Social Security Disability
Collection of Medical Evidence Could Be Improved with Evaluations to Identify Promising Collection Practices Gao ID: GAO-09-149 December 17, 2008The timely collection of relevant medical evidence from providers, such as physicians and psychologists, is key to the Social Security Administration (SSA) process for deciding whether an estimated 2.5 million new claimants each year have impairments that qualify them to receive disability benefits. The initial determinations are generally made by state agencies called Disability Determination Services (DDSs). We evaluated: (1) the challenges, if any, in collecting medical records from the claimants' own providers and ways SSA and the DDSs are responding to these challenges; (2) the challenges, if any, in obtaining high-quality consultative exams and ways SSA and the DDSs are responding to these challenges; and (3) the progress SSA has made in moving from paper to electronic collection of medical evidence. We surveyed 51 DDS directors, visited 5 state DDSs, reviewed sample case files, and interviewed officials with SSA, DDSs, and associations for claimants and providers.
Obtaining timely and complete medical records is a challenge to DDSs in promptly deciding disability claims, and DDSs have responded with additional provider contacts and adjustments to their payment procedures. Although DDSs pay most medical providers for medical records and SSA pays the DDSs to cover these expenses, 14 of 51 DDSs reported the percentage of requests for which they did not receive records was 20 percent or more in fiscal year 2007. In response to this challenge, all DDSs conduct follow-up with providers and claimants to urge them to provide records. Over half of the DDSs (34 of 51) have also implemented more timely payments for records and six increased the amount they pay. Although SSA evaluates DDS collection of medical records, it does not compile key data necessary to identify and share promising collection practices. Recruiting and retaining qualified providers is a challenge to obtaining consultative exams needed to supplement insufficient medical records. For example, 41 of 51 DDSs reported routinely asking claimants' own providers to perform these exams; yet 34 reported providers never or almost never agree to do so. DDSs directors in our survey believe that current payment rates account for some of the difficulty recruiting and retaining consultative exam providers. In response to these challenges, 32 DDSs rely on medical providers who specialize in performing disability evaluations, and 20 pay providers for time spent preparing for appointments claimants fail to attend. SSA evaluates evidence from consultative exams, but these evaluations and the data they yield are too limited to identify and share promising DDS practices. SSA has made progress moving to electronic collection of medical records, but faces challenges in fully implementing electronic retrieval and analysis of medical evidence. SSA now uses electronic images instead of paper copies of new claimants' records. Though SSA seeks to obtain all records electronically and provides options for online submission of records, only one large provider accounts for most of the records submitted online, and about half of all records received are on paper. To date, SSA has taken only limited action to identify and analyze the barriers providers face in using current electronic record submission options, and has not developed a strategy to address them. In the long run, SSA is participating in an advanced prototype to collect medical records in formats that can be searched and analyzed by electronically querying a hospital's records database and directly retrieving the claimants' records.
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Director: Team: Phone:GAO-09-149, Social Security Disability: Collection of Medical Evidence Could Be Improved with Evaluations to Identify Promising Collection Practices
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Could Be Improved with Evaluations to Identify Promising Collection
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Report to the Subcommittee on Social Security, Committee on Ways and
Means, House of Representatives:
United States Government Accountability Office:
GAO:
Social Security Disability:
Collection of Medical Evidence Could Be Improved with Evaluations to
Identify Promising Collection Practices:
GAO-09-149:
GAO Highlights:
Highlights of GAO-09-149, a report to the Subcommittee on Social
Security, Committee on Ways and Means, House of Representatives.
Why GAO Did This Study:
The timely collection of relevant medical evidence from providers, such
as physicians and psychologists, is key to the Social Security
Administration (SSA) process for deciding whether an estimated 2.5
million new claimants each year have impairments that qualify them to
receive disability benefits. The initial determinations are generally
made by state agencies called Disability Determination Services (DDSs).
We evaluated: (1) the challenges, if any, in collecting medical records
from the claimants‘ own providers and ways SSA and the DDSs are
responding to these challenges; (2) the challenges, if any, in
obtaining high-quality consultative exams and ways SSA and the DDSs are
responding to these challenges; and (3) the progress SSA has made in
moving from paper to electronic collection of medical evidence. We
surveyed 51 DDS directors, visited 5 state DDSs, reviewed sample case
files, and interviewed officials with SSA, DDSs, and associations for
claimants and providers.
What GAO Found:
Obtaining timely and complete medical records is a challenge to DDSs in
promptly deciding disability claims, and DDSs have responded with
additional provider contacts and adjustments to their payment
procedures. Although DDSs pay most medical providers for medical
records and SSA pays the DDSs to cover these expenses, 14 of 51 DDSs
reported the percentage of requests for which they did not receive
records was 20 percent or more in fiscal year 2007. In response to this
challenge, all DDSs conduct follow-up with providers and claimants to
urge them to provide records. Over half of the DDSs (34 of 51) have
also implemented more timely payments for records and six increased the
amount they pay. Although SSA evaluates DDS collection of medical
records, it does not compile key data necessary to identify and share
promising collection practices.
Recruiting and retaining qualified providers is a challenge to
obtaining consultative exams needed to supplement insufficient medical
records. For example, 41 of 51 DDSs reported routinely asking
claimants' own providers to perform these exams; yet 34 reported
providers never or almost never agree to do so. DDSs directors in our
survey believe that current payment rates account for some of the
difficulty recruiting and retaining consultative exam providers. In
response to these challenges, 32 DDSs rely on medical providers who
specialize in performing disability evaluations, and 20 pay providers
for time spent preparing for appointments claimants fail to attend. SSA
evaluates evidence from consultative exams, but these evaluations and
the data they yield are too limited to identify and share promising DDS
practices.
SSA has made progress moving to electronic collection of medical
records, but faces challenges in fully implementing electronic
retrieval and analysis of medical evidence. SSA now uses electronic
images instead of paper copies of new claimants' records. Though SSA
seeks to obtain all records electronically and provides options for
online submission of records, only one large provider accounts for most
of the records submitted online, and about half of all records received
are on paper. To date, SSA has taken only limited action to identify
and analyze the barriers providers face in using current electronic
record submission options, and has not developed a strategy to address
them. In the long run, SSA is participating in an advanced prototype to
collect medical records in formats that can be searched and analyzed by
electronically querying a hospital‘s records database and directly
retrieving the claimants‘ records.
Figure: Some DDSs Face Challenges Receiving Requested Medical Records,
Fiscal Year 2007:
[Refer to PDF for image]
More than 80% received: 23 DDSs;
80% or less received: 14 DDSs;
DAta not available: 14 DDSs.
Source: GAO survey of DDS directors.
[End of figure]
What GAO Recommends:
GAO recommends SSA identify DDS evidence collection practices that may
be promising, evaluate their effectiveness, and encourage
implementation of successful practices in other states, as applicable.
To do so, SSA should cost-effectively compile and assess additional
data on the collection process. SSA should also work to identify and
address barriers to expanded use of its online medical evidence
submission options.
To view the full product, including the scope and methodology, click on
GAO-09-149. For more information, contact Daniel Bertoni at (202) 512-
7215 or bertonid@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
DDSs Face Challenges Obtaining Medical Records from Claimants'
Providers:
DDSs Face Challenges Recruiting and Retaining Qualified Consultative
Exam Providers:
SSA Has Made Progress in Moving to Electronic Collection of Medical
Records, but Faces Challenges Shifting to the Use of Electronic Medical
Records:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Selected Results from Analysis of 100 Randomly Selected
Initial Disability Cases:
Appendix III: Medical Evidence Collection Process at the Administrative
Hearing Level:
Appendix IV: Comments from the Social Security Administration:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: DDS Directors' Opinions Regarding Providers' Responses to
Requests for Medical Records, Fiscal Year 2007:
Table 2: DDS Receipt and Characterization of Medical Source Statements
from Claimants' Treating Providers, Fiscal Year 2007:
Table 3: DDS Activities to Facilitate Claimant Attendance at
Consultative Exams, Fiscal Year 2007:
Table 4: Selected SSA Data for Five DDSs:
Table 5: Characteristics of Medical Evidence Collection in 100 Cases of
Initial DDS Disability Determinations, Fiscal Year 2007:
Table 6: Legibility of Records in 100 Cases of Initial DDS Disability
Determinations, Fiscal Year 2007:
Table 7: Characteristics of the Collection Process for Medical Records
from Claimants' Providers in 100 Cases of Initial DDS Disability
Determination, Fiscal Year 2007:
Table 8: Time Periods for Receipt of Medical Records and Disability
Determinations in 100 Initial DDS Disability Decisions, Fiscal Year
2007:
Table 9: Characteristics of the Medical Evidence Collection Process for
50 Cases at the Initial DDS Decision Level and at the Hearings Office
Appeal Level:
Table 10: Additional Examples of Medical Evidence Collection at
Hearings Office Level:
Figures:
Figure 1: SSA's Five-Step Process for Determining Disability:
Figure 2: Medical Evidence Collection for Initial Disability
Determinations:
Figure 3: Some DDSs Face Challenges Receiving Requested Medical
Records, Fiscal Year 2007:
Figure 4: Sources of DDS Consultative Exam Payment Schedules:
Figure 5: States Reporting Frequent Use of High-Volume Consultative
Exam Providers:
Figure 6: SSA Still Receives About Half of Records on Paper:
Abbreviations:
ALJ: administrative law judge:
DDS: Disability Determination Services:
DI: Disability Insurance:
HIPAA: Health Insurance Portability and Accountability Act of 1996:
SSA: Social Security Administration:
SSI: Supplemental Security Income:
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
December 17, 2008:
The Honorable Michael R. McNulty:
Chairman:
The Honorable Sam Johnson:
Ranking Member:
Subcommittee on Social Security:
Committee on Ways and Means:
House of Representatives:
The Social Security Administration (SSA) has faced challenges for
decades in making accurate and timely decisions on whether claimants
have impairments that qualify them to receive disability benefits. Some
disability applicants whose claims are denied and appeal wait years for
their claims to be decided at the final administrative appeals level,
which can be a hardship. In fiscal year 2006, 30 percent of claims
processed at the hearings stage alone took 600 days or more.[Footnote
1] To help avoid such hardships and improve its process, SSA
Commissioners have emphasized the need to make the right decision at
the beginning of the process. The prompt collection of relevant medical
evidence is key to SSA's process for deciding each year whether about
2.5 million new claimants have impairments that qualify them to receive
disability benefits. SSA estimates that in fiscal year 2007, disability
cases prompted an estimated 15 million to 20 million medical records
requests sent to providers including hospitals, physicians,
psychologists, and community health centers.[Footnote 2] The number of
new claimants is expected to increase as the baby boom generation ages.
To promptly make consistent and accurate decisions on a high volume of
claims, SSA needs efficient and effective methods to collect medical
evidence, including records from claimants' own medical providers as
well as consultative examinations and tests performed by other medical
providers.
To be eligible for disability benefits under SSA law, individuals must
have a medically determinable impairment that prevents them from
engaging in substantial gainful activity, and is expected to last at
least a year, or result in death. The initial determination of
disability is generally made by federally funded, SSA-authorized state
agencies called Disability Determination Services (DDS). DDSs help
claimants collect medical and other evidence of their impairments. When
medical records obtained from claimants' own providers are
inconclusive, DDSs obtain additional evidence through consultative
examinations. In most cases, DDSs pay medical providers for the medical
records and consultative exams at rates set by the states within limits
set by SSA, and SSA pays DDSs to cover these expenses. SSA reported
that in fiscal year 2007, it paid DDSs about $1.7 billion dollars for
their services, including $123 million for medical records and $311
million for consultative examinations. SSA and DDSs are working to
transform what is largely a paper process into a computerized one, as
the medical community moves to electronic medical records.
To respond to your concern about the adequacy of medical evidence
collection in the disability determination process, we evaluated: (1)
the challenges, if any, in collecting medical records from the
claimants' own providers and ways SSA and DDSs are responding to these
challenges; (2) the challenges, if any, in obtaining high-quality
consultative exams and ways SSA and DDSs are responding to these
challenges; and (3) the progress SSA has made in moving from paper to
electronic collection of medical evidence.
To address these topics, we conducted background research and
interviews with SSA, SSA Office of the Inspector General, and DDS
officials. We also spoke with representatives of professional
associations, including those representing people with disabilities;
disability examiners; physicians; representatives of claimants; and
medical providers. We conducted a Web-based survey of DDSs in all 50
states and the District of Columbia concerning medical evidence
collection for initial disability decisions, including DDS practices
for collection of medical records and medical opinions from claimants'
own providers and from consultative exam providers.[Footnote 3] To
learn more about how DDSs collect medical evidence, we reviewed a
random, but nonprojectable, sample of 100 claim folders for initial DDS
disability determinations during fiscal year 2007; to document the
differences in medical evidence collection between the initial and
appeals levels, we reviewed a random sample of 50 administrative law
judges' decisions and their associated claim folders. We conducted site
visits to DDSs in large and small states in various geographic regions
that purchased medical records for a relatively high or low percentage
of claimants, and that requested consultative examinations for a
relatively high or low percentage of claimants. Based on these
criteria, we visited California, Mississippi, New York, Vermont, and
Wyoming. We also analyzed SSA data concerning the disability
determination process, including SSA data on DDS cases, and quality
assurance reviews of DDS cases by SSA regional Disability Quality
Branches. To assess progress in moving from paper to electronic
collection of medical evidence, we reviewed SSA documents concerning
SSA and the health industry's efforts and analyzed data compiled by
SSA's computer system regarding receipts of evidence and discussed
efforts to encourage electronic submission with SSA and DDS officials,
as well as medical providers. We conducted our review between September
2007 and December 2008 in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for out findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
For details concerning our scope and methodology, see appendix I. For a
summary of our review of randomly selected claim folders from the
initial claim and the administrative appeal levels, see appendixes II
and III, respectively.
Results in Brief:
Obtaining timely and complete medical records is a challenge to
promptly deciding disability claims, and DDSs have responded to this
challenge with additional provider contacts and adjustments to their
payment methods. SSA regulations generally require DDSs to make every
reasonable effort to help claimants obtain records from the claimants'
medical providers, and to place particular emphasis on opinions from
the claimants' treating sources--providers who have an established
treatment relationship with the claimants. However, some providers are
slow or fail to submit requested medical records. In our survey of DDS
directors, 14 of the 51 directors reported that they did not receive
responses to 20 percent or more of their requests for medical records
during fiscal year 2007. In response, almost all DDSs in our survey
reported that they place additional follow-up calls to providers (45)
or ask claimants to encourage their providers to submit records (50).
Some have gone even further with more than half encouraging providers
to respond by improving the timeliness or increasing the amount of
their payments for medical records. Specifically, 34 DDSs reported
recently improving the timeliness of their payments for records, 6 DDSs
reported increasing the amount they pay, and 2 reported providing
incentive payments to providers who submit medical records promptly.
SSA routinely conducts quality assurance reviews of DDS compliance with
requirements for medical records collection and gathers data from DDSs
on budget and program operations, but SSA does not identify and review
the effectiveness of promising DDS medical evidence collection
practices or compile consistent data necessary for such an evaluation,
such as timeliness of medical records receipts.
Recruiting and retaining qualified providers is a challenge to
obtaining consultative exams needed to supplement insufficient medical
records and, in response, some DDSs have turned to providers who
specialize in consultative exams or adopted flexible payment rates. DDS
officials report difficulty finding enough medical providers willing to
perform consultative exams, even among claimants' own providers--the
preferred source for consultative exams under SSA regulations due to
their familiarity with the claimant's condition. For example, 41 DDSs
in our survey reported routinely asking claimants' own providers if
they are willing to perform a consultative exam, but 34 of these DDSs
said those providers never or almost never agree to do so. DDS
directors we surveyed believe that current payment rates and provider
concerns that disability claimants often fail to show up for scheduled
exams account for some of the difficulty DDSs face recruiting and
retaining willing providers. Most DDSs (32 of 51) reported that they
often make consultative exam appointments with specialized medical
providers whose practices focus primarily on disability evaluations,
and 29 DDSs said using such providers has a moderately positive or very
positive effect on the quality of the consultative exam reports they
receive. In addition, some DDSs have modified their payments for
consultative exams, paying providers for time spent preparing for a
missed appointment, for example. While SSA routinely conducts quality
assurance reviews of evidence obtained through consultative exams and
gathers extensive data from the DDSs on spending for consultative
exams, it has not evaluated the effectiveness of different DDS
approaches to recruiting and paying consultative exam providers. For
example, DDS officials cite provider frustration with missed
appointments as a contributor to recruitment and retention challenges,
yet SSA and the DDSs currently do not track the number of missed
consultative exam appointments. Such data could be key for SSA to
evaluate various DDS approaches to managing consultative exams and
determining which approaches are sufficiently cost-effective at
reducing "no-shows" and could be adopted in other DDSs.
SSA has made progress moving to electronic collection of medical
records, but faces challenges in implementing electronic retrieval and
analysis of medical records. As a beginning step in developing a more
advanced process for electronic collection of medical records, SSA now
uses electronic images instead of paper copies of new claimants'
medical records. If a physician or hospital submits paper copies of a
claimant's medical records, SSA scans them into its computer database.
Electronic access to the records enables authorized SSA staff in other
regions and policy staff in headquarters to review cases remotely. This
provides opportunities for collaboration, which may contribute to more
nationally consistent interpretations of SSA policy. SSA's goal is to
receive all medical records electronically, but SSA faces challenges
encouraging medical providers to use electronic submission options,
given their varied ability to use such options. According to a study
published in 2008, less than one-fifth of U.S. physicians surveyed have
moved from paper to electronic records, and only 4 percent had fully
functional electronic medical records systems. Despite maintaining
several avenues for online submission, SSA still receives about half of
all records on paper via the mail. Although SSA received 21 percent of
records for disability claims through its online submission methods in
September 2008, up from 12 percent about 2 years earlier, a single
provider accounts for most of the records SSA receives online. Although
SSA held a conference to give providers opportunities to air concerns
about the difficulties they faced using SSA's Web site for submitting
evidence online, SSA has conducted only limited study of the problems
related to electronic submission of medical records. Although SSA's
current process for collecting electronic images of medical records has
brought significant advantages, the images are not well suited for
electronic searches and analyses. For example, DDS examiners cannot use
computers to electronically search a claimant's record for particular
diagnoses and test results. SSA is taking steps to develop a more
advanced method of online exchange of medical records in formats that
are searchable. For example, SSA and a Boston hospital are developing a
prototype to allow SSA to electronically query and retrieve the
hospital's records for specific claimants--an innovation SSA hopes to
expand to additional providers in the future.
We are recommending that SSA evaluate DDS medical evidence collection
practices that may hold promise, compile key additional data to
facilitate such an evaluation, and step up its efforts to identify and
address barriers to online submission of medical evidence. SSA agreed
with our findings and recommendations and noted both ongoing and
planned actions to address our recommendations.
Background:
SSA administers two programs under the Social Security Act that provide
benefits to people with disabilities who are unable to work: Disability
Insurance (DI) and Supplemental Security Income (SSI). According to SSA
policy, to be eligible for either DI or SSI, an adult must be unable to
engage in "substantial gainful activity"--typically work that results
in earnings above a monthly threshold established each year by SSA--
because of a medically determinable physical or mental impairment that
is expected to last at least 12 months or result in death.[Footnote 4]
Established in 1954, the DI program provides monthly benefits to
workers (and their spouses and dependents) whose work history qualifies
them for disability benefits and whose impairment is disabling. In
2007, SSA paid about $99 billion in DI benefits to about 8.1 million
workers, spouses, and dependents. The average monthly benefit was
$1,004 for disabled workers.[Footnote 5] SSI is a means-tested income
assistance program created in 1972 that provides a financial safety net
for people who are aged, blind, or disabled, and have low incomes and
limited assets. Unlike the DI program, SSI has no prior work
requirements. In 2007, SSA paid about $37 billion in SSI benefits. As
of December 2007 about 7.4 million recipients received an average
monthly benefit of $468. Some individuals with disabilities receive
both DI and SSI benefits if they meet both DI's work history
requirements and SSI's income and asset limits.
Disability Determination Process:
The process to determine a claimant's eligibility for SSA disability
benefits is complex, involving several state and federal offices. The
disability determination process, which is the same for DI and SSI
claimants, involves an initial determination of disability and provides
up to two levels of administrative review within SSA. A claimant first
completes an application, or claim, for DI or SSI benefits, which
includes information regarding illnesses, injuries, or conditions and a
signature giving SSA permission to request medical records from medical
care providers. Once the SSA field office staff verify that nonmedical
eligibility requirements are met, the claim is sent to the state's DDS
office for determination of medical disability.[Footnote 6] If the
claim is approved, a claimant will be notified and will receive
benefits, including limited retroactive benefits for some DI claimants.
[Footnote 7] Additionally, if the claim is approved, a claimant may
become eligible for Medicaid or Medicare health coverage.[Footnote 8]
If the claim is rejected, a claimant has 60 days to request that the
DDS reconsider its decision.[Footnote 9] If the DDS reconsideration
determination concurs with the initial denial of benefits, the claimant
has 60 days to appeal and request a hearing before an SSA
administrative law judge (ALJ). A claimant may appeal an unfavorable
administrative law judge decision to SSA's appeals council, which
includes administrative appeals judges and appeals officers and,
finally, to federal court. SSA and DDS officials (examiners and ALJs)
determine disability using a five-step sequential process based on
evidence such as medical findings and statements of functional capacity
obtained during the initial determination process and updated as
necessary at each appeal level. (See figure 1.)
Figure 1: SSA's Five-Step Process for Determining Disability:
[Refer to PDF for image]
This figure is an illustration of SSA's Five-Step Process for
Determining Disability, as follows:
Step 1: Work Test:
Is the claimant engaged in substantial gainful activity?[A]
Yes: Benefits Denied;
No: Proceed to next step.
Step 2: Severity Test;
Does the claimant have a severe impairment that significantly limits
his or her ability to do basic work activities and that also meets the
duration requirements?[B]
Yes: Proceed to next step;
No: Benefits Denied.
Step 3: Medical listings test;
Does the condition meet SSA‘s medical listings, or is the condition
equal in severity to one found on the medical listings?[C]
Yes: Benefits awarded;
No: Proceed to next step.
Step 4: Previous work test;
Can a person with the claimant‘s residual functional capacity perform
the claimant‘s past work?[D]
Yes: Benefits Denied;
No: Proceed to next step.
Step 5: Any work test;
Can the claimant perform other types of work that exist in the national
economy?[E]
Yes: Benefits Denied;
No: Benefits awarded.
[A] In 2008, the substantial gainful activity threshold was $1,570 per
month for blind recipients and $940 per month for individuals with
other disabilities.
[B] Evidence considered at Step 2 must be primarily medical.
[C] Evidence considered at Step 3 must be primarily medical. Medical
listings are federal regulations detailing diagnoses and measures of
severity that qualify a claimant as disabled under SSA law. See 20
C.F.R. Part 404, Subpart P, Appendix 1.
[D] Evidence considered at Step 4 may include consideration of
nonmedical evidence such as vocational information and work experience.
[E] Evidence considered at Step 5 may include consideration of
nonmedical evidence such as vocational information, age, education, and
work experience.
[End of figure]
Development of Medical Evidence for Initial Determinations:
Generally, SSA requires DDSs to develop a complete medical history for
each claimant for at least a 12-month period prior to the application.
SSA guidance directs DDSs to request records from all providers who
have treated or evaluated the claimant during this time period, except
those who treated only ailments clearly unrelated to the claimed
impairment.[Footnote 10] DDSs generally pay providers for records and
SSA pays the DDSs to cover these expenses.[Footnote 11] Each DDS
determines its payment rates for medical and other services necessary
to make determinations, subject to certain limits.[Footnote 12] DDSs
request laboratory reports, X-rays, doctors' notes, and other
information used in assessing the claimant's health and functional
capability from many types of providers including: physicians or
psychologists; hospitals; community health centers; schools (for child
claimants); and Department of Veterans Affairs (VA), military, or
prison health care facilities. In addition to medical evidence, DDSs
review statements from the claimant or others about the claimant's
impairment and ability to perform daily activities. SSA directs DDSs to
make "every reasonable effort" to help the claimant obtain medical
reports, which SSA defines as one initial medical records request and,
if needed, one follow-up request within 10 to 20 days, when providers
have not responded, unless experience with a particular provider
warrants more time. DDSs allow a minimum of 10 days after the follow-up
request for the provider to reply. When records indicate the claimant
has been to other medical providers, DDSs also contact those providers
for records. Generally records are placed in the claimant's case
record.[Footnote 13]
SSA regulations require that disability determinations place more, and
in some cases controlling, weight on the opinions of a claimant's
treating providers.[Footnote 14] For example, a treating provider's
opinion about the nature and severity of the claimant's impairment
should generally be given controlling weight where their opinion is
well supported by other substantial evidence in a claimant's case
record.[Footnote 15]
In claims where the gathered medical and nonmedical evidence is
insufficient to support a disability determination, DDSs may order
consultative exams or tests.[Footnote 16] DDSs pay providers to perform
these examinations and SSA pays them to cover these costs. SSA
regulations require that payments to providers for consultative exams
not exceed the highest rate paid by federal or other state agencies for
the same or similar services. The regulation allows states to determine
the rates of payment and, as a result, DDS rates of payment for
consultative exams vary nationwide. SSA regulations specify the types
of providers who may perform these exams or tests, and require DDSs to
recruit, train, and oversee them. SSA regulations also state that the
claimant's own provider is generally the preferred source for
consultative exams if qualified, equipped, and willing to perform the
exams. (See figure 2.)
Figure 2: Medical Evidence Collection for Initial Disability
Determinations:
[Refer to PDF for image]
This figure is an illustration of Medical Evidence Collection for
Initial Disability Determinations, as follows:
Claimant:
* Apply for benefits:
- Medical history with provider contact information;
- Permission to release medical records;
- Personal health records (optional).
SSA field office:
* Review application;
* Verify nonmedical eligibility requirements;
* Submit verified application to State DDS.
State DDS:
* Gather medical evidence and medical opinions from providers;
* Request consultative exams when required;
* Compensate providers for records and consultative exams, if
applicable;
* Review evidence in the electronic folder and make initial disability
determination;
* Submit the following to Medical Providers:
- Request for records, opinions, and consultative exams;
- Follow-up requests;
- Compensation for records and consultative exams.
Medical providers:
* Locate and submit medical records;
* Perform consultative exams;
* Submit to State DDS:
- Medical records and opinions;
- Consultative exam reports[A].
Source: GAO analysis of SSA data; images (Art Explosion).
[A] Medical records, opinions, and consultative exams from medical
providers are stored in claimants' electronic folder by SSA or a
scanning contractor.
[End of figure]
To support DDSs' efforts to process claims quickly, SSA has established
an expedited process for claims in which a determination of disability
is likely. In September 2007, SSA implemented its Quick Disability
Determination process nationwide after testing it in the Boston region.
This process uses a computer model using certain key terms in the claim
file to identify claims for which a decision of disability is likely
and medical evidence establishing disability can be easily obtained.
DDSs can use expedited processes for these claims; for example, DDS
staff in a couple of states we visited explained how they request and
receive medical records for Quick Disability Determination cases by
fax.[Footnote 17] SSA reported, for fiscal year 2007, that the national
average processing time for all initial claims was 83 days. By
comparison, during the pilot, the Boston region decided Quick
Disability Determination claims in an average of 11 days.[Footnote 18]
SSA also has policies to expedite claims involving diseases such as
certain types of cancer that are terminal or otherwise so severe that
they clearly meet SSA's definition of disability.
SSA performs a quality assurance review of a sample of more than 30,000
DDS decisions each year. SSA assesses the accuracy of the DDSs'
determination and the sufficiency of the documentation for the DDSs'
compliance with requirements for medical records collection and
consultative exams process. Decisional deficiencies occur when a
different determination should have been made, and documentation
deficiencies occur when additional documentation is necessary in order
to make the correct determination. SSA also collects extensive data on
spending for consultative exams and requires DDSs to routinely report
substantial budget, program operations, and management data to SSA.
Electronic Medical Record Collection:
In 2004, President Bush called for widespread adoption of interoperable
electronic health records within 10 years and issued an executive order
assigning the coordination of the effort to the Department of Health
and Human Services.[Footnote 19] Under the department's leadership,
volunteer organizations designated to develop standards for the health
care industry have prepared initial certification criteria for health
information technology such as electronic patient records and records
management systems. As businesses, providers decide when and whether to
invest in these certified systems. Another executive order in 2006
directs certain federal agencies to "utilize, where available, health
information technology systems and products that meet recognized
interoperability standards."[Footnote 20] HHS also has awarded several
contracts related to health information technology to address issues
such as standardization, networking, and privacy and security. SSA
collection of medical evidence is affected by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) which defines the
circumstances in which an individual's health information may be used
or disclosed.[Footnote 21] In addition, HIPAA's security provisions
require entities that hold or transmit health information to maintain
reasonable safeguards to protect the information against unauthorized
use or disclosure and ensure its integrity and confidentiality.
DDSs Face Challenges Obtaining Medical Records from Claimants'
Providers:
Determining eligibility for disability benefits is a complex,
challenging task. DDS officials identified obtaining records from
claimants' medical providers as a major challenge to DDS examiners'
ability to quickly compile the necessary evidence for disability
determinations. DDSs cited problems with the consistency of provider
response to record requests, both in timeliness and completeness of
records submitted. DDSs have responded to these challenges by
conducting additional follow-up contacts with medical providers and
claimants, and more than half of the 51 DDSs we surveyed reported
adjusting their payment methods. Although SSA routinely reviews DDSs'
compliance with medical records collection requirements, SSA does not
systematically identify and review the effectiveness of promising DDS
medical evidence collection practices.
Medical Providers Do Not Respond Consistently to DDS Requests for
Records:
DDS officials identified provider response to medical records requests
as a challenge in our survey of 51 DDSs. One DDS director reported in
our survey that more than 300 providers in the state were considered
"nonproductive" so that the DDS must send claimants who are patients of
those providers to consultative exams when evidence from other sources
is insufficient. One DDS director noted that public health clinics and
hospitals are overburdened providing patient care and that medical
records programs get short shrift. According to both DDS officials and
providers we interviewed, generating records for disability claims
takes lower priority than patient care and costs money for medical
records staff time and contracted copy services, for example. One DDS
official told us that some providers do not bill the DDS for records
because the state's centralized payment system is slow and generates
payments that are hard to reconcile with invoices. Examiners in another
state told us that some providers refuse to submit requested records
for claimants with unpaid bills, or charge the claimants instead of the
DDS. DDSs also can have difficulty obtaining medical records when
medical records are purged or moved to another location, or when
facilities close or are destroyed.
DDSs request records from all providers who have treated the claimant
for at least the 12 months preceding the application for benefits,
except those who treated only minor ailments clearly unrelated to the
claimed impairment or when the claimed disability began more recently.
As a result, the volume of records requested is high: 13 DDSs reported
sending over 200,000 requests in fiscal year 2007. Provider response to
these requests for medical records is inconsistent; some submit records
to the DDSs within 10 days, others never respond at all. Timeliness of
medical record receipt is a central concern because SSA tracks how long
it takes to process initial claims, and measures DDSs against
regulatory performance standards. SSA reported that the national
average processing time for initial claims was 83 days in fiscal year
2007.[Footnote 22] Although not all DDSs were able to complete our
survey question on the volume of medical record requests and timeliness
of provider responses, 32 of the 37 DDSs who did provide numbers
reported receiving responses for up to 40 percent of their requests for
medical records within 10 days.[Footnote 23] However, a substantial
number of requests for medical records go unfulfilled. As shown in
figure 3, 14 DDSs received less than 80 percent of requested records.
Another 14 DDSs did not provide sufficient data in response to our
survey to calculate the percentage of requests for which they received
medical records.
Figure 3: Some DDSs Face Challenges Receiving Requested Medical
Records, Fiscal Year 2007:
[Refer to PDF for image]
More than 80% received: 23 DDSs;
80% or less received: 14 DDSs;
DAta not available: 14 DDSs.
Source: GAO survey of DDS directors.
Note: This figure indicates the estimated or computed percentage of
requests for which DDSs received medical records. It presents
information provided by 37 of the 51 DDS directors we surveyed about
medical records they requested and received from providers for initial
decisions during fiscal year 2007. Responses include both numbers
calculated from DDS internal records (25) and estimated by the
directors (9); the remaining 2 DDSs did not specify. Because of the way
many DDS computer systems classify provider responses to requests for
records, the counts of fulfilled requests could include responses from
providers stating that records were not available for that claimant or
for the dates requested by the DDS. See app. I for details about our
analysis of survey responses.
[End of figure]
DDS examiners request records from various types of providers including
physicians or psychologists in individual or group practices;
hospitals; community health centers; schools (for child claimants); and
VA, military, or prison health care facilities. As shown in table 1,
DDS directors we surveyed reported that some types of providers are
more responsive to medical records requests than others.
Table 1: DDS Directors' Opinions Regarding Providers' Responses to
Requests for Medical Records, Fiscal Year 2007:
Providers submit medical records within 2 weeks:
Provider type: Individual physician or psychologist;
Always or almost always: 3;
Very often: 10;
Often: 22;
Sometimes: 12;
Never or almost never: 0;
No answer: 4.
Provider type: Group practice or multi-specialty clinic;
Always or almost always: 3;
Very often: 13;
Often: 20;
Sometimes: 12;
Never or almost never: 0;
No answer: 3.
Provider type: Hospital;
Always or almost always: 5;
Very often: 11;
Often: 18;
Sometimes: 12;
Never or almost never: 2;
No answer: 3.
Provider type: VA health care facility;
Always or almost always: 9;
Very often: 15;
Often: 14;
Sometimes: 7;
Never or almost never: 3;
No answer: 3.
Provider type: Public or community health clinic;
Always or almost always: 2;
Very often: 8;
Often: 12;
Sometimes: 23;
Never or almost never: 2;
No answer: 4.
Provider type: Mental health clinic;
Always or almost always: 1;
Very often: 7;
Often: 15;
Sometimes: 23;
Never or almost never: 2;
No answer: 3.
Provider type: School[A];
Always or almost always: 0;
Very often: 7;
Often: 10;
Sometimes: 22;
Never or almost never: 9;
No answer: 3.
Provider type: Prison health care facility;
Always or almost always: 2;
Very often: 5;
Often: 7;
Sometimes: 16;
Never or almost never: 16;
No answer: 5.
Source: GAO survey of DDS directors.
[A] Schools may maintain records of evaluations performed by
individuals who meet SSA's definition of medical providers. In
addition, DDSs may request information from teachers and other school
personnel about how a child claimant is functioning on a day-to-day
basis when compared with other children who do not have impairments.
[End of table]
The task of obtaining a complete medical history[Footnote 24] is
further complicated when claimants do not identify all their medical
providers when applying for benefits. Almost all of the 51 DDS
directors (48) we surveyed reported that examiners at least sometimes
identify providers who had not been listed on the claimant's
application. Examiners may find out about additional medical providers
as they review the records in the file, for example, and must generally
request records from those providers. In our review of 100 initial
claim files, we identified 19 in which DDS examiners requested records
from providers who had treated the claimant but had not been identified
on the application.
In addition to contacting multiple providers, DDS examiners must
develop evidence for all of the claimed impairments, which can be
numerous and include both mental and physical conditions. During our
site visits, DDS claims examiners told us that claims involving mental
impairments posed particular documentation challenges, noting that some
claimants with mental impairments may have difficulty obtaining
treatment or accurately describing their medical histories.
Furthermore, SSA regulations include some specific requirements for
collecting evidence of mental impairments. For example, generally where
there is indication of a possible mental impairment, SSA regulations
establish a special technique to be used when evaluating the severity
of mental impairments, which includes rating the claimant's degree of
functional limitation in four broad functional areas and recording the
results of this evaluation on a standard document.
The opinions of providers with an ongoing treatment relationship with
the claimant are a particularly important source of evidence for
disability determinations. Treating providers' opinions about the
nature and severity of the claimant's impairment often are given great
deference in SSA regulations. Examiners must give controlling weight to
treating providers' opinions if they are not inconsistent with the
other substantial evidence in the case record and are well supported by
medically acceptable clinical and laboratory diagnostic techniques.
[Footnote 25] Yet, of the 51 DDSs we surveyed, none reported that half
or more were willing to provide such opinion statements, and 15
indicated that none or almost none were willing to provide the
statements. Almost all DDSs (48 of 51) reported asking for treating
sources' opinion statements in their initial medical records requests,
but as table 2 shows, DDSs are not always successful at obtaining those
statements, even after multiple requests, and the statements they
receive are not always helpful in making their determinations.
Table 2: DDS Receipt and Characterization of Medical Source Statements
from Claimants' Treating Providers, Fiscal Year 2007:
DDSs' receipt of medical source statements from treating providers:
Received after the DDS's initial request:
Always or almost always: 0;
Very often: 2;
Often: 4;
Sometimes: 24;
Never or almost never: 19;
No answer: 2.
Received after the DDSs' first follow-up request:
Always or almost always: 0;
Very often: 0;
Often: 1;
Sometimes: 27;
Never or almost never: 17;
No answer: 6.
Received after two or more follow-up requests:
Always or almost always: 0;
Very often: 0;
Often: 3;
Sometimes: 20;
Never or almost never: 20;
No answer: 8.
DDSs' characterization of medical source statements from treating
providers:
Consistent with the other medical records in the claimant's file:
Always or almost always: 0;
Very often: 2;
Often: 10;
Sometimes: 34;
Never or almost never: 2;
No answer: 3.
Supported by medically accepted clinical and laboratory diagnostic
techniques:
Always or almost always: 0;
Very often: 1;
Often: 7;
Sometimes: 35;
Never or almost never: 5;
No answer: 3.
Helpful in making the determination:
Always or almost always: 2;
Very often: 8;
Often: 13;
Sometimes: 22;
Never or almost never: 3;
No answer: 3.
Source: GAO survey of DDS directors.
[End of table]
In addition, as summarized in table 2, when DDSs receive medical source
statements from treating providers, more than half of the DDSs find
that those statements are only sometimes consistent with the other
medical evidence in the file or well supported by medically acceptable
clinical and laboratory diagnostic techniques.[Footnote 26] One DDS
director summarized the difficulty in obtaining medical source
statements as follows, in response to our survey:
A good and useful MSS [medical source statement] both states a
quantification of the effects of the condition on the claimant's
ability to function and an explanation as to how the assessment is
supported by the evidence. These are rare. More often we receive "less
useful" MSS's that only do the first part. Treating sources are
generally OK with just sending records or including a statement such as
"the patient has severe rheumatoid arthritis, remains under my care,
and can't return to work for the foreseeable future." When we get such
an MSS, we either are left to refute it or return it to the TS
[treating source] for a better underlying analysis. This annoys them
and usually does not come to a beneficial or happy result.
DDS officials and providers described various reasons why treating
providers may be reluctant to submit medical source statements.
Treating providers may be concerned that submitting their medical
opinion to the DDS might interfere with the doctor-patient
relationship, and they also typically focus on diagnosis and treatment
rather than evaluation of functional ability. Providers also may have
limited knowledge of SSA standards or the physical or mental
requirements for different types of work.
Almost All DDSs Engage in Additional Follow-up Contacts to Encourage
Provider Response; about Half Have Modified Their Payments:
SSA regulations and guidance specify the timing of DDS requests for
medical records but leave the methods of contact up to each DDS. If it
does not receive records after one request, the DDS must make one
follow-up request within 10 to 20 days unless the provider is known to
take longer to respond.[Footnote 27] After that, the DDS must generally
give the provider an additional 10 days and then may send the claimant
for a consultative exam if needed. Requests by mail remain the most
prevalent method for requesting medical records, used at least very
often by 42 of the 51 DDSs surveyed. All use fax to some extent, with
slightly more (27) reporting they use fax at least often and 24
reporting using fax sometimes.
During our site visits, 6 of the 28 DDS examiners we interviewed told
us that some providers raise concerns about privacy or compliance with
HIPAA, for example, by insisting on a hard copy of the claimant's
signed authorization to release medical records. According to SSA, hard-
copy, fax, or electronically transmitted versions of its official
authorization form, signed and dated by the claimant, all comply with
relevant state and federal laws and regulations, including HIPAA.
Once records are received, the DDS may need further contact with
providers to clarify ambiguities or request additional information. SSA
guidance require examiners to recontact a provider whose medical report
contains ambiguities, conflicts either internally or with other
evidence, is incomplete, or is not based on medically acceptable
clinical and laboratory diagnostic techniques. In addition, SSA
guidance directs the DDS's examiners to recontact a treating provider
if the report contains an opinion on an issue reserved for SSA, such as
whether the claimant is disabled or has a condition that meets one of
the medical listings, without identifying the basis for that opinion.
[Footnote 28]
If the initial recontact SSA requires is not successful, DDSs report
pursuing additional approaches to encourage providers to submit or
clarify records. These include making additional follow-up calls to
providers, their assistants, or medical records staff and asking
claimants to get in touch with their providers about sending in the
records. In addition, DDSs conduct outreach to emphasize the importance
of submitting medical records and contact providers to resolve
questions about privacy. Privacy of medical records came up frequently
in our discussions of the medical evidence collection process: DDS
officials in each of the five states we visited indicated that some
providers relay concerns about patient privacy and compliance with
applicable protections.
DDS professional relations officers also supplement the examiners'
contacts via provider education and outreach to medical societies. If
information in the medical records requires clarification, DDS medical
consultants, such as physicians or psychologists, also may contact
providers directly.[Footnote 29] SSA guidance permits DDSs to obtain
verbal statements from treating providers, then send summaries of those
statements to the providers for their signatures to expedite the DDS
determination process.
In addition to following up with providers and claimants, more than
half of the 51 DDSs we surveyed reported modifying their payment
methods for medical records.[Footnote 30] To encourage provider
response, 34 of the 51 DDS directors surveyed reported taking steps to
improve the timeliness of their payments and 6 reported increasing
their payment amounts. While only 30 DDS directors reported in our
survey that their payment rates were high enough to ensure adequate
medical records collection, some DDS directors commented that they had
heard from some types of providers that their rates were not adequate;
psychologists or other specialty providers, for example, reported that
payments were adequate for some types of providers but not others.
Asked in the survey how their payment rates compare with prevailing
rates for medical records in their states, 3 of the 51 DDSs reported
that their payment rates were above prevailing rates in their states,
19 reported that the rates were about the same, and 20 reported that
their payment rates were below prevailing rates.[Footnote 31] Vermont's
DDS instituted an incentive payment for prompt response because that
state prohibits providers from charging for providing copies of health
care records requested to support a claim or appeal under any provision
of the Social Security Act or any other federal or state needs-based
program.
SSA Conducts Quality Assurance Reviews, but Does Not Gather Some Key
Data on Varied DDS Approaches to Collecting Medical Records:
While SSA conducts quality assurance reviews and collects data on
program operations from DDSs, it has not systematically evaluated the
effectiveness of the DDSs' varied approaches to collecting medical
records. SSA regularly reviews DDSs' compliance with requirements for
medical records collection as part of its quality assurance review of a
sample of more than 30,000 DDS decisions each year.
These reviews take place before the DDS determination is communicated
to the claimant, and SSA returns the claim to the DDS for additional
work if SSA reviewers find that additional medical evidence or analysis
is needed.[Footnote 32] These reviews assess both the accuracy of the
DDSs' determinations and the sufficiency of the documentation the DDSs
obtained. Decisional deficiencies occur when the DDS should have made a
different determination, and documentation deficiencies occur when
additional documentation is necessary in order to make the correct
determination. Errors related to the collection of medical evidence
include cases in which insufficient medical evidence was obtained to
support the DDS determination, for example, to establish that the
claimant's impairment is severe or expected to last at least 12 months
or result in death.
SSA also requires DDSs to routinely report substantial budget, program
operations, and management data to SSA. While these data help SSA
oversee the DDSs, they may lack some key measures that SSA could use to
evaluate the effectiveness of different DDSs' medical records
collection practices. For example, not all DDSs' computer systems
routinely track the total number of requests they send and the
timeliness of provider responses. Of the 51 DDS directors we surveyed,
14 did not provide complete responses on the number of medical record
requests they sent and received responses to, and others were able to
provide only estimates. The lack of consistent data on receipts of
medical records from providers limits SSA's ability to evaluate the
effectiveness of different DDSs' medical records collection activities-
-evaluations which could lead to wider adoption of practices that are
found to be successful and cost effective.[Footnote 33] Nationally
consistent data could help SSA assess whether some DDSs' approaches are
more effective than others or whether adoption of new approaches, such
as incentive payments for prompt provider response, yields faster
submission of records.
DDSs Face Challenges Recruiting and Retaining Qualified Consultative
Exam Providers:
Recruiting and retaining enough medical providers to conduct
consultative exams was frequently cited by DDS representatives as one
of the main challenges to medical evidence collection, in part because
of provider concerns about missed appointments or DDS payment rates for
consultative exams. Responses to these challenges include scheduling
consultative exams with medical providers whose practices focus
primarily on performing disability evaluations and adjusting payments,
for example, by paying providers for the time they spend preparing for
a consultative exam that a claimant fails to attend.
Recruitment and Retention of Consultative Exam Providers Is Difficult:
We frequently heard from DDS directors, both during our site visits and
in response to our survey, about their difficulty finding medical
providers to conduct consultative exams. It is even difficult for DDSs
to obtain consultative exams from claimants' treating physicians--the
preferred source for consultative exams according to SSA guidance and
regulations.[Footnote 34] For example, 41 of the 51 DDS directors we
surveyed reported that their offices routinely ask claimants' treating
providers if they are willing to perform a consultative exam if needed,
but 34 of these directors reported that claimants' treating providers
are never or almost never willing to perform these exams. According to
DDS officials and providers, reasons for this reluctance may include
concern about disrupting the doctor-patient relationship through
involvement in the disability claim and dissatisfaction with DDS
payment rates. These inquiries often are included in the requests for
medical records sent by the DDSs to claimants' treating providers. For
example, in our review of 100 claim files for initial disability
determinations, 45 files contained one or more requests for medical
records that included an inquiry about the providers' willingness to
perform a consultative exam. However, only 2 claimants' files had
records of consultative exams conducted by the treating provider. In
many cases, DDSs make this request in the form of a yes or no question
that accompanies their requests for medical records or by asking
providers to contact them if they would be interested in performing a
consultative exam. Often providers either indicate they are not willing
to perform a consultative exam or leave the question blank. In some
cases, the requests for records indicate that the absence of a response
will be interpreted as an indication that they are not interested.
One reason why the DDSs may face difficulty recruiting and retaining
consultative exam providers is the frequency with which disability
claimants miss their consultative exam appointments. DDS directors
reported in our survey that claimants fail to attend approximately 16
percent of consultative exam appointments on average, with 40 of the 51
directors providing this information. When asked the reason why
claimants fail to attend these appointments, DDS directors reported
that claimants sometimes miss appointments for reasons including
transportation challenges, unmet needs for someone to accompany the
claimant to the appointment, reluctance to take part in the exam, or
inability to attend due to a mental or physical health condition.
Regardless of the reason for claimants' failure to attend scheduled
exams, several DDS examiners we spoke with identified missed
consultative exams as a major problem which may affect providers'
willingness to participate. If a claimant misses an appointment,
providers lose revenue if they are unable to substitute another patient
and cannot bill the DDSs for the missed exam. When asked to what extent
provider concerns about missed consultative exam appointments posed
challenges, almost half of DDS directors (24 of 51) reported that such
concerns posed challenges to a great or very great extent, although
some DDSs (20) reimburse providers for time spent preparing for missed
consultative exams.
Current payment rates also may contribute to the DDSs' challenges
recruiting and retaining consultative exam providers who submit high-
quality reports. Almost all DDS directors (50 of 51) reported that DDS
fee schedules posed a challenge, at least to some extent, to recruiting
and retaining a panel of highly qualified consultative exam providers.
Several DDS officials told us current consultative exam payment rates
affect their ability to recruit and retain consultative exam providers
in their states. For example, California DDS officials commented that
current consultative exam payment rates are below prevailing payment
rates in the state. Wyoming DDS officials also told us that payment
rates pose challenges to the recruitment of providers for Wyoming's
consultative exam provider pool.
Consultative exam payment varies among DDSs nationwide. SSA regulations
require that payments to providers for consultative exams not exceed
the highest rate paid by federal or other agencies in the state for the
same or similar services. Within those parameters, DDSs vary in the
type of payment rates they use as benchmarks for consultative exams.
(See figure 4.)
Figure 4: Sources of DDS Consultative Exam Payment Schedules:
[Refer to PDF for image]
This figure is a horizontal bar graph depicting the following data:
Sources of DDS Consultative Exam Payment Schedules:
Medicare rates: 24 DDSs;
Medicaid rates: 8 DDSs;
Schedule used by other state agencies: 16 DDSs;
Not based on other state or federal schedules: 2 DDSs;
Usual and customary rates in state: 2 DDSs;
Other: 8 DDSs.
Note: Five of the responding DDSs reported that their consultative exam
fee schedules were based generally on more than one of these sources.
[End of figure]
Many DDS directors (17 of 51) also indicated that in their opinion
current payment amounts in their states are not high enough to ensure
that the DDS receives timely, high-quality consultative exam reports.
For those DDSs, seven also reported that consultative exam reports only
sometimes demonstrated sufficient familiarity with the claimants'
medical records and history to support the assessment.
Some DDSs Rely on High-Volume Consultative Exam Providers or Pay
Providers for Preparing for Missed Appointments:
Some DDSs have adopted responses to the challenge of recruiting and
retaining consultative exam providers by (1) relying on high-volume
providers whose practices focus primarily on performing disability
evaluations and (2) adjusting consultative exam payments. As shown in
figure 5, most DDSs (32 of 51) report they often use high-volume
providers to conduct consultative exams for claimants in their state.
Twenty-nine indicated that using these providers has a moderately
positive or very positive effect on the quality of the consultative
exam reports they receive.
Figure 5: States Reporting Frequent Use of High-Volume Consultative
Exam Providers:
[Refer to PDF for image]
This figure is a map of the United States depicting States Reporting
Frequent Use of High-Volume Consultative Exam Providers. Two categories
are indicated:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Alabama:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Alaska:
No report.
Arizona:
No report.
Arkansas:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
California:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Colorado:
Often use high-volume consultative exam providers.
Connecticut:
Often use high-volume consultative exam providers.
Delaware:
No report.
District of Columbia:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Florida:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Georgia:
Often use high-volume consultative exam providers.
Hawaii:
No report.
Idaho:
No report.
Illinois:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Indiana:
Often use high-volume consultative exam providers.
Iowa:
No report.
Kansas:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Kentucky:
Often use high-volume consultative exam providers.
Louisiana:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Maine:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Maryland:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Massachusetts:
No report.
Michigan:
Often use high-volume consultative exam providers.
Minnesota:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Mississippi:
No report.
Missouri:
No report.
Montana:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Nebraska:
No report.
Nevada:
Often use high-volume consultative exam providers.
New Hampshire:
No report.
New Jersey:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
New Mexico:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
New York:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
North Carolina:
Often use high-volume consultative exam providers.
North Dakota:
No report.
Ohio:
No report.
Oklahoma:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Oregon:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Pennsylvania:
No report.
Rhode Island:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
South Carolina:
No report.
South Dakota:
No report.
Tennessee:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Texas:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Utah:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Vermont:
No report.
Virginia:
Often use high-volume consultative exam providers; and;
Often use high-volume providers and indicate positive effect on
quality.
Washington:
Often use high-volume consultative exam providers.
West Virginia:
Often use high-volume consultative exam providers.
Wisconsin:
No report.
Wyoming:
No report.
Source: GAO survey of DDS directors.
[End of figure]
At least one DDS has taken the concept of high-volume consultative exam
providers one step further. The New York DDS expanded its use of high-
volume consultative exam providers by hiring contractors to recruit
consultative exam providers and manage claimants' appointments. New
York DDS officials reported that the majority of consultative
examinations now are conducted through these contractors in areas of
the state covered by contracts. As described to us by New York DDS
officials, these contracts provide for extensive training of new
consultative exam providers that can last several months, content and
timeliness requirements for exam reports, and quality assurance
including surveys of claimants and inspection of providers' facilities.
Some DDSs have adjusted their payments for consultative exams to
address recruitment challenges in their states. For example, Wyoming
currently pays usual and customary rates that providers receive for
similar exams throughout the state. Wyoming DDS officials reported that
they make use of such a structure due to the sparse population and
small number of medical providers that service their state,
approximately 1,000. According to Wyoming DDS officials, a relatively
small portion of these providers are willing to perform consultative
exams for the DDS and they believe that without usual and customary
payment, even fewer providers would be willing to conduct them. In
addition, many DDSs (20 of 51) pay consultative exam providers for the
time they spend preparing for exams that claimants fail to attend,
which may help DDSs retain their consultative exam provider pool. Among
those 20 DDSs reporting that they offer such payments, the average
payment provided was about $44.
Finally, DDSs engage in various activities to facilitate claimant
attendance at consultative exams. The most common activities reported
are reminder letters and telephone calls and reimbursement for travel
costs (see table 3). Examiners at two of the DDSs we visited described
arranging for consultative exam providers to perform in-home
evaluations for claimants whose impairments kept them confined to their
homes. Examiners noted that "third parties"--family members or social
workers listed as contacts on the application for benefits--may help
facilitate consultative exam appointments, especially for claimants who
are homeless or who have mental or developmental impairments.
Table 3: DDS Activities to Facilitate Claimant Attendance at
Consultative Exams, Fiscal Year 2007:
DDS activity: Send reminder letter;
Frequency: Always or almost always: 48;
Frequency: Very often: 2;
Frequency: Often: 0;
Frequency: Sometimes: 1;
Frequency: Never or almost never: 0;
No answer: 0.
DDS activity: Place one reminder call;
Frequency: Always or almost always: 16;
Frequency: Very often: 14;
Frequency: Often: 11;
Frequency: Sometimes: 8;
Frequency: Never or almost never: 2;
No answer: 0.
DDS activity: Place multiple reminder calls;
Frequency: Always or almost always: 0;
Frequency: Very often: 2;
Frequency: Often: 5;
Frequency: Sometimes: 25;
Frequency: Never or almost never: 19;
No answer: 0.
DDS activity: Reimburse private transportation costs;
Frequency: Always or almost always: 14;
Frequency: Very often: 10;
Frequency: Often: 9;
Frequency: Sometimes: 10;
Frequency: Never or almost never: 6;
No answer: 2.
DDS activity: Reimburse public transportation costs;
Frequency: Always or almost always: 15;
Frequency: Very often: 3;
Frequency: Often: 4;
Frequency: Sometimes: 7;
Frequency: Never or almost never: 21;
No answer: 1.
DDS activity: Arrange for taxi or van service;
Frequency: Always or almost always: 4;
Frequency: Very often: 8;
Frequency: Often: 5;
Frequency: Sometimes: 13;
Frequency: Never or almost never: 20;
No answer: 1.
DDS activity: Reimburse for taxi or van service;
Frequency: Always or almost always: 10;
Frequency: Very often: 2;
Frequency: Often: 2;
Frequency: Sometimes: 15;
Frequency: Never or almost never: 20;
No answer: 2.
DDS activity: Provide sign or foreign language interpreters;
Frequency: Always or almost always: 18;
Frequency: Very often: 5;
Frequency: Often: 7;
Frequency: Sometimes: 21;
Frequency: Never or almost never: 0;
No answer: 0.
DDS activity: Coordinate with third parties, such as family members or
social workers;
Frequency: Always or almost always: 9;
Frequency: Very often: 14;
Frequency: Often: 16;
Frequency: Sometimes: 11;
Frequency: Never or almost never: 1;
No answer: 0.
Source: GAO survey of DDS directors.
[End of table]
SSA Reviews Consultative Exams and DDS Decisions, but Does Not Evaluate
DDS Practices to Address Recruitment and Retention Challenges:
While SSA evaluates consultative exams as part of its quality assurance
review process and collects data on spending for consultative exams, it
has not evaluated the effectiveness of varied DDS responses to
challenges related to recruiting and retaining consultative exam
providers. SSA reviews consultative exams as part of its ongoing
quality assurance reviews of more than 30,000 randomly sampled initial
disability determinations. SSA reviewers assess the claim file for
errors including unnecessary consultative exams; consultative exam from
an improper source (such as failure to use a psychiatrist or
psychologist to evaluate a mental disorder); or incomplete, inadequate,
or unsigned consultative exam reports.
Despite these overall quality reviews, SSA officials indicated they
were unable to locate any studies SSA has conducted to evaluate the
effectiveness of varied DDS collection practices. By undertaking such
studies, SSA program managers could identify promising DDS practices to
recruit and retain consultative exam providers or evaluate their
effectiveness and potential for wider adoption and thereby improve
accountability by facilitating wider adoption of DDS practices with the
potential to help the agency achieve its service delivery goals, such
as making the correct decision early in the process. SSA currently does
not collect some information, such as nationally comparable data on
missed consultative exams, that could help SSA evaluate DDS practices
that may hold promise for improved recruitment and retention of
consultative exam providers in other states.
SSA Has Made Progress in Moving to Electronic Collection of Medical
Records, but Faces Challenges Shifting to the Use of Electronic Medical
Records:
SSA's transition from paper medical records to the use of electronic
images of medical records has increased opportunities for program
efficiencies and agency collaboration. SSA prefers and encourages
providers to submit medical records online, but it continues to receive
a little more than half of these records in paper form. SSA has only
conducted limited studies of the problems related to electronic
submission of medical records and has not taken additional steps
necessary to facilitate greater use of online submission options. In
anticipation of the medical community's replacement of paper with
uniform electronic medical records, SSA is developing procedures to
electronically request and receive electronic medical records and
analyze them in ways that are expected to make the medical evidence
collection process and disability decision making more efficient.
Use of Electronic Images Enables SSA and DDSs to Collaborate More
Efficiently:
As a step toward automating its disability process, SSA has
successfully adopted the use of electronic images of medical records
instead of paper copies for new claimants. Electronic images of medical
records--records scanned, faxed, or uploaded into SSA's computer
database--are an important step in SSA's transition to an automated
process, as these images can be submitted, stored, and accessed
electronically by authorized staff from distant locations. Electronic
medical evidence--even in the form of electronic images--facilitates
collaboration between SSA and DDSs. For example, electronic files have
enabled SSA to implement a new process for resolving disagreements
concerning DDS disability decisions reviewed by SSA before initial
decisions are finalized. Rather than having SSA reviewers in each
regional office review DDS decisions only in that region, electronic
access to records enables staff in other regions and policy staff in
SSA headquarters to review cases remotely. SSA introduced this process
to promote more nationally consistent interpretations of SSA policy.
Additionally, SSA and DDSs are able to shift workloads from office to
office without mailing records, which takes time and increases the risk
that records will be lost. However, SSA officials and DDS directors
told us electronic image records have limitations in that they cannot
be electronically analyzed and searched.
Almost all surveyed DDS directors (50 of 51) reported that having
medical records in electronic folders has increased productivity, but
some indicated that frustrations exist, such as some computer system
usage problems. For example, several DDS examiners told us they were
frustrated by occasional data system interruptions, due in part to
performance problems with SSA's computer system. The SSA system manages
large amounts of data across multiple SSA and DDS computer systems.
Over half of DDS directors (27 of 51) reported that one of the
challenges to medical evidence collection was performance problems with
SSA's integrated computer system, and most (38 of 51) reported that
improvement in the stability or responsiveness of the system would add
a great or moderate value to the DDSs' medical evidence collection
efforts.[Footnote 35]
SSA Has Made Progress in Developing Options for Submitting Records
Electronically, but More than Half Are Still Submitted on Paper:
One of SSA's goals is to receive all medical records electronically.
[Footnote 36] SSA maintains several avenues for providers to submit
medical evidence online, and nearly all DDS directors (48 of 51)
reported that DDS outreach to providers very often addressed options
for electronic submission.[Footnote 37] Some providers, however, have
told DDS officials they find SSA's online submission options
inconvenient, difficult to use, or beyond their technical expertise.
For example, many providers do not use SSA's Electronic Record Express
Web site to submit records, although it was designed to provide an
efficient option for submitting medical records. This Web site limits
the number of files that can be sent at one time, which is problematic
for large providers such as big hospitals or medical centers.
Additionally, infrequent users must call a designated DDS official to
reset expired passwords if too much time has passed between
submissions.[Footnote 38] SSA officials told us some providers opt to
pay a commercial service to submit medical records, because the service
provides for the submission of many files at once, which can be a more
efficient option for providers of large volumes of medical records.
[Footnote 39] SSA has recently deployed its own tool for submission of
many files at once, called Webservices, but to use this option, medical
providers must develop their own software interface to SSA's Web site.
Although SSA provides some technical support, some providers may still
find this option beyond their technical expertise. As of November 2008,
only two medical record providers were using Webservices. SSA officials
noted that additional providers have expressed interest in using
WebServices but the agency temporarily limited its use to these two
because of limits on the system's capacity that it intends to resolve
after a planned upgrade.[Footnote 40]
DDS professional relations officers at a 2007 conference of the
National Association of Disability Examiners noted various difficulties
they face encouraging providers to use SSA's Web site for submitting
evidence online. In order to use online options for submitting medical
records to SSA, some providers with electronic medical record systems
may either need to convert files or print and scan them. In some cases,
providers may find this too time consuming to be feasible. Although
some providers have registered as Web site users, the difficulties
encountered were enough to make them stop using it. A DDS professional
relations officer said that they were getting so many calls from
providers having problems with the Web site that they had to designate
someone to handle the calls. On the other hand, the Mississippi DDS had
early success encouraging providers to use the Web site by contracting
with a former SSA official who provided detailed "start to finish"
guidance on how to use the Web site.
SSA held conferences in two cities in March 2008 to give its Web site
users an opportunity to express their concerns, and made some
modifications to the Web site in July 2008, but SSA has conducted only
limited study of the problems with electronic submission of medical
records or analyzed the barriers various groups of providers face using
the site (such as small-and medium-volume users), and they have not
developed a strategy for overcoming these barriers. The agency has made
progress responding to some user concerns, for example, by enabling
claimants' representatives to view clients' folders online, but SSA has
not developed a strategy to address the concerns of other user groups.
SSA's efforts to realize its electronic submission goal also are
hindered by the uneven pace of the medical community's acceptance of
electronic records. Despite a presidential call for widespread adoption
of electronic health records by the year 2014, the Robert Wood Johnson
Foundation estimated that less than one-fifth of responding U.S.
physicians (17 percent) had at least basic electronic health records
and only about 4 percent had fully functional electronic records
systems.[Footnote 41]
Nationwide, in September 2008, SSA received 52 percent of records for
disability claims on paper, 21 percent through online submission, and
27 percent by fax.[Footnote 42] (See figure 6.) One large provider
accounts for most of the records SSA receives online. In September
2008, 57 percent of online submissions came from this large medical
record copy service. We found variation among the DDSs in the
percentages of records received online. In September 2008, 13 DDSs
received more than 25 percent of records online while another 11 DDSs
received less than 10 percent. DDSs varied in the percentage of records
received by electronic fax, with 10 DDSs receiving less than 15 percent
of records by fax, and 5 DDSs receiving more than 50 percent.[Footnote
43] Although providers have submitted an increasing share of records
via fax and online over the last few years, the growth in nationwide
use of online submission options has slowed in recent months.[Footnote
44]
Figure 6: SSA Still Receives About Half of Records on Paper:
[Refer to PDF for image]
This figure is a stacked vertical bar graph depicting the following
data:
Date: October 2006;
Paper: 71%;
Fax (electronic): 16%;
Online: 12%.
Date: October 2007;
Paper: 58%;
Fax (electronic): 26%;
Online: 16%.
Date: September 2008;
Paper: 52%;
Fax (electronic): 27%;
Online: 21%.
Source: GAO analysis of DDS data compiled by SSA.
[End of figure]
SSA Is Beginning to Transform Its Process with Computer-to-Computer
Requests and Receipts of Records in Uniform Formats:
While encouraging providers to submit medical records electronically
speeds the collection of medical evidence, SSA is participating in
preliminary tests of new computer processes that are expected to bring
substantial additional efficiencies. With these new procedures, SSA
computers request and receive electronic medical records directly from
providers' computers--records in uniform formats that SSA's computer
system can search and use to begin analysis of the claimant's
condition. The electronic images of medical records they currently use
are not as suited for analysis as are electronic medical records in
uniform formats. For example, currently, DDS examiners cannot
electronically search a record or file for particular diagnoses and
test results. Instead they must review all the medical records--
hundreds of pages of records in some cases--in order to find the
pertinent evidence. Most surveyed DDS directors (32 of 51) reported
that options for submitting medical evidence in these new formats would
be of great or very great value.[Footnote 45] In its strategic plan for
fiscal years 2008 to 2013, SSA established a goal to transform its
medical evidence collection process by automatically requesting and
receiving electronic medical records through a nationwide health
information network.[Footnote 46] This network is expected to enable
medical providers to securely exchange electronic medical records in
uniform formats. This will enable SSA to automatically search and
analyze the records at the start of the disability determination
process.[Footnote 47] Software will flag medical records that contain
references to diagnoses and tests specified in SSA's medical listings,
and thus help examiners promptly determine whether claimants have
impairments that qualify as disabilities.
To help encourage the use of these processes, SSA is working with other
agencies and health providers to develop electronic methods to request,
receive, and analyze electronic medical records. For example, SSA and a
Boston hospital have launched a prototype effort by which SSA
electronically queries the hospital's computer and retrieves the
hospital's electronic medical records for specific claimants.[Footnote
48] SSA plans to expand the Boston initiative to additional providers
in the future. However, industry standards and protocols need to be
further developed before this process can be replicated widely. For
example, standards have only recently been developed for the document
format used in the Boston initiative called the "continuity of care
document." This format is an electronic exchange standard for sharing
patient summary information. In addition, challenges remain in
electronic authorization procedures designed to protect the privacy of
patients' health records, as we have reported in previous reports and
testimonies.[Footnote 49]
Conclusions:
The collection of medical evidence in the disability determination
process poses many challenges. The DDSs are operating in a high-volume
environment and must balance reasonable efforts to obtain complete
medical information with the need for timely determinations. Medical
providers have constraints on their time and resources as well, and
typically focus on diagnosis and treatment rather than assessment of
functional ability. The difficulties some DDSs have in obtaining
requested medical records and ensuring that claimants attend
consultative exams suggest opportunities for continued improvement in
the medical evidence collection process. Some DDSs have independently
developed varied approaches to respond to these challenges; and all
DDSs might benefit from learning from one another and testing and
adopting some of these approaches, as appropriate. SSA, however,
currently lacks some important data necessary to evaluate these
approaches and identify promising practices, which might be shared to
promote more timely and complete collection of relevant medical
evidence by all DDSs.
Meanwhile, SSA efforts to improve the use of consultative examinations
and the collection of medical records proceed as the medical community
undertakes a major transformation from paper to computer records. With
a presidential goal of widespread adoption of electronic medical
records by 2014, increasing numbers of providers may have certified
electronic records systems capable of fulfilling DDS records requests
in electronic formats. As a high-volume user of these records, SSA has
incentives to keep pace with industry standards. As such, the prospect
of electronically requesting and receiving medical records being
explored by SSA and a Boston hospital, and in the development of the
nationwide health information network, among other projects, holds
promise for achieving even greater efficiencies in medical evidence
collection for disability cases in the long run. In the near term, SSA
has opportunities to realize greater efficiencies in the collection of
medical evidence by encouraging providers to submit records online,
saving both time and money by dispensing with inefficient copying and
scanning. SSA has taken measures to improve its online submission
options, but some providers continue to face difficulties using them
and utilization remains limited. Reasons for this are unknown, even to
SSA. An evaluation that studies the utilization of SSA's online
submission options, identifies barriers to wider usage, and develops
strategies to address these barriers, may help SSA identify cost-
effective ways to encourage wider use of online submission methods,
especially as more providers begin to use electronic medical records.
Recommendations for Executive Action:
To foster timely and effective collection of medical evidence for
disability determinations, we recommend that the Commissioner of SSA
identify DDS medical evidence collection practices that may be
promising, evaluate their effectiveness, and encourage other DDSs to
adopt effective practices where appropriate. As a part of these
evaluations, the Commissioner should work with the DDSs to find cost-
effective ways to gather consistent data on the effectiveness of DDS
medical evidence collection activities. Such data should include key
indicators, such as the proportion of requests that yield medical
records, the timeliness of medical record receipts, and how frequently
claimants fail to attend consultative exams.
To achieve a more timely and efficient collection of medical records by
encouraging medical evidence providers to submit records
electronically, until the nationwide health information network is in
operation, we recommend that the Commissioner of SSA conduct an
evaluation of the limited utilization of its online submission options.
This evaluation should include an analysis of the needs of small,
medium, and large providers; identify any barriers to expanded use; and
develop strategies to address these barriers.
Agency Comments:
We provided a draft of this report to officials at SSA for their review
and comment. In its comments, SSA agreed with our findings and
recommendations. Specifically, SSA noted the need for consistent
nationwide data but indicated that this is complicated by fact that
each DDS uses one of 5 separate case processing systems. To address
this limitation, SSA plans to include consistent management data in its
common disability case processing system, currently in the planning
stage with implementation to begin in 2011. The agency also described
current and planned activities to identify and address barriers to
electronic submission of data. SSA's comments are reproduced in
appendix IV.
We are sending copies of this report to the Commissioner of SSA and
others who are interested. The report is also available at no charge on
GAO's Web site at [hyperlink, http://www.gao.gov].
Please contact me on (202) 512-7215 if you or your staffs have any
questions about this report. Other major contributors to this report
are listed in appendix V.
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Scope and Methodology:
To determine how Disability Determination Services (DDS) and the Social
Security Administration (SSA) collect medical evidence, we used four
primary sources of information: (1) a survey of the 51 DDSs including
all 50 states and the District of Columbia; (2) in-depth interviews and
site visits with 5 states; (3) a review of 100 randomly selected
initial claims files and 50 claim files at the appeals level; and (4)
analysis of SSA data concerning disability determinations. To assess
progress in moving from paper to electronic collection of medical
evidence, we reviewed SSA documents concerning SSA and the health
industry's efforts and analyzed data compiled by SSA's computer system
regarding receipts of evidence and discussed efforts to encourage
electronic submission with SSA and DDS officials, as well as several
medical providers.
GAO Survey of DDS Directors on Collection of Medical Evidence for
Initial DDS Disability Decisions:
Our survey of DDSs addressed the timeliness of provider responses to
DDS requests for medical records, practices and challenges associated
with collecting medical records, practices and challenges associated
with obtaining consultative exams, outreach to the medical provider
community, and SSA and DDS initiatives associated with medical evidence
collection. We pretested the complete survey questionnaire at four of
the five DDSs we visited during our site visits and tested selected
questions during our fifth DDS site visit. We revised our questionnaire
following these pretests, incorporating suggestions and feedback from
DDS and SSA regional office officials who reviewed the draft
questionnaire during these pretests. In May 2008, we sent confidential
access information to each of the 51 DDS directors in the 50 states and
the District of Columbia. We received a response from all 51 of these
directors, for a 100 percent response rate.
We analyzed the survey responses and present selected results in our
report. In a few instances, we include results only from DDSs that
submitted complete responses and computed national totals from DDS-
supplied information. For example, we limited our analysis of DDS
responses to questions about receipt of requested medical records to
the 37 DDSs that provided the numbers of requested records received
within 10 days, 11 to 20 days, 21 to 30 days, more than 30 days, and
the number not received. Several DDSs responded to some, but not all of
these questions, and other DDSs did not respond to any of these
questions. Some of the DDSs estimated their responses while others
indicated they were able to compute the information about medical
record requests and receipts from their database. One DDS director
indicated that the number of records not received included provider
responses indicating that the requested records were not available.
Another indicated that the number the DDS provided for records not
received included instances in which the DDS received records for which
no payment was due. Checking with DDS directors in our site visit
states, we determined that some of these DDSs used these same
approaches, but others did not. In addition, we enforced skip patterns
that were published in the survey.
State DDS Site Visits:
We visited DDS in five states--California, Mississippi, New York,
Vermont, and Wyoming--to gain a more detailed understanding of the
medical evidence collection process, related challenges, and the
availability of relevant data. At each of the DDSs we visited, we
typically met with the DDS Director, Professional or Medical Relations
Officer, and the Information Technology Specialist(s). SSA regional
office representatives joined us for some meetings as well. We also met
individually with several experienced claims examiners selected by the
DDS directors in each state. In addition to describing their collection
practices and challenges, DDS officials provided valuable feedback on
the content and organization of our questionnaire on medical evidence
collection in advance of its release to DDS directors in all 50 states
and the District of Columbia. In California and New York, we visited
two of those states' multiple DDS branch offices: Sacramento and
Oakland, California; and Albany and Manhattan, New York. During each of
these branch office visits we also spoke with experienced claims
examiners. The information we obtained from each DDS we visited
provided useful context to DDS operations and detailed examples of DDS
responses to challenges, but information from these site visits is not
intended to describe the operations of all DDSs.
We consulted a variety of factors in determining which DDSs to visit
including geographic diversity, size, type of administrative computer
processing system used, and SSA-provided performance data. These
performance data included productivity, accuracy, percentage of claims
with at least one invoiced medical record, percentage of all medical
records received electronically, and percentage of claims with at least
one consultative exam. We selected DDSs with both high and low
indicators on these measures to illustrate examples of states with a
variety of different medical evidence collection practices. The
information we obtained at our site visits is illustrative and not
intended to reflect the experiences of DDSs in other states. Table 4
presents some of the indicators we consulted in selecting the five DDSs
to visit.
Table 4: Selected SSA Data for Five DDSs:
DDS: California;
Filing rate[A]: 7.0;
Allowance rate[B]: 40.7%;
Productivity[C]: 249.9;
Accuracy[D]: 92.3%;
Invoiced medical record rate[E]: 64.5%;
Electronic receipt of medical records[F]: 28.3%;
Consultative examination rate[G]: 46.1%.
DDS: Mississippi;
Filing rate[A]: 15.0;
Allowance rate[B]: 23.4%;
Productivity[C]: 277.0;
Accuracy[D]: 93.0%;
Invoiced medical record rate[E]: 70.5%;
Electronic receipt of medical records[F]: 88.2%;
Consultative examination rate[G]: 44.2%.
DDS: New York;
Filing rate[A]: 8.2;
Allowance rate[B]: 41.5%;
Productivity[C]: 199.6;
Accuracy[D]: 93.5%;
Invoiced medical record rate[E]: 81.3%;
Electronic receipt of medical records[F]: N/A;
Consultative examination rate[G]: 62.6%.
DDS: Vermont;
Filing rate[A]: 6.8;
Allowance rate[B]: 51.0%;
Productivity[C]: 185.9;
Accuracy[D]: 96.3%;
Invoiced medical record rate[E]: 93.9%[H];
Electronic receipt of medical records[F]: 26.4%;
Consultative examination rate[G]: 25.3%.
DDS: Wyoming;
Filing rate[A]: 5.5;
Allowance rate[B]: 44.3%;
Productivity[C]: 253.4;
Accuracy[D]: 94.5%;
Invoiced medical record rate[E]: 87.8%;
Electronic receipt of medical records[F]: 27.6%;
Consultative examination rate[G]: 42.8%.
DDS: United States;
Filing rate[A]: N/A;
Allowance rate[B]: 34.6%;
Productivity[C]: 248.9;
Accuracy[D]: 93.6%;
Invoiced medical record rate[E]: 78.9%;
Electronic receipt of medical records[F]: 41.7%;
Consultative examination rate[G]: 41.4%.
Source: SSA and SSA compilations of DDS data.
[A] The filing rate is the number for fiscal year 2005 of initial
claims for Supplemental Security Income (SSI) or SSDI filed divided by
state resident population.
[B] The allowance rate for initial claims in fiscal year 2007 is the
number of initial claims in which the DDS made a determination of
disability divided by the total number of decisions on initial claims.
[C] Productivity is an SSA-generated measure for fiscal year 2007 of
DDS performance, obtained by dividing the total number of cases cleared
by the number of full-time-equivalent work years by employees at each
DDS.
[D] Accuracy rate is an SSA-generated measure for initial claims in the
fiscal year 2005-2007 period of how each DDS performs derived from
SSA's ongoing quality assurance reviews.
[E] The invoiced medical record rate is a DDS-reported rate for initial
claims in fiscal year 2007 calculated by dividing the number of claims
for which the DDS has obtained at least one medical record for which it
received (or expected) an invoice by the total number of claims cleared
by the DDS during the year.
[F] Electronic receipt of medical records is a DDS-reported rate for
September 2007 calculated by dividing the number of records received
through electronic means--including by fax and online methods, such as
via SSA's Web site--by the total number of medical records received by
that DDS.
[G] Consultative examination rate is a DDS-reported rate for initial
claims in fiscal year 2007 calculated by dividing the number of claims
with at least one consultative exam by the total number of claims
cleared by that DDS during the year. A higher rank indicates a greater
percentage of claims with at least one consultative exam.
[H] Because Vermont state law prohibits providers (or other custodians
of medical records) from charging for health care records requested to
support a claim or an appeal under any provision of the Social Security
Act, none of the medical records the DDS receives are expected to
include an invoice for providing records, but the Vermont DDS provides
an "expedite" fee for records received sent within 16 days.
[End of table]
Reviews of Random Samples of Claimants' Folders:
To obtain more detailed information about the medical evidence
collection process, we reviewed two sets of randomly selected, but not
projectable, samples of case files: (1) 100 initial disability claims
files--electronic folders containing documentation of the disability
determination for individual disability claimants and (2) 50 folders
for claims decided at the administrative law judge level (ALJ) or
appeal. For results from these reviews, see appendixes II and III.
To select these 100 initial disability claims folders, we reviewed all
DDS decisions during fiscal year 2007 for Supplemental Security Income
(SSI) and Disability Insurance (DI) disability benefits and excluded
reconsiderations, continuing disability reviews, reopenings, and
informal remands. For administrative purposes, we also excluded records
that SSA maintained using paper records, rather than certified
electronic folders. In order to avoid overrepresentation of claimants
who filed for both SSI and DI simultaneously (30 percent of DDS initial
decisions in fiscal year 2007), we eliminated duplicate listings of
these claimants in our data set. We then randomly selected 100 cases
from among the approximately 2.3 million cases in the selected data
set.
These folders contained copies of SSA and DDS forms used in the
development of the case including documentation for both DI and SSI
claims. These documents often included medical evidence received from
physicians and other providers, claimant and third-party assessments of
the claimant's functional abilities, reports from providers of
consultative exams of the claimant, forms providing evaluations of the
evidence by DDS medical consultants, DDS forms for obtaining medical
source statements from providers, forms and letters used to request
medical and nonmedical evidence, evidence submitted by the claimant or
his or her authorized representatives, and documents related to the
disability determination such as SSA form 831, and Personal Decision
Notices and similar notices for denied claims.
Similarly, to select a sample of cases decided by SSA ALJ hearings
offices, we obtained from SSA an extract of SSA's Case Processing and
Management System data set managed by SSA's Office of Disability
Adjudication and Review. We selected records for decisions by the ALJ
hearing offices during the first 6 months of fiscal year 2008
concerning initial claims for SSI and DI disability benefits that had
been denied at the DDS initial level.[Footnote 50] Some had been
appealed to the DDS (a "reconsideration") or to the federal reviewing
official, while others were appealed directly to the SSA ALJ hearing
office. We also excluded records for which SSA had paper records,
rather than certified electronic folders.[Footnote 51] We randomly
selected 50 of these records. SSA staff prepared a CD for each case
folder. These electronic folders provided documents compiled by SSA and
the DDS during the initial determination, as well as additional
documents compiled subsequently, including those obtained during
reconsideration of the initial decision by the DDS, documents provided
by authorized representatives of the claimant, copies of medical
evidence concerning treatment and examinations after the initial
determination, medical source statements, an interrogatory, a
deposition, and ALJ decision documents.
Analysis of SSA Data:
To obtain more detailed data concerning DDS collection practices and to
examine variations among DDSs, we obtained from SSA and analyzed a
variety of computerized data. These included data for:
* initial and reconsideration filings received, decided, and pending at
year end;
* filings approved and denied;
* filings for which one or more medical evidence of record was
purchased;
* filings for which one or more consultative exam was requested;
* expenditures for purchase of medical records and consultative exams;
* errors in DDS initial determinations identified by SSA quality
assurance reviewers;
* the results of evaluations of medical records collected and
consultative exam reports by SSA quality assurance reviewers; and:
* responses to medical records obtained via methods, including paper
and faxed submissions, and online submission options such as SSA's
Electronic Records Express Web site.
We used these data to summarize and compare how DDSs display these data
graphically. We also used these data to provide additional information
concerning the initial claim case files described above. To conduct
limited tests of the reliability of these data we obtained copies of
831 data and Case Processing Management System data from SSA and
compared results provided by SSA with results from our analysis of
these data sources.
[End of section]
Appendix II: Selected Results from Analysis of 100 Randomly Selected
Initial Disability Cases:
The following tables provide selected findings from our review of 100
randomly selected cases for claimants with initial DDS determinations
in fiscal year 2007.[Footnote 52]
Table 5: Characteristics of Medical Evidence Collection in 100 Cases of
Initial DDS Disability Determinations, Fiscal Year 2007:
Characteristic of evidence collection process: Number of claimants[A];
Approvals: 35;
Denials: 65;
Total cases: 100.
Characteristic of evidence collection process: How SSA received the
claim: Face-to-face interview;
Approvals: 20;
Denials: 23;
Total cases: 43.
Characteristic of evidence collection process: How SSA received the
claim: Telephone;
Approvals: 9;
Denials: 27;
Total cases: 36.
Characteristic of evidence collection process: How SSA received the
claim: No direct contact with the claimant (for example, Internet claim
or parent interviewed without child claimant present);
Approvals: 6;
Denials: 15;
Total cases: 21.
Characteristic of evidence collection process: No medical records
received from any of the providers identified by the claimant;
Approvals: 0;
Denials: 3;
Total cases: 3.
Characteristic of evidence collection process: Claimant did not cite
any medical providers;
Approvals: 1;
Denials: 1;
Total cases: 2.
Characteristic of evidence collection process: One or more provider
asked for medical records indicated they had no records or no records
for the specified time period;
Approvals: 11;
Denials: 23;
Total cases: 34.
Characteristic of evidence collection process: Medical records sought
from providers that had not been identified by claimant when they
filed[B];
Approvals: 7;
Denials: 13;
Total cases: 20.
Characteristic of evidence collection process: One or more consultative
exam report;
Approvals: 20;
Denials: 37;
Total cases: 57.
Characteristic of evidence collection process: Consultative exam
provided by claimant's own physician or other treating source;
Approvals: 1;
Denials: 1;
Total cases: 2.
Characteristic of evidence collection process: One or more missed
consultative exam[C];
Approvals: 0;
Denials: 11;
Total cases: 11.
Characteristic of evidence collection process: Most common bases of
decision;
Approvals: Met criteria set by medical listing in SSA regulations (15);
Medical and vocational considerations (17);
Denials: Capacity for substantial gainful activity, either resuming
relevant past work or other work (43)[D];
Total cases: [Empty].
Characteristic of evidence collection process: Personal decision notice
(or similar notice) indicated that the DDS decision was based on one or
more reports from medical sources that had not provided medical
records[E];
Approvals: Not applicable[F];
Denials: 10;
Total cases: 10.
Source: GAO review of initial claims files.
[A] Concurrent filings for benefits under Title II and Title XVI are
treated here as a single case.
[B] Excludes medical evidence obtained from schools and excludes
evidence sought after initial decision.
[C] Claimant failed to appear for the exam.
[D] This includes specific SSA codes H1, H2, J1, J2, N1, N2, N31, N32,
N42, N43, N33. Other codes indicate capacity for SGA in other specific
circumstances.
[E] Personal decision notices or similar notices are sent to claimants
denied benefits to describe in understandable language the basis and
evidence for the decision.
[F] Personal decision notices (or similar notices describing the
evidence used in making the decision) are not required in approved
cases.
[End of table]
Table 6: Legibility of Records in 100 Cases of Initial DDS Disability
Determinations, Fiscal Year 2007:
Characteristics of medical records or consultative exam reports
collected: One or more medical records included handwritten evidence;
Total cases: 82.
Characteristics of medical records or consultative exam reports
collected: One or more medical records included illegible or barely
legible evidence;
Total cases: 68.
Characteristics of medical records or consultative exam reports
collected: One or more consultative exam reports included handwritten
evidence;
Total cases: 8.
Characteristics of medical records or consultative exam reports
collected: One or more consultative exam reports included illegible or
barely legible records;
Total cases: 1.
Source: GAO review of initial claims files.
[End of table]
Table 7: Characteristics of the Collection Process for Medical Records
from Claimants' Providers in 100 Cases of Initial DDS Disability
Determination, Fiscal Year 2007:
Characteristics of records collection process: Total number of
requests;
Number of requests in 100 cases: 332.
Characteristics of records collection process: Medical record provided;
Number of requests in 100 cases: 261.
Characteristics of records collection process: Requested record not
obtained by date of initial decision;
Number of requests in 100 cases: 71.
Characteristics of records collection process: Providers indicated for
example that they did not have a medical record for the claimant or did
not have a claimant record for the time period specified;
Number of requests in 100 cases: 43.
Characteristics of records collection process: No evidence of response
from provider[A];
Number of requests in 100 cases: 28.
Characteristics of records collection process: DDS request for medical
records included either a detailed or general request for a medical
source statement[B];
Number of requests in 100 cases: 68.
Characteristics of records collection process: One or more DDS request
for medical records included an inquiry about the provider's
willingness to perform a consultative exam if needed[C];
Number of requests in 100 cases: 45.
Source: GAO review of initial claims files.
[A] This includes one case in which the mailed request was returned as
undeliverable.
[B] In 22 cases, the copies of medical records requests in the folder
did not include such a request; in other cases, no copy of the request
sent to provider was available.
[C] In 42 cases, copies of the medical records requests did not include
such an inquiry; in other cases, no copy of a request was available.
[End of table]
Table 8: Time Periods for Receipt of Medical Records and Disability
Determinations in 100 Initial DDS Disability Decisions, Fiscal Year
2007:
Time period: From date medical records requested to date medical
records received;
Number of days: Minimum: 1;
Number of days: Median: 15;
Number of days: Average: 22;
Number of days: Maximum: 182.
Time period: From date appointment made for consultative exam to date
of exam[A];
Number of days: Minimum: 4;
Number of days: Median: 24;
Number of days: Average: 26;
Number of days: Maximum: 63.
Time period: From date of consultative exam to date consultative exam
report received;
Number of days: Minimum: 0;
Number of days: Median: 9;
Number of days: Average: 12;
Number of days: Maximum: 40.
Time period: From date of DDS receipt of claim to date DDS initial
decision[B];
Number of days: Minimum: 13;
Number of days: Median: 81;
Number of days: Average: 90;
Number of days: Maximum: 354.
Source: GAO review of initial claims files.
[A] These figures are calculated, for cases with two or more
consultative exams, using the longest time period between appointment
and exam.
[B] Based on date of receipt recorded on disability worksheet and date
of decision recorded on SSA form 831.
[End of table]
[End of section]
Appendix III: Medical Evidence Collection Process at the Administrative
Hearing Level:
The process for collecting medical evidence at the administrative
hearing level typically differs from the process at the DDS level. If
the claimant for disability benefits is dissatisfied with the DDS's
initial decision, he or she can appeal. In many cases the initial
appeal is a request for a reconsideration by the DDS. Then, if is the
claimant is not satisfied with the DDS decision, he or she can appeal
and request a hearing before an administrative law judge (ALJ), who
will review the case in light of the evidence gathered by the DDS as
well as additional evidence obtained.[Footnote 53] The responsibility
for providing evidence to support the appeal falls on the claimant. A
claimant may be represented by an attorney or other representative, to
collect the additional evidence on his or her behalf. If necessary
evidence is not provided, the ALJ must attempt to fully and fairly
develop the evidence. Most claimants who appeal to an SSA hearings
office are represented by attorneys or others who enter into agreements
with SSA providing payment to the representative, which may be from a
specified proportion of awarded retroactive disability benefits in
cases where claimants win their appeal.
SSA requires ALJs to conduct a prehearing review of all evidence and
determine whether additional development is needed. Claimants'
representatives may submit updated medical records. If the ALJ is
unable to obtain adequate evidence, the ALJ also can request
consultative exams or tests. Similarly, if additional evidence is
needed, the ALJ may have an independent medical expert review the file
and answer written interrogatories, or testify at the hearing. Some
ALJs ask the DDS to gather additional evidence on their behalf.
[Footnote 54] Others have SSA hearings office staff gather evidence for
the hearing. ALJs have additional options to obtain opinion evidence
from claimants' providers, including sending interrogatories or
questionnaires, requesting testimony at the hearing, and, under certain
circumstances, issuing administrative subpoenas. Claimants'
representatives told us that letters describing the possibility of such
subpoenas are sometimes sent, but subpoenas are rare.
As part of SSA's continuing efforts to reduce the backlog of claims at
the hearing level, it has implemented the Medical Expert Screening
Initiative Business Process. This is a new pre-hearing initiative to
identify disability claimants whose impairments are most likely to meet
the requirements for disability with a pre-hearing interrogatory sent
to medical experts. If the medical expert responses to the
interrogatories show that a fully favorable decision may be made on the
record, without the need for additional evidence or a hearing, the case
is referred to an attorney adjudicator in that hearing office to issue
the decision, if warranted.
ALJs and DDSs use the same definition of disability, but use different
administrative guidance. SSA guidance for DDSs is included in SSA's
Program Operations Manual System. Its counterpart for ALJs is called
the Hearings, Appeals, and Litigation Law Manual.
To obtain information on how medical evidence is collected at the ALJ
hearing level, we reviewed electronic copies of 50 claims that were
decided at the appeals level during the first half of fiscal year 2008.
Claims were randomly selected from all decided initial disability
claims nationwide which had a certified, fully electronic folder. The
small sample size means that the information we obtained from these
selected cases cannot be considered representative of all cases at the
appeals level, but it provides examples of how medical evidence is
collected at the appeals level. These included 34 fully favorable
decisions, 1 partially favorable decision (a changed date for onset of
the claimant's disability), and 10 unfavorable decisions. In 4 cases,
the case was dismissed or the claimant withdrew. The tables below
summarize results from our review of these cases:
Table 9: Characteristics of the Medical Evidence Collection Process for
50 Cases at the Initial DDS Decision Level and at the Hearings Office
Appeal Level:
Characteristic: Number of cases for which no medical records added;
Initial DDS Level: 3;
Hearings Office Level: 8.
Characteristic: Number of cases for which DDS obtained medical records;
Initial DDS Level: 47;
Hearings Office Level: 4.
Characteristic: Medical source statement added[A];
Initial DDS Level: 13;
Hearings Office Level: 20.
Characteristic: Consultative exam report(s) added;
Initial DDS Level: 30;
Hearings Office Level: 1.
Characteristic: Claimant was represented;
Initial DDS Level: 6;
Hearings Office Level: 45.
Source: GAO review of appealed disability claims.
Note: This table shows how many of the 50 cases had each characteristic
at either the initial DDS or the hearings level.
[A] A medical source statement is a medical source's opinion on what
the claimant can still do despite his or her impairments. In other
cases, evidence of a medical source was unclear or not present.
[End of table]
Table 10: Additional Examples of Medical Evidence Collection at
Hearings Office Level:
Example: Representative obtained medical source statement from a source
that had provided records, but not a medical source statement at the
initial DDS level;
Number of cases identified: 10.
Example: Representative obtained a medical source statement from a new
medical source;
Number of cases identified: 5.
Example: Evidence indicates that the claimant's condition worsened
after initial decision;
Number of cases identified: 12.
Example: Evidence indicates that the claimant died after initial
decision, but before hearing was held;
Number of cases identified: 1.
Example: Claimant was initially denied because the disability was not
expected to last 12 months, but new evidence indicated it did and
received a fully favorable decision at the ALJ level;
Number of cases identified: 6.
Example: ALJ's decision gives "little weight" to state agency medical
opinions provided at initial DDS level[A];
Number of cases identified: 16a.
Example: ALJ's decision gives "no weight" to state agency medical
opinions provided at initial DDS level;
Number of cases identified: 1.
Example: ALJ dismissed the case because claimant did not appear at the
hearing;
Number of cases identified: 2.
Example: Claimant withdrew the appeal to ALJ level;
Number of cases identified: 2.
Source: GAO review of appealed disability claims.
[A] For example, one ALJ writes, "The state agency medical opinions are
given little weight because other medical opinions are more consistent
with the record as a whole and evidence received at the hearing level
shows that the claimant is more limited than determined by the state
agency consultants." Another ALJ uses similar language and adds that,
"Because the examiners did not have access to additional evidence
submitted subsequent to the opinions, the opinions were not a full and
accurate assessment of the claimant's condition."
[End of table]
ALJs often gather nonmedical as well as medical evidence to reach a
decision. They typically observe the claimant during the hearing, in-
person, or by video conference. One ALJ wrote, for example,
"Furthermore, the state agency consultants did not adequately consider
that the claimant's statements concerning the intensity, persistence
and limiting effects of these symptoms are generally credible."
Hearings also sometimes involve evidence from vocational experts--
experts in assessing a claimant's ability to perform various jobs. In 3
of the 50 cases reviewed, the ALJ cited medical-vocational rules as the
basis of their decision. By the time the cases we reviewed were decided
by the SSA hearings office, medical evidence had typically been added
that was not available at the time of the initial DDS decision. In most
of these cases, the claimant's representative collected the new
evidence and submitted it to SSA. Often this included evidence from
sources that had not provided medical records at the initial DDS level.
In several cases the representative obtained a medical source statement
from a source that had not previously submitted one, but had provided
medical records.[Footnote 55] In 12 cases, evidence indicated that the
claimant's condition proved more prolonged than the DDS expected.
[End of section]
Appendix IV: Comments from the Social Security Administration:
Social Security:
The Commissioner:
Social Security Administration:
Baltimore, MD 21235-0001:
December 9, 2008:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 C Street, NW:
Washington, D.C. 20548:
Dear Mr. Bertoni:
Thank you for the opportunity to review and comment on the draft
report, "Social Security Disability: Collection of Medical Evidence
Could Be Improved with Evaluations to Identify Promising Collection
Practices" (GAO-09-149).
Enclosed are our detailed comments to the draft report recommendations
along with suggested technical revisions.
If you have any questions, please contact Candace Skurnik, Director,
Audit Management and Liaison Staff, at (410) 965-4636.
Sincerely,
Signed by:
Michael J. Astrue:
Enclosure:
Comments On The Government Accountability Office (GAO) Draft Report,
"Social Security Disability: Collection Of Medical Evidence Could Be
Improved With Evaluations To Identify Promising Collection Practices"
(GAO-09-149):
Thank you for the opportunity to review and comment on the draft
report. In general, your report provides accurate background
information and accurate explanations of our disability process and
policy, and Disability Determination Services (DDS) development. As the
report indicates, there are many factors that contribute to the
challenges the DDSs face in acquiring necessary medical evidence. The
report accurately highlights issues such as: 1) claimants not showing
up for scheduled appointments with medical providers; thus the medical
providers lose revenue; 2) claimants not identifying all medical
providers when applying for benefits; 3) medical providers skepticism
about sending information because of the Health Insurance Portability
and Accountability Act of 1996; and 4) medical providers assigning a
low priority to sending medical evidence to the DDSs.
We will share methods of dealing with these challenges which were
developed by one or more of the DDSs. In our new Agency Strategic Plan,
we commit to transform our medical evidence collection process by
automatically requesting and receiving electronic medical records
through a nationwide health information network. The Department of
Health and Human Services has the lead to develop this network.
Developing new methods for the collection of medical evidence should
decrease processing time considerably. Additionally, we are exploring
options that would allow a custodian of records to disclose relevant
personal information to us, when we make a request on behalf of an
individual who files an application for initial or continuing benefits,
without the use of paper authorization forms. This option will also
relieve health care institutions and professionals from legal concerns
about making the requested disclosure. These approaches will also
enable us to reduce the burden on all parties involved and provide more
timely decisions to disabled individuals while respecting the
confidentiality of their personal information. However, these
approaches will likely require legislation to be enacted.
We are in the process of building a common system, the Disability
Claims Processing System, that will: 1) reduce transactions and
simplify the interconnections, thereby improving systems
responsiveness; 2) build in electronic receipt of medical evidence of
record; 3) consider a national "vendor" source list; 4) consider
national fiscal (bill paying) options; 5) address case analysis
(medical source opinion) concerns; and 6) consider "contacting"
external databases to obtain medical evidence.
We will continue in our efforts to improve the collection of medical
evidence; however, limited budget and resources constrain our efforts
to implement enhancements to resolve the identified barriers.
Our responses to the recommendations are as follows.
Recommendation 1:
To foster timely and effective collection of medical evidence for
disability determinations, the Social Security Administration (SSA)
should identify DDS medical evidence collection practices that may be
promising, evaluate their effectiveness, and encourage other DDSs to
adopt effective practices where appropriate. As a part of these
evaluations, SSA should work with the DDSs to find cost-effective ways
to gather consistent data on the effectiveness of DDS medical evidence
collection activities. Such data should include key indicators such as
the proportion of requests that yield medical records, the timeliness
of medical record receipts, and how frequently claimants fail to attend
consultative exams.
Comment:
We agree, below is a summary of actions we took to address medical
evidence collection issues at the DDSs:
* Conducted various User Needs Analysis (UNA) meetings with DDS staff
to identify issues and obtain user suggestions for improvement.
* Held annual national meetings with DDS systems staffs and DDS
Professional Relations Officers to discuss issues and to share best
practices.
* Conducted conference calls with the Regional Offices and DDS offices
on a quarterly, monthly, biweekly, and weekly basis, depending on the
specific subject and audience of the call, to discuss issues and best
practices.
* Encouraged the DDSs to notify their Regional Office contacts with
issues and best practices that include medical evidence collection.
* Conducted pilots of new business processes to evaluate their
effectiveness, and if successful, encouraged other DDSs or Regions to
implement these business practices. One example of this collaboration
is the adoption of software programs developed by the Florida and Ohio
DDSs to locate medical evidence that a medical provider submitted, but
for various reasons, were not placed in the claimant's electronic
folder. After determining the effectiveness of these software
applications in locating medical evidence, we are now using them in all
of the DDSs. In addition, we added functionality to the Electronic
Records Express Website to accompany the functionality of these
software applications (these enhancements are known as Track Status of
Submissions and Customer Status Inquiries and were implemented in July
2008.)
We also agree that we should find ways to gather consistent data on the
effectiveness of DDS medical evidence collection activities. However,
because there are five separate DDS case processing systems, it is
virtually impossible to gather consistent national data at this time.
In an effort to obtain consistent national management information, we
will continue our initiative to develop a common disability case
processing system which is intended to be used by all of the DDSs. In
November 2008, we began the planning and analysis efforts to identify
the requirements for the common system. We and the DDSs have agreed to
the need for consistent management information to be built into the
common system. The new system will include medical evidence collection
practices.
We have also scheduled the project plan for the common system. That
plan spans several years with a "Phase 1" implementation scheduled for
fiscal year 2011.
Recommendation 2:
To achieve a more timely and efficient collection of medical records by
encouraging medical evidence providers to submit records
electronically, until the nationwide health information network is in
operation, SSA should conduct an evaluation of the limited utilization
of its online submission options. This evaluation should include an
analysis of the needs of small, medium, and large providers, identify
any barriers to expanded use, and develop strategies to address these
barriers.
Comment:
We agree. We are currently evaluating the methods used by medical
providers and copy services to submit medical records electronically
and have identified barriers to the use of these methods. In an effort
to address their barriers, we have:
* Participated in two UNA meetings that included DDS staff and medical
providers and copy services to identify issues and obtain user
suggestions for improvement.
* Compiled and prioritized the identified issues and user suggestions
and requested systems enhancements to resolve the issues and improve
usability.
* Conducted Joint User Review conference calls to obtain user input on
upcoming enhancements to various systems.
* Attended multiple medical community conferences, including the
American Health Information Management Association, Medical Group
Management Association, American Academy of Child and Adolescent
Psychiatrists, and American Speech and Hearing Association. At these
conferences, we and DDS staff discuss the various methods of submitting
medical evidence electronically with the medical community.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Daniel Bertoni (202) 512-7215 or bertonid@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Michael J. Collins, Assistant
Director; Benjamin P. Pfeiffer; Susan L. Aschoff; Alexander G. Galuten;
Catherine M. Hurley; Karen A. Jarzynka; Katherine N. Laubacher;
Jennifer R. Popovic; Suzanne C. Rubins; Meghan H. Squires; Vanessa R.
Taylor; Rachael C. Valliere; and Walter K. Vance, made key
contributions to this report.
[End of section]
Related GAO Products:
Social Security Disability: Management Controls Needed to Strengthen
Demonstration Projects. [hyperlink,
http://www.gao.gov/products/GAO-07-331]. Washington, D.C.: September
26, 2008.
Federal Disability Programs: More Strategic Coordination Could Help
Overcome Challenges to Needed Transformation. [hyperlink,
http://www.gao.gov/products/GAO-08-635]. Washington, D.C.: May 20,
2008.
Social Security Disability: Better Planning, Management, and Evaluation
Could Help Address Backlogs. [hyperlink,
http://www.gao.gov/products/GAO-08-40]. Washington, D.C.: December 7,
2007.
High Risk Series: An Update. [hyperlink,
http://www.gao.gov/products/GAO-07-310]. Washington, D.C.: January
2007.
Disability Programs: SSA Has Taken Steps to Address Conflicting Court
Decisions, but Needs to Manage Data Better on the Increasing Number of
Court Remands. [hyperlink, http://www.gao.gov/products/GAO-07-331].
Washington, D.C.: April 5, 2007.
Social Security Administration: Agency Is Positioning Itself to
Implement Its New Disability Determination Process, but Key Facets Are
Still in Development. [hyperlink,
http://www.gao.gov/products/GAO-06-779T]. Washington, D.C.: June 15,
2006.
Electronic Disability Claims Processing: SSA Is Proceeding with Its
Accelerated Systems Initiative but Needs to Address Operational Issues.
[hyperlink, http://www.gao.gov/products/GAO-05-97]. Washington, D.C.:
September 23, 2005.
Social Security Administration: More Effort Needed to Assess
Consistency of Disability Decisions. [hyperlink,
http://www.gao.gov/products/GAO-04-656]. Washington, D.C.: July 2,
2004.
Social Security Disability: Commissioner Proposes Strategy to Improve
the Claims Process, but Faces Implementation Challenges. [hyperlink,
http://www.gao.gov/products/GAO-04-552T]. Washington, D.C.: March 29,
2004.
Electronic Disability Claims Processing: SSA Needs to Address Risks
Associated with Its Accelerated Systems Development Strategy.
[hyperlink, http://www.gao.gov/products/GAO-04-466]. Washington, D.C.:
March 26, 2004.
Social Security Administration: Strategic Workforce Planning Needed to
Address Human Capital Challenges Facing the Disability Determination
Services. [hyperlink, http://www.gao.gov/products/GAO-04-121].
Washington, D.C.: January 27, 2004.
SSA Disability Decision Making: Additional Steps Needed to Ensure
Accuracy and Fairness of Decisions at the Hearings Level. [hyperlink,
http://www.gao.gov/products/GAO-04-14]. Washington, D.C.: November 12,
2003.
Electronic Disability Claims Processing: Social Security
Administration's Accelerated Strategy Faces Significant Risks.
[hyperlink, http://www.gao.gov/products/GAO-03-984T]. Washington D.C.:
July 24, 2003.
Social Security Disability: Efforts to Improve Claims Process Have
Fallen Short and Further Action is Needed. [hyperlink,
http://www.gao.gov/products/GAO-02-826T]. Washington, D.C.: June 11,
2002:
Social Security Disability: Disappointing Results from SSA's Efforts to
Improve the Disability Claims Process Warrant Immediate Attention.
[hyperlink, http://www.gao.gov/products/GAO-02-322]. Washington, D.C.:
February 27, 2002.
SSA Disability Redesign: Actions Needed to Enhance Future Progress.
[hyperlink, http://www.gao.gov/products/GAO/HEHS-99-25]. Washington,
D.C.: March 12, 1999.
[End of section]
Footnotes:
[1] For a discussion of SSA's disability case backlog, see GAO, Social
Security Disability: Better Planning, Management, and Evaluation Could
Help Address Backlogs, [hyperlink,
http://www.gao.gov/products/GAO-08-40] (Washington, D.C.: Dec. 7,
2007).
[2] For convenience, we use the term "medical record" to refer to
medical evidence of record, which state agencies collect from
claimants' medical providers in order to make disability determinations
for SSA benefits. We use the term "electronic medical record" to refer
to providers' computerized records.
[3] For convenience, we refer to the 50 states and the District of
Columbia as "states."
[4] Monthly earnings thresholds for 2008 were $1,570 for individuals
whose eligibility is statutory blindness and $940 for other
individuals. Individuals under the age of 18 are considered disabled
for the purposes of SSI if they have a medically determinable physical
or mental impairment that results in "marked and severe functional
limitations" expected to last at least 12 months or result in death.
[5] Average DI benefits amounts vary by recipient type. On average,
disabled widow(er)s and disabled children receive lower monthly
benefits than disabled workers.
[6] SSA verifies different nonmedical requirements for the DI and SSI
programs; for example SSA field offices verify, among other things,
age, work credits, and current earnings for DI claimants and income and
assets for SSI claimants. DDSs are separate state agencies with
guidance and oversight provided by SSA.
[7] DI claimants may be eligible for retroactive benefits up to maximum
of 12 months.
[8] In 32 states and the District of Columbia, claimants approved for
SSI benefits become eligible for Medicaid. In several other states a
separate application is required, and other states have their own
eligibility requirements for Medicaid subject to certain limits. If
approved for DI benefits, claimants will be eligible for Medicare
benefits beginning 2 years after they were entitled to disability
benefits. Some DI beneficiaries become eligible for Medicare benefits
without a 2-year waiting period, for example, claimants who are kidney
transplant or kidney dialysis patients.
[9] DDS officials not involved in the initial determination reconsider
original and any new evidence. In some states, however, the decision is
appealed directly to the SSA ALJ hearings office.
[10] Medical records covering the full year prior to the application
generally are not required when claimants reports they became disabled
more recently. Certain situations may require medical records from
earlier time periods.
[11] According to SSA, federal providers, such as the VA, are not
eligible for payments for medical records. Congress authorized SSA to
pay for medical records for SSI claims from the program's inception
because it was considered unreasonable to expect a claimant to pay for
medical evidence for a need-based federal program. In 1980, Congress
amended the Social Security Act to also allow payment for medical
records under the DI program with the intent to obtain timely medical
records and thereby reduce the need to order more expensive
consultative exams.
[12] DDS payments for individual medical services are subject to
federal or state limits. The DDSs have discretion within the available
funding SSA provides them to purchase medical records and consultative
exams as is necessary to process their workload target.
[13] As of January 2007, all DDSs were certified for processing initial
claims electronically. A key feature is the use of claimant electronic
folders. Electronic folders are electronic data repositories that
replaced SSA's paper folder system, allowing information to be viewed
and shared electronically by all disability processing components
regardless of location.
[14] In order to establish whether claimants have a medically
determinable impairment, SSA and DDSs must have evidence from medical
providers who meet the definition of "acceptable medical sources,"
which generally include physicians, psychologists and, for the limited
purpose of documenting a diagnosis within their fields of practice,
podiatrists, optometrists, and speech-language pathologists. In this
report, use of the term "medical provider" is intended to refer to an
acceptable medical source as defined by SSA, and "treating provider" as
a claimant's own medical provider as defined by SSA.
[15] The effect of controlling weight is that the DDS may not
substitute its judgment for that of the treating provider. According to
SSA's regulations, treating providers' opinions are entitled to more
weight because those providers are most likely to have long-standing,
detailed knowledge of claimants' medical impairments and "may bring a
unique perspective to the medical evidence that cannot be obtained from
the objective medical findings alone or from reports of individual
examinations, such as consultative exams or brief hospitalizations." 20
C.F.R. §404.1527(d)(2), §416.927(d)(2).
[16] DDSs will not order diagnostic tests that involve significant risk
to the claimant.
[17] According to SSA, though DDSs are required to perform expedited
development for Quick Disability Determination claims, DDSs may fax
requests for medical records for any claim regardless of the priority
status of the claim. In addition to manually faxing, the DDSs may use
SSA's Electronic Outbound Request (EOR) system to automatically fax the
medical evidence request directly from the case processing system
instead of printing.
[18] This was the Quick Disability Determination average from the start
of the pilot until the preparation of SSA's 2007 Performance and
Accountability Report, which was issued Nov. 7, 2007.
[19] Executive Order 13335, Incentives for the Use of Health
Information Technology and Establishing the Position of the National
Health Information Technology Coordinator (Washington, D.C., Apr. 27,
2004).
[20] Executive Order 13410, Promoting Quality and Efficient Health Care
in Federal Government Administered or Sponsored Health Care Programs
(Washington, D.C., Aug. 22, 2006). Since SSA does not administer or
sponsor a health care program, it does not fall within the executive
order's directives. Programs subject to these directives include the
Federal Employees Health Benefit Program, the Medicare program,
programs operated directly by the Indian Health Service, the TRICARE
program for the Department of Defense and other uniformed services, and
the health care program operated by VA.
[21] Pub. L. No. 104-191 (1996).
[22] SSA, Social Security Administration: Fiscal Year 2007 Performance
and Accountability Report, at 49. This particular measure includes all
calendar days from the date of application through either the date of
the denial notice or the date the system completes processing an award
of benefits for DI and SSI initial claims. In contrast, the regulatory
performance standards for DDSs measure processing from the date the DDS
receives the claim, and distinguish between DI and SSI claims. See 20
C.F.R. §404.1642.
[23] Only 37 of the 51 DDSs surveyed provided complete information to
our question on the number of medical records sent and responses
received within different time frames. The 37 DDSs provided either data
calculated by DDS internal records or estimates from the directors. The
counts of fulfilled requests could include responses from providers
stating that the requested records were not available. In addition to
the records received within the defined time frames, 27 of the 37
responding DDSs also reported the percentage of requested records they
received after the DDS had made its determination, which ranged from
less than 1 percent to 47 percent of requested records. See app. I for
details about our analysis of survey responses.
[24] SSA regulations require the DDSs to develop a complete medical
history, defined as records of the claimants' medical sources covering
at least the 12 months preceding the application for benefits unless
there is reason to believe additional time is needed or the claimant's
application stated he or she became disabled less than 12 months
before. 20 C.F.R. §§404.1512(d), 416.912.
[25] As discussed above, the effect of controlling weight is that the
DDS may not substitute its judgment for the opinion of the treating
provider.
[26] Even if medical opinion statements from treating providers do not
meet the conditions required to be given controlling weight, they are
still important evidence that the DDS must consider. Opinions from
providers who have treated or examined the claimant generally are given
more weight than those from providers who have not. In our review of
100 fiscal year 2007 claimant files, DDS medical consultants' review
forms indicated that a medical source statement from a treating or
examining provider was present in 25 claims where the form was
completed; in 10 of these cases, the medical consultants indicated that
the statements were inconsistent with other evidence in the file.
[27] All but four of the DDS directors reported that their DDS systems
automatically generate a follow-up request for records that are not
received after a certain time; the most frequently reported times are
12 and 21 days after the initial request.
[28] These are administrative findings made on the basis of the medical
and other evidence that must be made by SSA, or DDSs on its behalf.
Issues reserved for SSA include a determination that the claimant is
disabled according to the statutory requirements or a finding that the
claimant's impairment meets or is equivalent to one of the listed
impairments. SSA guidance does not require DDSs to recontact providers
whom they know from experience are unable or unwilling to provide the
requested information.
[29] Other professionals, such as speech and language specialists, may
also serve as DDS medical consultants.
[30] By regulation, DDS payments for purchasing medical or other
services necessary to make disability determinations may not exceed the
highest rate paid by federal or other agencies in that state for the
same or similar services. Within these parameters, DDSs medical records
payments vary widely by method and amount, according to data they
reported to SSA for fiscal year 2007. Methods include flat fees, per-
page fees, and a combination of the two (a handling fee or standard
payment for the first 10 pages, for example, and a per-page fee for
additional pages). Regarding amounts, 36 DDSs have a maximum flat fee
from a low of $10 to a high of $40, and per-page fees range from $0.10
to $1.00. One DDS (Alaska) pays providers for medical records on the
basis of usual and customary charges rather than a fee schedule.
[31] The remaining nine directors either responded that they did not
know how their payment rates compared with the prevailing rates in
their states.
[32] Although SSA considers such instances to be errors, it is possible
that the DDS obtained sufficient medical evidence from other sources,
such as a consultative exam, to support its determination. Not all
errors identified in SSA quality assurance reviews indicate that the
claim was incorrectly decided.
[33] Obtaining consistent data on medical records and requests and
receipts is key to ensuring that both DDS and SSA program managers have
sufficient operational data to ensure efficient use of resources. See
GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD00-21.3.1] (Washington,
D.C., November 1999) (pp. 18-19).
[34] SSA regulations governing the disability determination process
note that when, in the judgment of the DDS examiner, a claimant's
treating source is qualified, equipped, willing to perform consultative
examinations or tests for the fee schedule payment used by the DDS and
generally furnishes complete and timely reports, a claimant's treating
source will be the preferred source to conduct a consultative
examination. The guidance to DDSs indicates that this is because the
treating provider is usually in the best position to provide detailed
longitudinal information about the claimant's condition. SSA provides
options to the DDSs to determine the willingness of treating providers
to perform consultative exams, including a general survey of providers
in the state every 3 years, an inquiry on the letter requesting medical
records, a telephone call to the treating provider at the time a
consultative exam is ordered, or a combination of these.
[35] This included 20 directors that indicated it would add very great
value, and 12 directors that indicated it would add great value.
[36] SSA, E-Government Annual Report, Letter to OMB, Sept. 14, 2007.
SSA regards fax as one of the options providers have for submitting
records electronically. Providers may fax paper copies of the records
or use a computer to send electronic files by fax.
[37] This included 42 directors that indicated that outreach to
providers always or almost always included this topic.
[38] SSA designed the ERE Web site for small-to medium-volume
providers, copy services, and consultative exam providers. To identify
issues and obtain user suggestions for improving the ERE Web site, SSA
held two meetings during fiscal year 2008, which also included DDS
provider relations and information technology professionals. SSA
obtained a list of almost 300 suggestions to improve its ERE Web site
and is making enhancements based in large part on these provider
suggestions. SSA noted that competing priorities and budgetary
constraints limit the number of enhancements the agency can make in
each fiscal year.
[39] To submit a large volume of requested records online to SSA, one
release of information ("copy") service uses software called
Connect:Direct, which is owned by Sterling Commerce, an AT&T company.
SSA indicated that it developed WebServices to provide a lower-cost
option for electronic submission of large numbers of medical records,
and that the agency plans to upgrade WebServices in the first quarter
of fiscal year 2009.
[40] Both of these were copy services. After it completes its planned
WebServices upgrade, SSA will work with a third high-volume provider to
test the enhancements with the goal of allowing additional medical
providers and copy services to use this technology in the near future.
[41] David Blumenthal et al., eds., Health Information Technology in
the United States: Where We Stand, 2008 (Princeton, N.J., Robert Wood
Johnson Foundation, 2008). These estimates were based on analysis of
data from selected surveys of medical providers. They also found that
17 percent of those that were not using electronic health records had
purchased such systems, but had not yet implemented them. Another 26
percent indicated that they intended to acquire an electronic health
record system within 2 years.
[42] In contrast, during the same month, SSA received only 6 percent of
consultative examination reports on paper, 26 percent through online
submissions, and 68 percent by fax.
[43] These results do not include data from the New York DDS; data from
New York were not available.
[44] Online submissions increased from 12 percent of submissions in
October 2006 to 20 percent in March 2008, then rose slowly to 21
percent in September 2008. Over this recent period, 19 DDSs saw a
decline in the proportion of records submitted online.
[45] Medical evidence in these formats provides coded information as
uniform structured data, as opposed to electronic images. They enable
SSA and DDSs to electronically search and analyze records, not just
view them on a computer screen.
[46] The Department of Health and Human Services is leading the effort
to develop a nationwide health information network for the purpose
sharing health care information over a secure, cost-effective
communication system.
[47] Although SSA has participated in the development of this
nationwide health information network as well as the standards that
support it, SSA has no direct control over these or their acceptance,
as the Department of Health and Human Services is the federal agency
leading the effort.
[48] These efforts are initiatives under the Department of Health and
Human Services' plans to achieve health information technology
infrastructure to improve the quality and efficiency of health care.
[49] GAO, Health Information Technology: HHS Has Taken Important Steps
to Address Privacy Principles and Challenges, Although More Work
Remains, [hyperlink, http://www.gao.gov/products/GAO-08-1138]
(Washington, D.C.: Sept. 17, 2008); Health Information Technology:
Early Efforts Initiated but Comprehensive Privacy Approach Needed for
National Strategy, [hyperlink, http://www.gao.gov/products/GAO-07-238]
(Washington, D.C.: Jan. 10, 2007); and Health Information Technology:
Efforts Continue but Comprehensive Privacy Approach Needed for National
Strategy, [hyperlink, http://www.gao.gov/products/GAO-07-988T]
(Washington, D.C.: June 19, 2007).
[50] As claimants appealing to an ALJ typically wait months for a
hearing, many of the cases decided in fiscal year 2007 relied on paper
records. Using the first 6 months of fiscal year 2008 rather than
fiscal year 2007 as the more recent period gave us a larger population
of ALJ decisions with electronic folder cases from which to draw our
sample.
[51] We identified 82,080 cases that met our criteria. A total of
194,896 cases met our other sample selection criteria before applying
the certified electronic folder criteria. Whether the 42 percent of
records that had certified electronic folders were representative of
all cases that otherwise met our study criteria is not clear. We
nonetheless concluded that this sample selection was sufficiently
reliable for the purpose of providing illustrative examples of the ALJ
hearing-level medical evidence collection process.
[52] See app. I for details concerning our selection of these cases. We
included only cases for which SSA had electronic folders, versus
documentation in paper form.
[53] This includes evidence obtained by the DDS at the reconsideration
level of appeal. In several states, however, appeals of DDS decisions
go directly to the hearings offices.
[54] During fiscal year 2007, the DDSs provided assistance in
collection of evidence for hearings offices in about 59,000 cases.
[55] Why the representatives were able to obtain medical source
statements while the DDSs were not is not clear based on the evidence
in the case folder.
[End of section]
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