Quality Review Process
Quality Review Process:
Some clients’ cases may be reviewed by additional departments within SSA. For your convenience, we have listed these departments below.
Everyone at SSA has a responsibility to make sure the work they perform meets the highest possible standards. To support this principle, SSA created a quality assurance program that is directed by the Office of Quality Performance. OQP has ten regional field sites around the country that measure and monitor our services in all 50 states. Each regional field site contains two program branches: The Assistance and Insurance Program Quality Branch (AIPQB) and the Disability Quality Branch (DQB). Each branch conducts independent random reviews to ensure the laws, regulations, and policies of the SSA administration are applied equally and fairly to each individual that contacts the agency.
Assistance and Insurance Program Quality Branch (AIPQB):
The AIPQB branch conducts reviews on the non-medical factors of eligibility within the retirement, survivor, disability, Medicare, and Supplemental Security Income claims to ensure payment accuracy. Cases that are selected for review are selected randomly. Any case can be selected for review. These reviews are conducted by a Quality Review Analyst with the beneficiary or their representative payee through direct face-to-face interviews or through telephone contact. Although not as common as the phone interview, home visits by an analyst do occur. AIPQB also monitors and reports on the quality and accuracy of the telephone services provided by field offices and 800-number staff throughout the country.
Disability Quality Branch (DQB):
The DQB branch conducts reviews on the medical portion of disability claims completed by the State Agency, Disability Determination Services and by field offices. All DQB reviews are conducted on live cases; in other words, these are cases where a medical decision has not been finalized and payments have not yet been issued. Therefore, it is important that we make every effort to move these cases as quickly as possible through our review process while still ensuring the accuracy of the decision.
Q and A
Q. How long does DQB have to complete a review?
A. Most cases are reviewed in 30 days or less; however, there is no required time frame. If a case is returned to the DDS because of a deficiency, they have 30 days to correct the deficiency (sometimes longer under certain circumstances). In rare cases, a claim may be returned to the DDS more than once.
Q. What are the criteria for selection and why?
A. For this question, we will focus our answer on the two primary types of reviews of initial claims and reconsiderations; however, please note that other types of cases are subject to review as well. Social Security Regulations require the DQB to assess the accuracy of the DDS determinations. Cases that are pulled for review are selected randomly from all of the cases that are approved or denied by DDS in a given calendar quarter. The number of these random reviews is a set amount found to be a statistically valid representation of a DDS’ overall accuracy. The second type of case review is based on our policy Section 221(c) of the Social Security Act requires SSA to review 50 percent of favorable SSDI and concurrent SSDI and SSI initial and reconsideration determinations made by State agencies on a pre-effectuation basis. The purpose of the review is to detect and correct erroneous determinations as well as documentation requirements before the determination is effectuated. Providing a precise number of cases that are reviewed is not possible because the varying amount of favorable determinations.
Q. If DQB has a case review, do they request info from the clients? Or is it just a folder review?
A. Generally only the case file information is reviewed to determine the accuracy of the DDS decision to allow or deny a case. If during the course of a review additional documentation is required, the DQB review office will return the folder to DDS to secure any needed information from the client. DQB will not contact the client directly.
Q. What happens if DQB disagrees with a decision?
A. If the DQB, in the process of reviewing a case, finds DDS in error in their determination, they will generally return the folder to DDS for correction. In some cases this could be a reversal of the original decision. Most often, it’s smaller changes that are needed and in certain cases DQB can make corrections to the decision or can assume jurisdiction and change the determination altogether.