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Tennessee doctors earn big money denying disability claims

269 points by howard941 8y ago

crankylinuxuser 8y ago
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 8y ago
  The MD cause more damage than he can possibly pay for if found guilty. The state was the beneficiary of this fraud.
  - crankylinuxuser 8y ago
    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.
- longerthoughts 8y ago
  Even if the doctors could be sued directly is that necessarily better than going after the flawed system with the additional hope that the individual is dismissed?
- onetimemanytime 8y ago
  Nope, you sue the state or SS and get your money....eventually. Sucks but
- wonderwonder 8y ago
  Unfortunately that will likely happen right after you are allowed to sue individual police officers for assaulting innocent people and illegal arrests.
- MaupitiBlue 8y ago
  No. There is no doctor patient relationship created in this situation.
bluedino 8y ago
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.
- maxxxxx 8y ago
  I thought disability is the new unemployment insurance for people who can't find a job. Once you have no other options you apply for disability.
  - assblaster 8y ago
    With the unemployment rate so low and the number of jobs created increasing, why would disability application be a logical next step?
    - freedomben 8y ago
      rconti posted some interesting links above: https://www.theatlantic.com/business/archive/2013/03/disability-insurance-americas-124-billion-secret-welfare-program/274302/ https://www.theatlantic.com/business/archive/2013/03/disabil... http://apps.npr.org/unfit-for-work/ http://apps.npr.org/unfit-for-work/
    - maxxxxx 8y ago
      I am not an expert but from what I have read after a few years people drop off the unemployment numbers and aren't counted anymore. They pretty much cease to exist as far as the employment world goes. Either they have to go on welfare or disability.
      - assblaster 8y ago
wonderwonder 8y ago
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.
- onetimemanytime 8y ago
  If all the papers are submitted and checked by other staff, I don't think 40 minutes or so is not enough to decide. The doctor is simply checking what is submitted. I'm only commenting on the time aspect.
  - wonderwonder 8y ago
    From the article: "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."
    - briandear 8y ago
      Is it possible that 78% should have been denied? What rate is acceptable? If the doctor approved 78% wouldn’t that also be concerning? One of the biggest areas of fraud is in disability claims. I am not saying that 78% denial is accurate, but what evidence do we have that it isn’t?
lordnacho 8y ago
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 8y ago
  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 8y ago
    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 8y ago
      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
hindsightbias 8y ago
"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?
- rusanu 8y ago
  Perhaps his practice has employees. Junior staff do all the work, he (reviews and) signs the papers.
- tehwebguy 8y ago
  Seriously, that's 36 / week day (or 24 / day if he works weekends) with no vacation!
- newnewpdro 8y ago
  while read app; echo "DENIED" >> ${app}; done
  - nathancahill 8y ago
    Needs more nested ifs to be truly AI.
    - nickpsecurity 8y ago
      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.
rconti 8y ago
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/disability-insurance-americas-124-billion-secret-welfare-program/274302/ https://www.theatlantic.com/business/archive/2013/03/disabil... http://apps.npr.org/unfit-for-work/ http://apps.npr.org/unfit-for-work/
- Spooky23 8y ago
  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 8y ago
    > 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 8y ago
      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..
- 8y ago
mltony 8y ago
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 8y ago
  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 8y ago
    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.
- nvusuvu 8y ago
  So sorry to hear that. This is my fear too. Are you trying to enter the workforce again with the tools available for the vision impaired?
itissid 8y ago
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 8y ago
  You are exactly right but you always get what you optimize for. In this case, it worked exactly as intended.
ada1981 8y ago
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 8y ago
  > 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.
jws 8y ago
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.
- jakobegger 8y ago
  > the doctor was not provided... 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...
- hangonhn 8y ago
  "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 8y ago
    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 8y ago
MaupitiBlue 8y ago
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 8y ago
  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
asaph 8y ago
> 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 8y ago
  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.
dillius 8y ago
What does this have to do with computer science and entrepreneurship?
zackmorris 8y ago
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 8y ago
  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 8y ago
    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 8y ago
      >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.
mnm1 8y ago
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?
richard_todd 8y ago
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 8y ago
  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 8y ago
    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 8y ago
      Well then it's an obvious first step to take, I think. Good idea.
partiallypro 8y ago
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 8y ago
  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 8y ago
    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.
- magissima 8y ago
  And in reviewing quickly, they're making mistakes, denying a man dying of cancer the disability money he was entitled to under the law. Perhaps some people who don't meet the qualifications are being approved, but I think most people would view false positives as less of a problem than false negatives in this case, and the fact that the denial rate is higher in Tennessee suggests to me that it's faster to deny than approve anyway.
deleted 8y ago
[deleted]
pasbesoin 8y ago
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.
dbg31415 8y ago
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.

269 points by howard941 8y ago

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 8y ago
The MD cause more damage than he can possibly pay for if found guilty. The state was the beneficiary of this fraud.
- crankylinuxuser 8y ago
  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.
longerthoughts 8y ago
Even if the doctors could be sued directly is that necessarily better than going after the flawed system with the additional hope that the individual is dismissed?
onetimemanytime 8y ago
Nope, you sue the state or SS and get your money....eventually. Sucks but
wonderwonder 8y ago
Unfortunately that will likely happen right after you are allowed to sue individual police officers for assaulting innocent people and illegal arrests.
MaupitiBlue 8y ago
No. There is no doctor patient relationship created in this situation.

bluedino 8y ago

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.

maxxxxx 8y ago
I thought disability is the new unemployment insurance for people who can't find a job. Once you have no other options you apply for disability.
- assblaster 8y ago
  With the unemployment rate so low and the number of jobs created increasing, why would disability application be a logical next step?
  - freedomben 8y ago
    rconti posted some interesting links above: https://www.theatlantic.com/business/archive/2013/03/disability-insurance-americas-124-billion-secret-welfare-program/274302/ https://www.theatlantic.com/business/archive/2013/03/disabil... http://apps.npr.org/unfit-for-work/ http://apps.npr.org/unfit-for-work/
  - maxxxxx 8y ago
    I am not an expert but from what I have read after a few years people drop off the unemployment numbers and aren't counted anymore. They pretty much cease to exist as far as the employment world goes. Either they have to go on welfare or disability.
    - assblaster 8y ago

wonderwonder 8y ago

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.

onetimemanytime 8y ago
If all the papers are submitted and checked by other staff, I don't think 40 minutes or so is not enough to decide. The doctor is simply checking what is submitted. I'm only commenting on the time aspect.
- wonderwonder 8y ago
  From the article: "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."
  - briandear 8y ago
    Is it possible that 78% should have been denied? What rate is acceptable? If the doctor approved 78% wouldn’t that also be concerning? One of the biggest areas of fraud is in disability claims. I am not saying that 78% denial is accurate, but what evidence do we have that it isn’t?

lordnacho 8y ago

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 8y ago
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 8y ago
  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 8y ago
    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

hindsightbias 8y ago

"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?

rusanu 8y ago
Perhaps his practice has employees. Junior staff do all the work, he (reviews and) signs the papers.
tehwebguy 8y ago
Seriously, that's 36 / week day (or 24 / day if he works weekends) with no vacation!
newnewpdro 8y ago
while read app; echo "DENIED" >> ${app}; done
- nathancahill 8y ago
  Needs more nested ifs to be truly AI.
  - nickpsecurity 8y ago
    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.

rconti 8y ago

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/disability-insurance-americas-124-billion-secret-welfare-program/274302/ https://www.theatlantic.com/business/archive/2013/03/disabil... http://apps.npr.org/unfit-for-work/ http://apps.npr.org/unfit-for-work/

Spooky23 8y ago
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 8y ago
  > 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 8y ago
    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..
8y ago

mltony 8y ago

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 8y ago
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 8y ago
  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.
nvusuvu 8y ago
So sorry to hear that. This is my fear too. Are you trying to enter the workforce again with the tools available for the vision impaired?

itissid 8y ago

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 8y ago
You are exactly right but you always get what you optimize for. In this case, it worked exactly as intended.

ada1981 8y ago

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 8y ago
> 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.

jws 8y ago

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.

jakobegger 8y ago
> the doctor was not provided... 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...
hangonhn 8y ago
"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 8y ago
  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 8y ago

MaupitiBlue 8y ago

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 8y ago
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

asaph 8y ago

> 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 8y ago
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.

dillius 8y ago

What does this have to do with computer science and entrepreneurship?

zackmorris 8y ago

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 8y ago
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 8y ago
  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 8y ago
    >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.

mnm1 8y ago

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?

richard_todd 8y ago

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 8y ago
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 8y ago
  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 8y ago
    Well then it's an obvious first step to take, I think. Good idea.

partiallypro 8y ago

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 8y ago
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 8y ago
  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.
magissima 8y ago
And in reviewing quickly, they're making mistakes, denying a man dying of cancer the disability money he was entitled to under the law. Perhaps some people who don't meet the qualifications are being approved, but I think most people would view false positives as less of a problem than false negatives in this case, and the fact that the denial rate is higher in Tennessee suggests to me that it's faster to deny than approve anyway.

deleted 8y ago

[deleted]

pasbesoin 8y ago

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.

dbg31415 8y ago

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.