Tennessee has among the highest denial rates for disability applicants in the nation, rejecting 72 percent of all claims in 2017.

Doctors are paid a flat rate for each application file they review. How much they earn depends on how fast they work.

One doctor, a felon, earned $420,000 in one year for reviewing the applications of 9,088 Tennesseans applying for disability.

State and federal offices review a tiny percentage of denied disability claims for accuracy. In the last fiscal year, 7,400 people died waiting for their disability appeals to be heard.

By the time Alan Chrisman was diagnosed with stage 4 colorectal cancer, he was too sick to work. The cancer had spread to his lungs. His doctors said he may never get better.

Chrisman, 59, applied for disability, the federal safety net program he contributed to with every paycheck during his 30 years working as a stonemason.

But a doctor hired by Tennessee’s Disability Determination Services to review applications quickly concluded Chrisman wasn’t sick enough to get the $804 monthly benefit.

That physician, Dr. Thomas Thrush, is one of about 50 doctors contracted to review applications for Tennesseans seeking disability.

The doctors are paid a flat rate for each application file they review. How much they earn depends on how fast they work.

Thrush, like many of the doctors who contract with the state, works very fast.

In fiscal year 2018, he reviewed — on average — one case every 12 minutes.

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.

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

6 takeaways from this investigation:Doctors speed through disability claims, make millions

Tennessee has among the highest denial rates for disability applicants in the nation, rejecting 72 percent of all claims in 2017. The national average for denials was 66 percent.

Outside experts and former and current state employees say it’s impossible to review cases so quickly without making mistakes that lead to wrongful rejections of disability benefits.

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.

A USA TODAY NETWORK - Tennessee investigation examined 5½ years of data for physicians and psychologists who review disability applications. The investigation found that between January 2013 and July 2018:

• Some doctors raced through cases. More than half of all contract physicians outpaced the federal standard of 1.5 cases per hour, and 1 out of every 5 doctors doubled that pace.

• A whistleblower was fired. The contract of a former medical consultant was terminated in 2017 after he raised concerns about some physicians reviewing a high volume of cases.

• Speed pays. Seven high-volume doctors billed for more than $1 million each between fiscal 2013 and 2018. These physicians’ annual payments range from $103,000 to $451,000. By contrast, the acting chief of the Social Security Administration, a Cabinet-level position, earned $240,000. For some physicians, this was not their sole source of income.

• 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.

• Some doctors have a history of misconduct. At least two doctors under contract with the state are felons, including Thrush. Two other physicians had their medical licenses placed on probation. Another physician had his license revoked twice in the past 20 years and now works on a restricted license that bars him from treating patients.

Five current and former contractors and state employees said they believe disability applicants are being wrongfully denied in an effort to process as many applications as possible. Most spoke to The Tennessean on the condition of anonymity, for fear of reprisal.

“It’s like a cash register,” said one contract physician. “From our perspective it’s unethical. From a consumer’s point of view it can be a tragedy.”

One doctor who raised the issue through official channels lost his contract. Dr. John Mather, the whistleblower, was the former chief medical officer for disability programs at the federal Social Security Administration, and worked as a contract doctor for the state after he retired.

“Who knows how many applicants for disability benefits have had their applications denied without justification,” he said.

DISABILITY DATABASE: Click here to see doctors, how many patients they've processed and how much they earn

A whistleblower

Mather said he warned James Stanfield, director for the state disability department, and Raquel Hatter, then commissioner of the Department of Human Services, in 2016 about the dangers of some doctors performing large numbers of reviews. The Human Services Department’s general counsel responded in a letter saying there was nothing illegal or fraudulent.

Mather emailed the Social Security Administration, which referred the matter to the Office of Inspector General. That office determined no investigation was warranted. Mather met with auditors at the Comptroller of the Treasury, then received no further response.

In 2017, Stanfield declined to renew Mather’s contract.

“I don’t think they care about the claimant,” Mather said of administrators. “They just want to see the cases out. I don’t think they care too much about quality. People who are high producers — they are very happy to have them around.”

Current and former personnel said they were speaking up now because they want an outside investigator to review all cases to ensure individuals have not been wrongly denied.

“These findings are troubling,” Tennessee U.S. Rep. Jim Cooper said in a statement. “Physicians, especially those dealing with state and federal funds, should be careful and thorough in their work. Social Security Disability Insurance is a vital program, and we have to keep it strong.”

A spokesman for the Department of Human Services, which oversees the disability program in Tennessee, disputed any connection between how fast doctors review case files and their mistakes.

“We have no reason to believe that doctors that average faster reviews are more prone to have errors in their reviews,” Sky Arnold said in a statement.

The Social Security Administration provided its own statistics that showed Tennessee doctors were spending on average 47 “medical minutes per case.” Patti Patterson, a spokeswoman, noted that was more than the national average of 38 minutes.

But the federal data adds the time multiple physicians spend reviewing the same case, a common occurrence when someone is claiming both a mental and physical disability requiring two different specialists. The state data analyzed by The Tennessean details each doctor’s speed.

A letter brings crushing news

For weeks, Chrisman did not feel well. Some days he would lose control of his bowels.

After stonemason work became scarce, he got a job as a maintenance man at a McDonald’s in Sevierville, Tennessee, two years ago. One day in November 2017, he showed up to work at the restaurant and promptly soiled himself.

At the insistence of his wife, Joyce, he headed straight to a walk-in clinic. It was his first medical visit in a long time. The Chrismans cannot afford insurance.

He was referred to a doctor, then another. The diagnosis was swift.

Chrisman had late-stage cancer of the intestine. The cancer had spread. There were two spots on his lung.

A golf ball-sized tumor and about a foot of his intestine were removed in surgery.

Weakened by chemotherapy and radiation, emaciated after shedding 40 pounds, and in extreme discomfort with tubes protruding from his backside, Chrisman occasionally can’t sit or stand. On a good day he can walk outside to pick up a single log for the fireplace in the couple’s unheated two-bedroom cabin.

The Chrismans earned about $32,000 a year between his earnings and his wife’s $10 hourly wage cleaning laundry at a Smoky Mountain resort. The mounting medical bills and Chrisman’s lost wages devastated his wife, who tried to arrange payment plans with medical providers.

Chrisman applied for disability in November 2017.

The rejection letter came six months later.

“Although your therapy is currently causing you discomfort, it is expected these effects will be temporary,” said the denial letter, based on the recommendation from Thrush.

Joyce Chrisman cried when she read the letter.

Mistakes unlikely to be caught

The disability process has two layers of oversight designed to catch errors, but doctors know there is little likelihood anyone would catch a mistake in denying someone's application.

First, a quality assurance department in Nashville spot-checks approvals and denials to make sure staff and doctors have followed procedures. Then, federal regional offices review a portion of disability applications.

Tennessee has consistently ranked high in the quality of its case reviews, averaging a 95.8 percent quality rating since 2016, said Arnold, the state spokesman. In 2017 DDS earned a Social Security Administration "Phoenix Award" for its performance.

But the state and federal offices review a tiny percentage of denied disability claims for accuracy.

By law, half of all approvals by state DDS personnel are reviewed by Social Security Administration staff — a provision meant to safeguard public funds.

The law, however, doesn’t set specific requirements for denials. As a result, the Social Security Administration reviewed fewer than 2 percent of all rejections, according to an analysis by the National Organization of Social Security Claimants' Representatives.

“If the adjudicator is making poor decisions, if they tend towards denials, they’re just not going to be reviewed,” said Jen Burdick, an attorney with Community Legal Services of Philadelphia. She is is among advocates nationwide asking for Social Security to review more denials.

Wrongful denials may be appealed, but long delays for a hearing can take a devastating toll in lost wages, lack of access to health care and medical bills. In fiscal year 2017, at least 9,570 people died waiting for their disability appeals to be heard.

Speed pays — sometimes millions

The Social Security Administration oversees two disability programs: Supplemental Security Income, or SSI, for low-income individuals without a work history, and Social Security Disability Insurance for workers who become disabled.

The federal government delegates to the states the administration of the programs. Tennessee received $8.5 million last year from the Social Security Administration to hire medical consultants with a variety of specialties to review medical records.

These doctors never examine claimants in person, although they occasionally order a physical exam by another doctor.

Seven days a week, setting their own schedules, the doctors swipe their badges to access secured floors of a brown and glass office building on the outskirts of downtown Nashville, logging into a computer system that generates a queue of cases to review.

Some applications contain just a few pages. Others include hundreds of pages of doctor’s notes, hospital reports, X-rays, lab results and employment records. Doctors must write a brief report to justify their findings, too.

The decision to grant or deny benefits is officially made by a state employee, but doctors who work for the state say it is their recommendation that carries the most weight.

For this work, the doctors are paid a flat fee ranging from $30 to $47 per case. Doctors also bill $68 per hour in most instances for the time they spend consulting with staff or mentoring other physicians.

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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.

State officials later noted that the denial data included cases in which multiple doctors made assessments, meaning Chaudhuri and other doctors may not have made the final assessment.

Asked whether she felt pressured to review cases too quickly, Chaudhuri said:

"No direct pressure. They recommend that we must keep up. They always recommend you do your best. There are so many applications and so few doctors. We are overwhelmed with cases."

Jenaan Khaleeli, a psychologist, has averaged 4½ cases an hour since 2013. Nearly 80 percent of those cases were denied. Over the five years, Khaleeli earned $1.2 million, including $209,000 in fiscal 2018.

Dr. Frank Pennington, an ear, nose and throat specialist who is also a felon, earned $144,000 reviewing cases in fiscal 2018, and more than $1 million since 2013. During the five-year period he reviewed 20,835 cases, at a rate of three per hour.

Pennington is one of five contract physicians with a history of misconduct. Pennington is confined to the administrative practice of medicine after three separate felony cocaine convictions and two stints in federal prison in the 1990s.

Thrush had his license placed on probation for four years in 2008 after he pleaded guilty to prescription fraud in 2006.

Arnold, the DHS spokesman, said the physicians were all doctors in good standing while employed.

"It's important to remember these are not forward-facing doctors," Arnold said. "Their role is to examine medical records and reports. They do not meet with patients in person."

Thrush, Pennington and Khaleeli did not respond to messages.

'A flawed system'

Tennessee’s pay-by-the-case model — and the sums paid to contract doctors — surprised even advocates and attorneys who routinely assist people with disabilities.

“There is an obvious financial incentive under such a payment arrangement — to process cases as quickly as possible,” said Russ Overby, an attorney with the Legal Aid Society of Middle Tennessee, who represents individuals seeking disability.

“I am concerned that some clients who are in fact eligible for disability benefits will be denied because there has not been a sufficient review of the case.”

Carrie Hobbs Guiden, executive director of The Arc of Tennessee, advocates for individuals with developmental and intellectual disabilities who occasionally apply for Social Security disability benefits. Doctors have to invest the time to properly review cases, she said, especially when it involves people with untreated mental health issues.

“If they’re getting paid based on how many they get done, that’s a flawed system,” Guiden said. “That’s not encouraging quality. You have to question if the purpose is to deny as many people as possible.”

Under pressure to meet 'workload goals'

State disability determination departments face enormous pressures to meet "workload goals" set by the Social Security Administration.

In 2018, the Social Security Administration set a goal of 103,161 disability applications to be cleared by Tennessee's office.

The staff and consultants needed to clear those cases in Tennessee have shrunk by 24 percent between 2010 and 2016.

Failure to meet goals can result in a financial penalty from the federal government, according to Jeffrey Price, the past legislative director for the National Association of Disability Examiners.

Doctors elsewhere push back

About half of all state disability offices in the United States operate on a similar model to Tennessee’s, in which physicians reviewing applications are paid by the case, according to Price.

The contract model, in which doctors receive a fee for each assessment, introduces some risks, Price said.

“If you were paid by the case, it behooves you to sign off on as many cases as you can,” he said. “I think that model at least has the potential for increased error rates.

“A doctor can review cases effectively at about two cases per hour,” Price said. “You’re hoping that the doctor will actually look at the whole case, not just what the examiner wrote.”

Doctors like Thrush, who processed more than five cases per hour, might be valued in an office trying to shovel itself out of a large caseload, Price said, but the pace is implausible.

“I think that would be dangerous, actually,” Price said. “Inherently you would be missing something if you’re looking at five cases an hour.”

At the North Carolina Disability Determination Services office, where Price has worked for nearly 40 years, managers recently asked doctors to process an average of three cases per hour instead of two. Doctors in that office are all on staff, as opposed to contractors.

“Some of our doctors are pushing back,” Price said. “They say that’s too many.”

A rule put into place by the Social Security Administration in 2017 has made the work of DDS physicians even more critical in deciding an outcome of an application.

Previously a “treating physician rule” required DDS to give more weight to the opinions of an applicant’s personal doctor than doctors hired by DDS. That rule was eliminated, giving doctors hired by DDS more influence in deciding the outcome of applications.

'Something needs to be done'

After Chrisman was denied, he and his wife found a lawyer in Sevierville tofile a request for reconsideration.

In September, Joyce Chrisman came home from work and brought the mail inside their cabin. The letter from Social Security said, “We found that you became disabled under our rules on November 8, 2017.” That was the day after she urged Chrisman to visit the walk-in clinic.

Another physician had examined Alan Chrisman's file and recommended he be granted disability.

“We said ‘wow,' ” Chrisman said. “We couldn’t believe it.”

George Garrison, his lawyer, said he was troubled by The Tennessean's findings.

“People come to me at a point they’re about to lose everything they’ve got,” he said. “They’re sick. They’re dying. They’re having to deal with a complex system.”

The benefit meant that Joyce Chrisman no longer had to worry about paying medical bills. The bills would be paid dating back to the time her husband applied for disability.

His disability approval also automatically qualified Alan Chrisman for TennCare, which is now covering his ongoing chemotherapy, medications and hospitalizations.

Chrisman sits on his couch most of the time. He’s on his 11th dose of chemotherapy. After his 12th next month, he will return for a scan. “Then we’ll go from there,” he said.

Thinking about the months he spent rejected — when he and his wife were barely scraping by — Chrisman gets angry.

“Something needs to be done,” he said. “They’re either getting too much of a caseload or they’re getting greedy.”

Reach Anita Wadhwani at awadhwani@tennessean.com or 615-259-8092 and on Twitter @AnitaWadhwani.

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