cases. Alternatively, could
it just be a big pool e.g. the race to get through them is a cash grab, so the
faster you go you'll get to drink more of the milkshake? In that case denial
is more of a way to avoid scrutiny.

~~~
logfromblammo
Cutting government staff doctors in favor or more expensive contractor doctors
is a red flag. You can't fire a staff doctor for approving too many
applications, but you can direct more contract business towards doctors with a
proven track record of denials.

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](https://en.wikipedia.org/wiki/Battle_of_Athens_%281946%29)

------
asaph
> On average, 80 percent of the cases he reviewed were denied.

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?

~~~
thaumasiotes
It means one of two things:

\- 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.

------
pasbesoin
Well, this should be defined as practicing medicine. (Ultimately, you are
controlling whether and what treatment occurs.)

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.

------
crankylinuxuser
So.. if a MD has made a determination upon reviewing medical records
submitted, that makes them a "patient", no?

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.

~~~
dandare
The MD cause more damage than he can possibly pay for if found guilty. The
state was the beneficiary of this fraud.

~~~
crankylinuxuser
Potentially true. However that's what medical malpractice insurance is usually
for. And if they're found to be doing fraud according to a court, lets just
say they are in for a very unpleasant time.

------
MaupitiBlue
As an ambulance chaser I am confident most disability claims should be denied.
These cases have exploded over the last decade as job opportunities for obese
middle aged workers have been obliterated, dependence on opioids has surged,
and the shame of not supporting yourself has largely gone away.

~~~
todipa
I largely agree with this.

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

