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The Program Integrity Initiative is an SSA program that reviews disability and Medicare to reduce improper payments.
Until recently, continuing disability reviews and Medicare investigation were virtually nonexistent until SSA discovered that for every $1 spent on investigating improper payments returned $10.00 in savings.
The 10 to 1 return on investment has caused the number of investigations to increase from 317,000 medical reviews in 2009 to 1.4 million in 2011. Other factors that are driving the increase in this trend are:
> Terms of disability are shorter
> Conditions get new treatments and medical technology
How will you know
You will receive a short mailer most likely asking for an update on your condition or a longer 10 to 12 page letter asking for details about work, treatment, daily activities, and work.
If your review results in your benefits being denied, you will be sent a denial letter.
What you need to prove:
There has been no medical improvement relative to your condition that would allow you to work. It will also take into consideration new impairments.
If there has been medical improvements that have decreased the impairment since time of the decision and you could work, then you could be found not disabled.
Liver treatment: Had a surgery resulting in an increase of motion, a reduction in pain, and a decrease in medicine.
HIV AIDS: Ten to 15 years ago there were no significant medical improvements available, and the outcome was not good for this diagnosis. Since then, there have been significant advancements in treatments.
How to protect your check.
Those who are most vulnerable are the ones who have not been staying on their treatment plan.
1. Follow prescribed treatment
2. Keep a journal
3 Track your limitation
4. In case you need this page go to the top of this page and use the bookmark feature.
How to appeal a denial:
1. Step one: File this form within 10 days
This is a one-page form that asks basic information (name, address, and Social Security number), plus it gives you the opportunity to state why you disagree with the decision to stop your benefits. You must file this form within 60 days of receiving your denial.
2. Step two: File this form with SSA-789 in step one:
To request that your disability benefits be continued, submit a written signed statement to the SSA when you submit the Request for Reconsideration.
If your request for reconsideration in step 2 is denied , you must file a separate request for continuing benefits with your hearing request, within 10 days after you receive your notice of reconsideration.
You can choose to continue benefits with your hearing request even if you did not complete this step with step 1 request for reconsideration.
Please understand that if your appeal is denied and you were paid benefits during the appeal, this will trigger an over payment and you will owe the monies back to SSA.
Need help with your appeal?
A. Contact your local Social Security office and ask for help 800-772-1213.
B. Contact your local Center for Independent living and ask for free legal aid.
See section 8 in the members area here
C. Hire a Disability Representative:
Historically, disability representatives have not been interested in representing these because there is no retroactive pay involved in these cases. A creative idea to get a representative's attention so they will represent your case is to have an agreed percentage of your check go into escrow until the agreed-upon fee amount is paid off.
Recourses to help
Learn more about the Program Integrity Initiative here
Sample of a CDR letter you may receive
Rules for following treatment
Need a refresher course on how to prove you are disabled? Then listen to the get-orientated interview in the disability mini course here.
Bookmark this page just in case you need it.