Disability Programs

SSA Consultative Medical Examination Process Improved; Some Problems Remain Gao ID: HRD-86-23 December 10, 1985

In response to a congressional request, GAO reviewed the Social Security Administration's (SSA) management of consultative examinations (CE) in its disability programs. GAO evaluated: (1) SSA ability to ensure the quality and reliability of examinations and reports; (2) SSA controls to ensure the necessity and appropriateness of CE purchases; and (3) the operations of major volume providers nationwide.

Disability decisions are made by state disability determination services (DDS), which are regulated by SSA regional offices. If a claimant's treating physician is unavailable to provide evidence of medical impairment, CE are purchased from private medical sources. GAO found that: (1) increased SSA claims documentation requirements, emphasis on decisional accuracy, and continuing investigations of persons already receiving disability benefits increased the rate of CE purchasing; (2) as the demand for CE grew, states would purchase them from volume providers; (3) there were few substantive problems in on-site reviews of volume providers by state and federal teams; (4) SSA required states to establish CE management plans with oversight by SSA regional offices; (5) new SSA policies have provided better direction on physician standards and CE reporting requirements; and (6) states have increased their monitoring of CE providers. GAO also found that: (1) SSA did not specify how the states should structure their management systems to control the CE process; (2) SSA still lacks reasonable assurance that it obtains good quality medical examinations and reports and prevents the purchase of unnecessary examinations; and (3) some SSA regional offices have not reviewed their states' implementation plans and are not performing monitoring activities as SSA requires.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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