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Appendix C: Interim Report, December 2005
Pages 125-238

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From page 125...
... However, the committee also made clear that, after completing all of its deliberations, it might refine those preliminary recommendations. The committee issued its interim report, Improving the Social Security Disability Decision Process: Interim Report, on these three tasks on December 21, 2005.
From page 126...
... 2 IMPRoVIng thE SoCIal SECuRIty DISabIlIty DECISIon PRoCESS tification has become the norm for physicians, relatively few psychologists are board certified. The committee therefore modified its recommendation to recommend that SSA continue the current requirements for psychologists participating as MCs or MEs but establish a long-term goal requiring that psychologists be board certified.
From page 127...
... Improving the Social Security Disability Decision Process Interim Report Committee on Improving the Disability Decision Process: SSA's Listing of Impairments and Agency Access to Medical Expertise Medical Follow-Up Agency
From page 128...
... SS00-04-60083 between the National Academy of Sciences and Social Security Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s)
From page 129...
... "Knowing is not enough; we must apply. Willing is not enough; we must do." -- Goethe Advising the Nation.
From page 130...
... The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters.
From page 131...
... MASSANARI, Former Acting Commissioner, Social Security Administration, Exton, PA STEPHEN G PAUKER, Professor, Tufts University School of Medicine, Vice Chairman for Clinical Affairs, Department of Medicine, Associate Physician-In-Chief, Tufts-New England Medical Center, Boston, MA LINDA A
From page 132...
... CRAIG A VELOZO, Professor and Associate Chair, Department of Occupational Therapy, College of Public Health and Health Professions, University of Florida; Research Health Scientist, Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System Project Staff MICHAEL McGEARY, Study Director MORGAN A
From page 133...
... Owens, Consultation in Health & Disability Programs, Brooklyn, NY James M Perrin, Massachusetts General Hospital, Boston, MA Harold A
From page 134...
... Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Joseph P
From page 135...
... The committee's final report is due in 2006, but SSA asked the committee to focus first on the expertise issues and provide early recommendations on the qualifications of the medical and psychological experts involved in the disability decision process in a short interim report. SSA is currently in the process of revamping its disability decision process and, according to a Notice of Proposed Rulemaking (NPRM)
From page 136...
... The National Association of Disability Examiners submitted a written statement. At the second meeting, the committee also heard from panels of experts on training and certification requirements that might improve the level of medical expertise in the disability decision process.
From page 137...
... Barnhart, Commissioner of Social Security, who met with the committee on October 6, 2005, to describe her plans for improving the disability decision process and answer questions from committee members; Martin H Gerry, Deputy Commissioner for Disability and Income Security Programs; Glenn Sklar, Associate Commissioner for Disability Programs; Pamela Mazerski, Associate Commissioner for Program Development and Research; and Nancy Schoenberg, Office of Disability Programs, the project officer for this study who greatly facilitated responses to the committee's requests for information.
From page 138...
... Mocarski, Northwestern Mutual; Mark Nadel, Georgetown University; William E Narrow, American Psychiatric Institute for Research and Education; Dorothy Nettles, Office of Disability Determinations; Paul Newacheck, University of California-San Francisco; Barbara Otto, Health & Disability Advocates, Chicago; Georgann Ozanich, Minnesota State Retirement System; Diane M
From page 139...
...  PREfaCE Schmidt, Office of Workers' Compensation Programs, U.S. Department of Labor; Frank Schuster, Office of Medical Policy, SSA; Art Spencer, Office of Disability Programs, SSA; Steven Sperka, Northwestern Mutual Life; Kaye Sullivan-McDevitt, UnumProvident Portland Disability Benefits Center; Lauren Swanson, CIGNA Disability Management Solutions; Patricia Thomas, MetLife Disability; Tiana Tozer, The Standard; Michael Weinrich, National Center for Medical Rehabilitation Research, National Institutes of Health; Mimi Wirtanen, NADE; Gooloo Wunderlich, NRC; Sandra Yost, American Academy of Disability Evaluating Physicians; and Barry Zevin, Tom Waddell Health Center, San Francisco Department of Public Health.
From page 141...
... Contents Executive Summary 149 Introduction 163 Overview of Social Security Disability Programs, 163 IOM Study Charge, 165 IOM Committee, 165 Interim Committee Report, 166 SSA's Proposed Disability Decision Process Changes, 167 Trends in the Disability Decision Process 168 Program Growth, 169 Variability in Disability Decisions, 169 Appeals and Allowances on Appeal, 170 Decision Timeliness, 171 Implications of Trends for the Interim Report, 173 Constraints on the Disability Decision Process 173 Organization of Medical Expertise 175 Medical Expertise and the Disability Adjudication Process, 176 Specialization of Medical Consultants, 177 Qualifications of Medical Consultants, 186 Training of Medical Consultants, 190 Better Use of Medical Expertise, 191 Other Sources of Medical Expertise, 193 Involvement of Treating Physicians and Other Treating Sources, 194 Qualifications of OHA Medical Experts, 197 
From page 142...
... 2 ContEntS Training and Certification of Consultative Examiners 200 Training and Certification Requirements for Consultative Examiners, 201 Adequate Reimbursement of CE Providers, 205 Focused Requests for CEs Based on What Is Needed in Each Case, 208 Presumptive Disability Categories 209 Revising the Presumptive Disability Categories with Explicit Criteria, 213 Increasing Consistency in Use of Presumptive Disability, 217 Learning from Terminal Illness (TERI) Procedures, 218 Afterword 219 References 219 Annex: List of Study Tasks 222 Annex Tables 224
From page 143...
... Figures and Tables FIGURES 1 Processing time for disability claims in days, CY 2004, 171 2 Percentage of allowed claims by decision level, CY 2004, 172 3 Medical consultants by specialty, June 2004, 179 4 Comparison of MC specialty mix with initial case mix, 179 5 Medical experts by specialty, June 2005, 180 6 Number of different medical expert specialties, by region, June 2005, 181 TABLES 1 Field Office Presumptive Disability Decisions, by Presumptive Disabil ity Category, CY 2004, 212 2 DDS Presumptive Disability Decisions, by Impairment Code, CY 2004, 213 3 Approximate Costs of Presumptive Disability Cases Ultimately Disal lowed, CY 2004 Data, 215 4 Approximate Costs of Adopting Different Allowance Rates to Deter mine Presumptive Disability Cases, CY 2004 Data, 216 5 Field Office Use of Presumptive Disability Categories for High Allowance-Rate Impairments, CY 2004, 217 
From page 144...
...  fIguRES anD tablES ANNEx TABLES 1 DDS Medical Consultants by Specialty, June 2004, 224 2 Number of DDS Medical Consultants by Specialty and State, June 2004, 225 3 Case Mix Compared with Mix of Medical Consultant Specialties, 228 4 Number of Medical Experts by Specialty, June 2005, 229 5 Number of Medical Experts by Specialty and Federal Region, June 2005, 230 6 Impairment Codes of DDS Presumptive Disability Decisions with a Reversal Rate of Less Than 5 percent, CY 2004, 231 7 SSA Impairment Codes by Allowance Rate, from Highest to Lowest, CY 2004, 233
From page 145...
... Abbreviations and Acronyms AAMRO American Association of Medical Review Officers ABMS American Board of Medical Specialties ABPP American Board of Professional Psychologists ACUS Administrative Conference of the United States AHC academic health center ALJ administrative law judge ALS amyotrophic lateral sclerosis AMA American Medical Association AME aviation medical examiners AUCD Association of University Centers on Disabilities CE consultative examination CFR Code of Federal Regulations CME continuing medical education COPD chronic obstructive pulmonary disease CPP/OAS Canada Pension Plan/Old Age Security CPT Current Procedural Terminology, AMA CY calendar year DDS Disability Determination Services DE disability examiner DHHS U.S. Department of Health and Human Services DOL U.S.
From page 146...
... doctor of medicine ME medical expert MRO medical review officers NIH National Institutes of Health NIOSH National Institute for Occupational Safety and Health NPRM Notice of Proposed Rulemaking OHA Office of Hearings and Appeals, SSA OWCP Office of Workers' Compensation Programs, DOL PD presumptive disability PER pre-effectuation review Ph.D. doctor of philosophy POMS DI Program Operations Manual System -- Disability Insurance, SSA Psy.D.
From page 147...
...  abbREVIatIonS anD aCRonyMS SSDI Social Security Disability Insurance SSI Supplemental Security Income TERI terminal illness U.S. United States VA Department of Veterans Affairs
From page 149...
... 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.
From page 150...
... In July 2005, SSA published a notice of proposed rulemaking (NPRM) that included establishment of a Federal Expert Unit that would set up and administer a national network of medical, psychological, and vocational experts to support the disability decision process at the initial decision point and subsequent levels of appeal.
From page 151...
... Constraints on the Disability Decision Process The committee supports the primary goals of SSA's new disability decision process -- to make the right decision as early in the claim process as possible, and to improve the accuracy, consistency, and timeliness of disability decisions at all levels of the disability process. Because the agency has not adopted the final version of its new plan, it is too early to reach any conclusions about the new process itself.
From page 152...
... 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.
From page 153...
... The committee also heard from administrative law judges that they are not always able to find certain specialists to serve as medical experts at hearings. According to DDSs and administrative law judges, the main reasons for lack of access to all specialties are inadequate compensation to attract higher-paid specialties and scarcity of specialists in rural areas and less populous regions of the country.
From page 154...
... Likewise, if members of the network perform CEs, they should be instructed to be impartial and not be permitted to serve in other roles in the same case. Qualifications of Medical Consultants Currently, DDSs rely on state licensure or, in the case of psychologists and speech-language pathologists, certain alternative qualification requirements, to ensure a minimum level of medical expertise and competence among MCs.
From page 155...
... . This policy has the effect of excluding from DDSs many medical personnel who could contribute to the disability decisionmaking 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)
From page 156...
... 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. Involvement of treating Physicians and other treating Sources Greater participation by treating sources is an excellent means of obtaining all the relevant medical and functional information early in the disability decision process, which speeds the process, leads to more informed decisions, and saves the costs of going back to the treating physician for additional information or of having to order a CE.
From page 157...
... Rates are generally low relative to fees paid by other disability benefit agencies, which discourages the participation of treating sources. Qualifications of oha Medical Experts MEs function as independent expert witnesses in a quasi-judicial process.
From page 158...
... Currently, each state makes its own arrangements for orienting and training CE providers. SSA furnishes CE providers with a guide, known as the Green Book, which provides general information about the Social Security disability programs and how claims are adjudicated, including the
From page 159...
... SSA should establish reasonable requirements for training and certification of consultative examination providers. The training and certification should focus on two competencies: evalu ation of limitations on ability to work resulting from impairments, and evidentiary and other requirements of SSA's disability decision-making process.
From page 160...
... Higher fees should increase the pool of medical sources willing to perform CEs, especially in harder-to-recruit specialties such as orthopedics. It should also provide the incentive for more treating physicians to be willing to perform CEs.
From page 161...
... eligibility requirements. SSA field offices can make presumptive disability determinations in cases involving certain impairments specified by SSA.
From page 162...
... The range for DDSs is from 0.6 percent to 34.6 percent. The majority of field offices do not use all 15 presumptive disability categories.
From page 163...
... The DDSs use a five-step decision process, called the sequential evaluation process by SSA, for each claim for disability benefits, whether under SSDI or SSI.1 The first decision is whether the applicant is currently engaged in substantial gainful employment, which is defined as earning more than 1 For overviews written for physicians, see Nibali (2003) and Robinson and Wolfe (2000)
From page 164...
... . Among the initiatives proposed in the NPRM was the establishment of a Federal Expert Unit that would set up and administer a national network of medical, psychological, and vocational experts to support the disability decision process at the initial decision point and 2 The statutorily blind are subject to different earnings rules.
From page 165...
... The 16 committee members are experts in clinical decision making, physical medicine and rehabilitation, orthopedic surgery, occupational medicine and nursing, psychiatry and psychology, pediatrics, public health, functional assessment, occupational rehabilitation, legal and economic aspects of disability, social security disability administration, claimant advocacy, and private disability insurance. The committee expects to issue its final report in 2006.
From page 166...
... After further information gathering and analyses of the effectiveness of the disability decision process in identifying those who qualify for benefits and those who do not, the committee may refine its recommendations concerning medical and psychological expertise in the final report. The final report will address a number of issues with potential implications for the qualifications of the medical experts involved in the disability decision process.
From page 167...
... For purposes of the medical expertise issues addressed in this interim report, the relevant aspect of the plan is the intent to establish a national network of medical and psychological consultants who would be used by all adjudicators, including disability examiners in the DDSs and administrative law judges (ALJs)
From page 168...
... This will make it possible for medical experts in remote locations to review medical records, assuming that arrangements to keep claimant files secure are made. TRENDS IN THE DISABILITY DECISION PROCESS The Social Security disability programs have grown rapidly in recent years, and several problems have come with this growth -- problems that promise to become worse as the baby boomer generation reaches the age when disability becomes more likely (the oldest baby boomers will turn 60 in 2006)
From page 169...
... . This finding suggests that up to half of the variance in allowance rates among the states may be due to differences in state administrative practices (e.g., use of consultative examinations, involvement of doctors in making disability decisions, payment amounts for medical evidence of record and consultative examinations, salaries and qualifications of disability decision makers, and training practices)
From page 170...
... . Possible reasons for the high allowance rates by ALJs in appeals cases include (SSAB, 2001b:5-6)
From page 171...
... : • 95 days for initial disability claims; • 97 days for reconsiderations; • 394 days for hearings; and • 251 days for decisions on appeals of hearings at the Appeals Council. 400 350 300 Processing Time in Days 250 200 150 100 50 0 Initial decision Reconsideration ALJ hearing Appeals Council Decision level FIGURE 1 Processing time for disability claims in days, CY 2004.
From page 172...
... . Nevertheless, most of the disability allowance decisions in FY 2004 were made at the initial level of the decision process (Figure 2)
From page 173...
... These include fuller development of cases before the initial decision and a quality assurance system with incentives that balance the need for making the right decision with the need for making decisions as quickly as possible. CONSTRAINTS ON THE DISABILITY DECISION PROCESS The committee supports the primary goals of SSA's new disability plan -- to make the right decision as early in the claim process as possible, and to improve the accuracy, consistency, and timeliness of disability decisions at all levels of the disability process.
From page 174...
... The development of a full record at the beginning of the disability decision process and evaluation of the record by appropriate experts, including medical experts, may not be essential for an accurate initial disability decision in every case. However, fuller case development at the front end of the process should reduce the impetus for appeals, reduce the number of allowances on appeal, and shorten the average length of time before reaching final adjudication.
From page 175...
... The committee will address the role of balanced incentive systems in improving the disability decision process in its final report. ORGANIZATION OF MEDICAL ExPERTISE Task 9: "advise on how best to provide medical expertise needed to support the entire disability adjudication process.
From page 176...
... ." Medical Expertise and the Disability Adjudication Process Under the law, impairments cannot qualify a claimant for disability benefits unless they have a medical basis. SSA's disability decision-making process relies on several types of medical expertise to provide medical evidence (including treating physicians and independent medical examiners)
From page 177...
... Providers. Medical expertise is also provided by medical personnel who perform examinations and tests on claimants at SSA's request when needed information is not available from existing medical records.
From page 178...
... . SSA staff also expressed concern about state-to-state variation in the mix of different areas of medical expertise.
From page 179...
...  IntERIM REPoRt Other specialties Psychology 23.6% 33.1% Family practice 6.6% Pediatrics 9.8% Internal Psychiatry medicine 10.9% 16.0% FIGURE 3 Medical consultants by specialty, June 2004. NOTE: Each MC is classified by one primary specialty.
From page 180...
... Medical Experts In June 2005, the OHA regional offices had blanket purchase agreements with 1,575 MEs representing 1,861 specialties (some MEs were specialists in more than one field of medicine)
From page 181...
... The use of generalists to handle most situations and call on 14 See,for example, Anfield (2002) , for a description of UnumProvident's use of "the appropriate level of medical expertise" for each case.
From page 182...
... Additional specialist MCs, such as cardiologists, oncologists, endocrinologists, ophthalmologists, and rheumatologists, who would be appropriate for more complex cases, could be accessed through the national network if the DDS does not have an MC with the needed specialty. Nevertheless, it is vital that all SSA adjudicators have a full range of medical expertise available.
From page 183...
... . The FEU would create and maintain a national network of medical, psychological, and vocational experts15 who would be available to adjudicators through the entire disability decision process, including DEs in DDSs and the administrative judges in OHA.16 These experts would be recruited and paid by SSA at rates to be established by the Commissioner.17 The Commissioner evidently intends to recruit members of the national network of experts from practitioners in private practice, who would agree to review medical evidence in case files and either consult to MCs in the DDS and ALJs in OHA or participate as an MC in the disability determination decision, depending on the case.
From page 184...
... The consulting role appears to be similar to the role that MCs play in the prototype decision process being tested in 10 states, in which DEs may act as single decision makers or, if they deem it necessary to evaluate the medical evidence properly, involve an MC in the decision process. But the NPRM proposes to abolish the prototype process demonstrations.
From page 185...
... Members of the national network would clearly serve as consultants when acting as expert witnesses at ALJ hearings or reviewing medical records in cases before the Appeals Council (or before reviewing officials and the Decision Review Board, if they are implemented as proposed in the NPRM)
From page 186...
... . 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 ALJs in de novo proceedings)
From page 187...
... (See "Training of Medical Consultants," below, for additional discussion on this topic.) Currently, DDSs rely on state licensure or, in the case of psychologists and speech-language pathologists, certain alternative qualification requirements, to ensure a minimum level of medical expertise and competence.
From page 188...
... This will necessitate an increase in compensation in order to recruit and retain qualified physicians and psychologists as MCs and MEs or as members of the national network of experts, if it is established. SSA also should allow current MCs with qualified program experience who are not board certified to continue for a time period of five years.
From page 189...
... . It does not ensure that they are skilled in evaluating disability or knowledgeable of Social Security disability program requirements, which is the basis for Recommendation 1-3, below.
From page 190...
... The committee recognizes that implementing a board certification requirement will pose practical problems but believes that it should be the standard for medical experts in SSA's disability decision process. In discussions with the committee, SSA staff also raised the issue of whether there should be a requirement that program physicians, psychologists, and others be currently (or recently)
From page 191...
... . This policy has the effect of excluding from DDSs many medical personnel who could support the disability decision-making process, for example, 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)
From page 192...
... SSA might also consider encouraging DDSs to employ nurses as DEs, as has been done in the New York DDS. If a quick decision process is developed, nurses could have the expertise, with physician backup, to identify suitable cases.
From page 193...
... SSA should consider developing demonstration projects with academic clinical research centers that focus on conditions that are difficult to evaluate. Academic research centers focus on improving diagnosis and treatment and few medical experts in them will be familiar with the SSA disability
From page 194...
... Involvement of Treating Physicians and Other Treating Sources Treating sources are an important component of SSA's disability decision process. Under its rules, SSA develops evidence from a claimant's own medical sources before evaluating evidence obtained on a consultative basis.
From page 195...
... Greater participation by treating sources is an excellent means of obtaining all the relevant medical and functional information early in the disability decision process, which speeds the process, leads to more informed decisions, and saves the costs of going back to the treating physician for additional information or of having to order a CE. Recommendation 1-6.
From page 196...
... Obtaining sufficient information from treating sources at the initial level is the best way to improve the accuracy and timeliness of the decisions and to make the right decision as early in the process as possible. Examples of actions needed to be taken to improve the process include: • Providing higher compensation for the costs of providing records and preparing a proper report; • Providing materials -- written, audio, and audiovisual -- developed to communicate what is expected from treating sources with regard to patients who apply for social security disability benefits, similar to understanding SSI Disability for Children, a booklet and video developed with the American Academy of Pediatrics as an educational tool for pediatricians who have patients with disabilities.26 26 The booklet and video were designed to be used for continuing education.
From page 197...
... For example, reimbursement for providing medical records is about $20. As will be discussed in the section on consultative examinations, below, reimbursement for performing a disability examination is also low, especially compared with comparable examinations performed for workers' compensation and for private disability insurance carriers.27 qualifications of OHA Medical Experts At the hearing level of the disability claim process, ALJs are solely responsible for making the disability decision, including all medical, functional, and vocational aspects.
From page 198...
... They have no direct adjudicative function, and they do not examine the claimant. They provide needed medical expertise to the proceedings to help the parties to the hearing understand complex medical issues in the case in layman's terms.
From page 199...
... who could support the disability decision-making process by providing expert assessment of impairment severity and functional limitations, including functional components of Listings. These experts would be a valuable source of information at the ALJ hearing level, as well as at the DDS level.
From page 200...
... Each DDS is charged with recruiting and orienting medical personnel who agree to be available to perform CEs in return for a fee set by each state. If the claimant's treating source is qualified, equipped, and willing to perform the examination or test and generally furnishes complete and timely reports, the treating source is the preferred source for the CE, because "The individual's treating source is often in the best position to provide detailed longitudinal information about the individual."28 If the treating source prefers not to do the CE, there are conflicts and inconsistencies in the file that cannot be resolved by going back to the treating source, or the DDS knows from prior experience that the treating source has consistently failed to provide complete or timely reports, the DDS can obtain the CE from a nontreating source.
From page 201...
... . These requirements were contained in the Social Security Disability Benefits Reform Act of 1984, in response to complaints about the quality of CEs, especially those performed by so-called bulk providers (Bloch, 1992:98108)
From page 202...
... . The guide, which is available online as well as on paper, provides general information about the Social Security disability programs and how claims are adjudicated, including the role of CEs, how CE providers are selected, and what the DDSs look for in a report of a CE.
From page 203...
... SSA should establish reasonable requirements for training and certification of consultative examination providers. The training and certification should focus on two competencies: evalu ation of limitations on ability to work resulting from impairments, and evidentiary and other requirements of SSA's disability decision-making process.
From page 204...
... The higher compensation for CEs recommended below, if brought in line with the fees in workers' compensation and other disability benefit programs, should offset the cost to potential CE providers of reasonable training and certification requirements. SSA should: • Develop a training curriculum on disability evaluation and SSA disability policies, rules, criteria, and procedures for CE providers, including both acceptable medical sources and other providers who evaluate function, such as nurses, occupational and physical therapists, and psychiatric social workers.
From page 205...
... The national network experts should receive training that clarifies the different roles they would have as consultants to MCs, as MCs themselves, as CE providers, and as expert witnesses (MEs) at ALJ hearings.
From page 206...
... SSA should consider adopting a standard fee schedule for DDSs to use in purchasing CEs, adjusted for geographic differences in practice costs, with several fee levels depending on how focused or comprehensive the examination is. The maximum fees should be substantially higher than Medicare's fees for regular office visits, because of the increased time it takes to perform a disability evaluation.34 This could be done in several ways.
From page 207...
... Alternatively, SSA could use CPT codes 99455 and 99456, which are for "work-related or medical disability evaluation services." Medicare does not use these services and therefore has not assigned a relative value to them, but the federal Office of Workers' Compensation Programs (OWCP) has assigned them RVUs of 6.96 and 9.16, respectively.36 This would mean fees up to $264 and $347, respectively, using the Medicare conversion factor, and up to $352 and $463 using the OWCP conversion factor.37 These fees are paid to treating physicians for an examination at the time of maximum medical improvement to assess permanent disability.
From page 208...
... Focused Requests for CEs Based on What Is Needed in Each Case Improving the quality of CEs depends not only on the skill and knowledge of the CE providers but also on whether they have been asked for the right information. DEs, in consultation with MCs, if needed, are supposed to develop a complete medical history for at least the preceding 12 months; evaluate the medical evidence to identify missing, inconsistent, or ambiguous information; and, if the treating physician does not supply the missing information or clarify inconsistencies and ambiguities, purchase a CE to obtain the information.
From page 209...
... eligibility requirements. SSA field offices are authorized only to make presumptive disability determinations for certain specified impairments.
From page 210...
... The impairment categories for which field offices may make presumptive disability decisions currently are: 1. Amputation of a leg at the hip.
From page 211...
... Field offices accounted for 17,191 (13 percent) of the 135,603 presumptive disability decisions made in CY 2004 (the rest were made by DDSs)
From page 212...
... . Almost 90 percent of DDS cases granted presumptive disability status were eventually allowed after going through the regular disability determination process, but they did not achieve this rate in every type of case.
From page 213...
... The increase was entirely due to DDSs; field offices granted presumptive disability in slightly fewer cases in 2004 than in 2001, 17,191 compared with 18,862. Although the number of presumptive disability decisions more than doubled, the overall rate of reversals fell from 13 percent to 9 percent.
From page 214...
... Taking this as the average cost of a presumptive disability decision and assuming that reversed presumptive disability cases were paid for the full six months, or $2,681.80 each, moving the reversal bar from 10 percent to 15 percent (thus adding 679 presumptive disability cases) would have cost approximately $1.8 million in 2004 (Table 3)
From page 215...
... The committee also notes that the presumptive disability categories do not include conditions that consistently have high allowance rates, which therefore on equity grounds could be considered as candidates for inclusion as presumptive disability categories. As noted in the findings section, above, title SSI claims having one of 12 primary impairment codes had a 90 percent chance of approval in CY 2004.
From page 216...
... TABLE 4 Approximate Costs of Adopting Different Allowance Rates to Determine Presumptive Disability Cases, CY 2004 Data PD Number Cost of Number Number Cost of Category Number of Paying of Impair- of Paying Allowance of PD Disallow- Disallowed ment Disallow- Disallowed Rate Categories ances Cases Codes ances Cases 90% or more 9 338 $906,447 12 1,182 $3,169,083 85-89.9% 3 679 $1,820,940 6 2,324 $6,232,503 80-84.9% 1 38 $101,908 9*
From page 217...
... If SSA has a presump TABLE 5 Field Office Use of Presumptive Disability Categories for HighAllowance-Rate Impairments, CY 2004 Overall Number of States without Impairment Allowance Rate* PD Cases in the Category Down syndrome 97.6% 3 Birth weight less than 1,200 grams 98.0% 5 Chronic renal failure (ESRD)
From page 218...
... TERI cases are subject to special procedures through which the case is expedited through every step of the disability determination process,
From page 219...
... It focuses on one important part of improving SSA's disability decision process: the qualifications of medical personnel participating in the decision process. It also makes recommendations for improving the implementation of the presumptive disability policy.
From page 220...
... 2003. Introducing nonadversarial government Representatives to Improve the Record for Decision in Social Security Disability Decisions.
From page 221...
... 2003. Social Security Disability Programs.
From page 222...
... 2002. Social Security Disability Programs: assessing the Variation in allowance Rates.
From page 223...
... 9. Advise on how best to provide medical expertise needed to support the entire disability adjudication process.
From page 224...
... 22 IMPRoVIng thE SoCIal SECuRIty DISabIlIty DECISIon PRoCESS ANNEx TABLE 1 DDS Medical Consultants by Specialty, June 2004 Specialty Number Percentage Psychology 707 33.1 Internal medicine 341 16.0 Psychiatry 233 10.9 Pediatrics 209 9.8 Family practice 141 6.6 Speech-language pathology 59 2.8 General medicine 42 2.0 Neurology 38 1.8 Cardiology 36 1.7 Orthopedic specialist 35 1.6 Surgery 35 1.6 Ophthalmology 25 1.2 Gynecology/obstetrics 21 1.0 Anesthesiology 21 1.0 Emergency medicine 20 0.9 Physical medicine and rehabilitation 19 0.9 Orthopedic surgery 18 0.8 Osteopathy 14 0.7 Occupational medicine 13 0.6 All others 122 5.7 Total 2,136 100.0 NOTE: The percentage of specialists in each category that are board certified or board eligible is not known. SOURCE: Unpublished tables provided by the Office of Disability and Income Support Programs, SSA.
From page 225...
... ANNEx TABLE 2 Number of DDS Medical Consultants by Specialty and State, June 2004 Family Internal State DDS Practice Medicine Pediatrics Psychology Psychiatry Cardiology Neurology Orthopedics Other Total Connecticut 0 9 1 15 4 0 2 0 4 35 Maine 0 0 1 7 0 1 0 1 4 14 Massachusetts 3 24 2 28 6 0 1 0 2 66 New Hampshire 3 1 1 4 0 0 0 0 1 10 Rhode Island 0 8 1 6 2 0 0 0 1 18 Vermont 0 4 2 5 1 1 1 0 0 14 Region I Total 6 46 8 65 13 2 4 1 12 157 New Jersey 0 23 5 22 3 3 0 8 3 67 New York 3 23 16 18 33 0 0 1 15 109 Puerto Rico 0 8 0 8 3 1 1 0 3 24 Delaware 1 3 1 4 1 0 0 0 1 11 District of Columbia 0 3 3 2 0 0 0 0 0 8 Region II Total 4 60 25 56 40 4 1 9 22 219 Maryland 1 4 4 11 5 1 0 0 4 30 Pennsylvania 5 7 4 45 2 0 1 3 12 79 Virginia 6 6 8 20 2 2 0 2 9 55 West Virginia 2 7 2 9 2 0 0 0 1 23 Region III Total 14 24 18 85 11 3 1 5 26 187 Alabama 1 4 6 14 4 3 1 2 7 42 Florida 20 11 33 76 9 2 0 1 28 180 Georgia 1 18 5 24 1 1 2 4 7 63 Kentucky 0 5 4 15 1 0 0 1 14 40 Mississippi 0 3 2 11 1 0 0 2 8 27 North Carolina 9 5 4 19 4 0 1 1 6 49 225
From page 226...
... ANNEx TABLE 2 continued 22 Family Internal State DDS Practice Medicine Pediatrics Psychology Psychiatry Cardiology Neurology Orthopedics Other Total South Carolina 2 4 4 21 1 0 1 1 11 45 Tennessee 2 5 8 20 3 1 1 1 15 56 Region IV Total 35 55 66 200 24 7 6 13 96 502 Illinois 6 11 10 22 4 3 0 0 22 78 Indiana 0 5 1 8 0 1 2 0 10 27 Michigan 8 17 5 15 21 0 2 0 14 82 Minnesota 0 6 2 12 1 0 0 5 2 28 Ohio 12 11 5 41 1 0 0 2 16 88 Wisconsin 0 5 3 9 0 0 1 0 2 20 Region V Total 26 55 26 107 26 4 5 7 66 323 Arkansas 0 1 5 3 2 1 1 3 2 18 Louisiana 2 5 5 19 2 2 1 2 12 50 New Mexico 5 5 2 2 2 0 0 0 1 17 Oklahoma 2 5 1 10 1 0 0 0 1 20 Texas 6 6 2 10 9 1 3 2 6 45 Region VI Total 15 22 15 44 16 4 5 7 22 150 Iowa 7 0 3 17 1 2 0 0 4 34 Kansas 9 4 1 11 3 1 0 0 2 31 Missouri 2 9 9 31 5 2 1 2 20 81 Nebraska 6 1 2 8 0 0 0 0 2 19 Region VII Total 24 14 15 67 9 5 1 2 28 165 Colorado 0 5 2 3 5 2 2 2 4 25 Montana 1 1 1 4 0 0 0 1 2 10 North Dakota 0 3 0 4 1 1 0 1 1 11
From page 227...
... SOURCE: Unpublished tables provided by the Office of Disability and Income Support Programs, SSA.
From page 228...
... Less than 0.1 percent. NOTE: Part-time medical consultants are assumed to work 20 hours a week.
From page 229...
... SOURCE: Unpublished table provided by the Office of Hearings and Appeals, SSA.
From page 230...
... 20 ANNEx TABLE 5 Number of Medical Experts by Specialty and Federal Region, June 2005 Clinical Internal Orthopedic Cardiovascular Federal Region Psychology Medicine Psychiatry Surgery Pediatrics Neurology Diseases Ophthalmology Other Total Region I 18 23 16 10 6 9 4 5 18 109 Region II 13 25 20 7 9 7 5 5 29 120 Region III 31 35 28 3 7 13 5 5 45 172 Region IV 110 85 78 42 39 25 20 12 93 504 Region V 73 56 30 20 23 17 7 8 52 286 Region VI 47 46 22 16 6 14 6 6 48 211 Region VII 12 14 3 1 3 1 3 1 16 54 Region VIII 37 7 0 0 2 4 0 1 10 61 Region IX 43 53 32 16 12 8 19 14 47 244 Region X 31 27 6 6 8 4 2 0 16 100 All regions 415 371 235 121 115 102 71 57 374 1,861 SOURCE: Unpublished table provided by the Office of Hearings and Appeals, SSA.
From page 231...
... 637 12 1.9 3180-Mental retardation 9,643 185 1.9 1720-Malignant melanoma of skin 179 3 1.7 5850-Chronic renal failure 4,173 62 1.5 2990-Developmental disabilities including 2,558 36 1.4 autism (children) 1620-Malignant neoplasm/trachea, bronchus, lung 2,606 35 1.3 1980-Malignant neoplasm/distant sites 78 1 1.3 3320-Parkinson's disease 154 2 1.3 1500-Malignant neoplasm/esophagus 367 4 1.1 1630-Malignant neoplasm/pleura 98 1 1.0 3350-Anterior horn cell disorder (ALS)
From page 232...
... 22 IMPRoVIng thE SoCIal SECuRIty DISabIlIty DECISIon PRoCESS ANNEx TABLE 6 continued Number of Reversal DDS PD Number Rate SSA Impairment Code Decisions Reversed (percent) 1570-Malignant neoplasm/pancreas 400 0 0.0 1760-Malignant Kaposi's sarcoma 8 0 0.0 1780-Malignant neoplasm/skeletal system 4 0 0.0 2730-Disorders of plasma protein metabolism 3 0 0.0 3210-Arachnoiditis 10 0 0.0 5010-Asbestosis 6 0 0.0 7050-Hidradenitis suppurativa 16 0 0.0 9330-Chronic fatigue syndrome 11 0 0.0 SOURCE: Unpublished table provided by the Office of Disability and Income Support Programs, SSA.
From page 233...
... 1,534 1,506 98.2 7650-Birth weight under 1200 grams 17,235 16,890 98.0 7580-Chromosome anomaly/Down syndrome 5,242 5,111 97.5 1980-Malignant neoplasm/distant sites 619 599 96.8 1630-Malignant neoplasm/pleura 806 776 96.3 1560-Malignant neoplasm/gallbladder 450 432 96.0 1620-Malignant neoplasm/trachea, bronchus, lung 19,291 18,307 94.9 1500-Malignant neoplasm/esophagus 2,916 2,744 94.1 2990-Developmental disabilities including 10,759 9,920 92.2 autism (children) 1910-Malignant neoplasm/brain 6,302 5,754 91.3 1510-Malignant neoplasm/stomach 1,966 1,779 90.5 5850-Chronic renal failure 22,195 19,998 90.1 1780-Malignant neoplasm/skeletal system 20 18 90.0 1720-Malignant melanoma of skin 1,832 1,618 88.3 2070-Leukemias 6,166 5,408 87.7 1760-Malignant Kaposi's sarcoma 40 35 87.5 1410-Malignant neoplasm/tongue 1,392 1,197 86.0 2990-Childhood origin psychosis (adult)
From page 234...
... 2 IMPRoVIng thE SoCIal SECuRIty DISabIlIty DECISIon PRoCESS ANNEx TABLE 7 continued Number Number Allowance of of Rate SSA Impairment Code Decisions Allowances (percent) 3430-Cerebral palsy 9,864 7,546 76.5 3320-Parkinson's disease 3,853 2,894 75.1 1950-Malignant neoplasm/other sites 5,399 4,049 75.0 8060-Vertebral fracture/cord lesion 4,699 3,449 73.4 1880-Malignant neoplasm/bladder 1,535 1,122 73.1 7840-Loss of voice 5,162 3,742 72.5 1380-Late effects of acute poliomyelitis 1,859 1,346 72.4 1710-Malignant neoplasm/connective and 902 650 72.1 other soft tissue 7410-Spina bifida 1,867 1,344 72.0 1530-Malignant neoplasm/colon, rectum, anus 11,184 8,019 71.7 2950-Schizophrenic/paranoid functional disorders 56,218 40,308 71.7 3300-Cerebral degeneration/childhood 616 439 71.3 3750-Cardiac transplantation 319 226 70.8 1420-Malignant neoplasm/salivary glands 234 165 70.5 4380-Late effects of cerebrovascular disease 32,139 22,529 70.1 1790-Malignant neoplasm/uterus 2,566 1,783 69.5 4430-Peripheral vascular disease 8,979 6,240 69.5 4160-Chronic pulmonary heart disease 2,137 1,481 69.3 2840-Aplastic anemia 738 505 68.4 7830-Malnutrition, marasmus/growth impairment 2,388 1,631 68.3 3590-Muscular dystrophies 3,188 2,155 67.6 3150-Developmental/emotional disorders -- infant 4,521 3,034 67.1 0300-Leprosy 3 2 66.7 4960-Cronic pulmonary insufficiency/COPD 40,287 26,348 65.4 1940-Malignant neoplasm/other endocrine 242 158 65.3 glands and related 3310-Other cerebral degenerations 3,901 2,536 65.0 2940-Organic mental disorders 57,567 36,958 64.2 3210-Arachnoiditis 231 145 62.8 9070-Late effects/nervous system injuries 6,740 4,125 61.2 3690-Blindness/low vision 24,669 14,752 59.8 4280-Heart failure 15,865 9,440 59.5 1740-Malignant neoplasm/breast 17,865 10,558 59.1 3620-Other retinal disorders 3,455 2,038 59.0 3153-Speech and language delays 32,332 18,914 58.5 4460-Periarteritis nodosa/allied condition 296 171 57.8 1870-Malignant neoplasm/penis, male genital organs 158 91 57.6 7500-Congenital anomalies/upper alimentary tract 372 212 57.0 1850-Malignant neoplasm/prostate 3,233 1,827 56.5 4920-Emphysema 4,382 2,471 56.4 2760-Diabetic acidosis 222 123 55.4 4540-Varicose veins/low extremities 2,374 1,294 54.5 3570-Diabetic/peripheral neuropathy 13,714 7,460 54.4 2020-Lymphoma 7,075 3,799 53.7 3890-Deafness 15,352 8,183 53.3
From page 235...
... 21,121 9,927 47.0 2390-Neoplasm/unspecified/unknown behavior 308 144 46.8 7050-Hidradenitis suppurativa 295 135 45.8 4410-Aortic aneurysm 1,341 607 45.3 1730-Other malignant neoplasm of skin 463 209 45.1 3610-Retinal detachment with retinal defects 1,592 716 45.0 2250-Benign neoplasm/brain, nervous system 3,049 1,332 43.7 4590-Other diseases of the circulatory system 7,004 3,061 43.7 3370-Disorders of the autonomic nervous system 1,408 614 43.6 1840-Malignant neoplasm/other female 1,141 496 43.5 genital organs 4140-Chronic ischemic heart disease 44,127 19,195 43.5 4030-Hypertensive vascular/renal disease 376 162 43.1 7200-Ankylosing/inflamnatory spondylopathies 1,007 430 42.7 2820-Hereditary hemolytic anemias 4,167 1,771 42.5 including sickle cell 5010-Asbestosis 289 122 42.2 7300-Osteomyelitis/other infections involving bone 1,837 775 42.2 1930-Malignant neoplasm/thyroid gland 782 327 41.8 5710-Chronic liver disease/cirrhosis 30,970 12,853 41.5 7150-Osteoarthritis/allied disorders 113,194 45,730 40.4 4480-Diseases of capillaries 145 57 39.3 0930-Cardiovascular syphilis 36 14 38.9 2730-Disorders of plasma protein metabolism 93 36 38.7 3490-Other nervous system disorders 15,534 5,996 38.6 3000-Anxiety-related disorders 46,037 17,724 38.5 3138-Oppositional/defiant disorder 7,776 2,955 38.0 3650-Glaucoma 2,958 1,121 37.9 3580-Myoneural disorders 3,118 1,160 37.2 5810-Nephrotic syndrome 2,447 903 36.9 3120-Conduct disorder 5,856 2,102 35.9 2960-Affective disorders (adult) 277,560 99,089 35.7 7590-Other congenital anomalies 3,324 1,160 34.9 2850-Other anemias 1,864 641 34.4
From page 236...
... 1,009 345 34.2 3010-Personality disorders 14,295 4,860 34.0 1360-Other infectious/parasitic diseases 1,488 487 32.7 5780-Gastrointestinal hemorrhage 979 311 31.8 9050-Late effects/musculoskeletal and 14,412 4,525 31.4 connective tissue injuries 7100-Diffuse diseases of connective tissue 9,056 2,835 31.3 2880-Diseases of white blood cells 145 45 31.0 3140-Attention deficit hyperactivity disorder 94,862 29,312 30.9 3950-Diseases of aortic valve 3,889 1,190 30.6 4100-Acute myocardial infarction 5,254 1,608 30.6 3070-Eating and tic disorders 349 106 30.4 2870-Purpura/other hemorrhagic conditions 499 151 30.3 2380-Neoplasm/uncertain behavior 204 60 29.4 5190-Other diseases of respiratory system 8,111 2,385 29.4 1350-Sarcoidosis 1,904 554 29.1 5300-Diseases of esophagus 984 286 29.1 3860-Vertiginous syndromes 2,155 625 29.0 7330-Other bone/cartilage disorders 16,067 4,659 29.0 4940-Bronchiectasis 674 193 28.6 7649-Birth weight between 1,200 and 2,000 grams 6,951 1,981 28.5 2810-Deficiency anemias 1,365 388 28.4 4020-Hypertensive vascular disease 7,426 2,109 28.4 3980-Other rheumatic heart disease 629 177 28.1 9490-Burns 1,925 537 27.9 4510-Phlebitis/thrombophlebitis 1,012 280 27.7 4240-Valvular heart diseases/other stenotic defects 3,923 1,067 27.2 3910-Rheumatic fever/heart involvement 169 45 26.6 4270-Cardiac dysrhythmias 4,966 1,311 26.4 2890-Other diseases blood/blood forming organs 1,313 339 25.8 5050-Pneumoconiosis 240 61 25.4 5560-Idiopathic proctocolitis 1,369 344 25.1 6940-Bullous disease 517 128 24.8 4130-Angina pectoris 1,761 426 24.2 2860-Coagulation defects 826 199 24.1 2720-Hyperlipidemia 175 42 24.0 7160-Other and unspecified arthropathies 27,885 6,469 23.2 6960-Dermatitis 1,951 451 23.1 2780-Obesity 20,758 4,754 22.9 5550-Regional enteritis/granulomatous colitis 4,723 1,053 22.3 3680-Visual disturbances 6,158 1,324 21.5 8690-Internal injury 506 108 21.3 8940-Lower limb open wounds 3,117 664 21.3 3152-Learning disorder 36,123 7,622 21.1 8270-Lower limb fractures 34,015 7,075 20.8
From page 237...
... 39 0 0.0 3040-Addiction disorders/drugs (adult) 7,167 0 0.0 Unknown, missing, invalid codes 145,328 8,284 5.7 SOURCE: Unpublished table provided by the Office of Disability and Income Support Programs, SSA.


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