Consultative Examinations: A Guide for Health Professionals
Part I - General Information
The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (the Act) and the supplemental security income (SSI) program (title XVI of the Act).
Title II provides for payment of disability benefits to individuals who are "insured" under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides for SSI payments to individuals (including children under age 18) who are disabled and have limited income and resources.
The Act and SSA's implementing regulations
prescribe rules for deciding if an individual is "disabled." SSA's criteria
for deciding if someone is disabled are not necessarily the same as the
criteria applied in other Government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
What is a "Medically Determinable
A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities, which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings -- not only by the individual's statement of symptoms.
The Disability Determination Process
Most disability claims are initially processed through a network of local Social Security field offices and State agencies (usually called disability determination services or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA's Office of Hearings and Appeals (ODAR).
Social Security Field Offices
SSA representatives in the field offices usually obtain applications for disability benefits, either in person, by telephone, or by mail. The application and related forms ask for a description of the claimant's impairment(s), names, addresses, and telephone numbers of treatment sources, and other information that relates to the alleged disability. (The "claimant" is the person who is requesting disability benefits.)
The field office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status, or Social Security coverage information. The field office sends the case to a DDS for evaluation of disability.
Disability Determination Services
The DDSs, which are fully funded by the Federal Government, are State agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled or blind under the law.
Usually, the DDS tries to obtain evidence from the claimant's own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a CE in order to obtain the additional information needed. The claimant's treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part III for more information about CEs.)
After completing its initial development, the DDS makes the disability determination. The determination is made by a two-person adjudicative team consisting of a medical or psychological consultant (who is a physician or psychologist) and a disability examiner. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may recontact a medical source (s) and ask for supplemental information.
The DDS also makes a determination whether the claimant is a candidate for vocational rehabilitation (VR). If so, the DDS makes a referral to the State VR agency.
After the DDS makes the disability determination, it returns the case to the field office for appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the field office in case the claimant decides to appeal the determination.
If the claimant files an appeal of an initial unfavorable determination, the appeal is usually handled much the same as the initial claim, except that the disability determination is made by a different adjudicative team in the DDS than the one that handled the original case.
Office of Disability Adjudication and Review
Claimants dissatisfied with the first appeal of a determination may file subsequent appeals. A hearing office within the Office of Disability Adjudication and Review (ODAR) processes the second appeal. An administrative law judge makes the second appeal decision, usually after conducting a hearing and receiving any additional evidence from the claimant's medical sources or other sources.
Medical development by ODAR is frequently conducted through the DDS. However, hearing offices may also contact medical sources directly. In rare circumstances, an administrative law judge may issue a subpoena requiring production of evidence or testimony at a hearing.
The Role of the Health Professional
- Health professionals play a vital role
in the disability determination process and participate in the process
in a variety of ways:
- As treating sources or other medical sources who provide medical evidence on behalf of their patients;
- As CE sources to perform, for a fee, examinations and/or tests that are needed;
- As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA's regional offices, or in SSA central office; or
- As medical experts who testify at administrative law judge hearings.
A treating source is a claimant's own physician, psychologist, or other acceptable medical source that has provided the claimant with medical treatment or evaluation and has or has had an ongoing treatment relationship with the claimant. The treating source is usually the best source of medical evidence about the nature and severity of an individual's impairment (s).
If an additional examination or testing is needed, SSA usually considers a treating source to be the preferred source for performing the examination or test for his or her own patient.
The treating source is neither asked nor expected to make a decision whether the claimant is disabled. However, a treating source will usually be asked to provide a statement about the claimant's ability, despite his or her impairments, to do work-related physical or mental activities.
Program Medical Professionals
Physicians of virtually all specialties and psychologists at the State, regional or national levels review claims for disability benefits. The review work is performed in the State DDSs or SSA's regional office or headquarters. It is strictly a paper review in which the program physician or psychologist usually has no contact with the claimant.
Because there is no direct involvement of medical professionals in the disability decisions made by administrative law judges in the Office of Disability Adjudication and Review, administrative law judges sometimes request expert testimony on complex medical issues. Each hearing office maintains a roster of medical experts who are called to testify as expert witnesses at hearings. The experts are paid a fee for their services.
Confidentiality of Records
Two separate laws, the Freedom of Information Act and the Privacy Act, have special significance for Federal agencies. Under the Freedom of Information Act, Federal agencies are required to provide the public with access to their files and records. This means the public has the right, with certain exceptions, to examine records pertaining to the functions, procedures, final opinions, and policy of these Federal agencies.
The Privacy Act permits an individual or his or her authorized representative to examine records pertaining to him or her in a Federal agency. For disability applicants, this means that an individual may request to see the medical or other evidence used to evaluate his or her application for disability benefits under the Social Security or the SSI programs. (This evidence, however, is not available to the general public.)
>SSA screens all requests to see medical evidence in a claim file to determine if release of the evidence directly to the individual might have an adverse effect on that individual. If so, the report will be released only to an authorized representative designated by the individual.