Improving the Social Security Disability Decision Process Interim Report (2006) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-14
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SSA reimburses the states for the full costs of the DDSs. The DDSs apply a sequential decision process specified by SSA to make an initial decision whether a claim should be allowed or denied.
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Currently, each DDS has medical consultants on staff and a roster of outside medical sources it uses to conduct independent medical examinations, called con sultative examinations, and each regional office of the Office of Hearings and Appeals has a roster of medical experts who have agreed to provide their opinions in cases being heard by administrative law judges. Other than state licensure, SSA does not have national qualification standards or training and certification re quirements for any of these medical sources.
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More complete case development at the front end of the process may not be essential for an accurate initial disability decision in every case, but overall it should reduce the impetus for appeals, reduce the number of reversals on appeal, and shorten the average length of time before reaching final adjudication. This is difficult to accomplish, however, because disability decision makers in the DDSs are subject to strong pressures from SSA to decide cases quickly and to reduce administrative costs (including medical costs)
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The applicant's own medical providers, called treating sources by SSA, are the primary source of medical evidence throughout the entire disability decision-making process. By regulation, DDSs must seek medical evidence and opinions from treating sources and, unless there are inconsistencies or ambiguities, give their evidence controlling weight.
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. However, establishing a national network of experts who would play different roles at different points in the process (e.g., acting as agency adjudicators in initial decisions and providing expert opinions to administrative law judges in de novo proceedings)
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. This policy has the effect of excluding from DDSs many medical personnel who could contribute to the disability decision-making process, including personnel trained to evaluate functional limitations and their impact on ability to work (e.g., nurse practitioners, occupational therapists, physical therapists, registered nurses, psychiatric social workers)
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The centers would nevertheless be an excellent source of medical expertise in reviewing complex cases, a means of learning how to improve adjudicative evaluation and decision making and improving the training of disability examiners, MCs, and administrative law judges, and an input to the revision and updating of the Listings.
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They use their medical expertise at hearings to help the administrative law judges and other participants understand complex medical issues of the case in layman's terms. SSA has not required specific qualification standards for MEs.
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CE providers are not required to be what SSA defines to be an "acceptable medical source," if a medically determinable impairment is established and the issue at hand is the severity of the impairment and how it affects an individual's functioning. CE providers may be what SSA calls "other sources," who may be other medical practitioners such as nurse-practitioners, physical therapists, occupational therapists, chiropractors, and audiologists, or nonmedical sources such as teachers, day care providers, social workers, and employers.
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Few pay more than $165. These fees are quite low compared with the fees that other disability benefit programs pay for disability evaluations and reports, including the federal and state workers' compensation programs and private disability insurers.
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DDSs can make presumptive disability findings in any case in which the available evidence indicates a "strong likelihood" that the claim will be allowed after going through the regular formal determination process. Revising the Presumptive Disability Categories with Explicit Criteria Presumptive disability is primarily a social policy which recognizes that applicants for SSI have little or no income or assets and probably need immediate assistance with the costs of living.
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The answer depends on the tradeoff society wishes to make between helping groups of low-income persons with a given probability of being determined disabled by SSA and the cost of paying for cases that end up being disallowed. Increasing Consistency in Presumptive Disability Decision Making The percentage of SSI claims that are granted presumptive disability status varies widely across SSA field offices and DDSs, a situation that SSA could improve.
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These include uniform special procedures through out the decision process that promote consistency as well as speed. TERI cases are subject to special procedures through which the case is expedited through every step of the disability determination process, including the appeals process and the payment process.
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