Social Security Disability
Improving Notices to Denied Claimants Gao ID: GAO-09-183R January 9, 2009On December 17, 2008, GAO issued a report concerning our findings on the Social Security Administration's (SSA) collection of medical evidence in the disability determination process. In the course of our review, an issue arose that was outside the scope of our work but is important to how SSA communicates its disability determinations to claimants. During this review, we examined a limited random selection of electronic folders for initial disability determinations for fiscal year 2007. The folders included notices sent to each denied claimant to explain the reasons for the denial of their claim and the evidence used to make the determination. Our findings related to these notices and current SSA policy regarding them is the subject of this report. This report also contains a recommendation that warrants SSA management's consideration.
Notices sent to denied claimants may provide inconsistent and sometimes misleading information about the evidence obtained. Our review of a sample of electronic folders with initial determinations revealed, in some cases, that notices provided claimants with a confusing list of reports from medical sources that did not clearly indicate the medical evidence the Disability Determination Services (DDS) used to reach its determination. In response to DDS requests for medical records, some providers responded that they have no records, either for the individual or the period in question. In some cases, the notice sent to these claimants may include only those providers who actually submitted medical records. However, some notices include all providers who responded to the medical records request. By also including those providers who responded that they have no records, without distinguishing between these varied responses, SSA is providing additional information that may confuse claimants. Federal regulations require that notices providing an unfavorable determination to a claimant discuss, in understandable language, the evidence used to reach a determination on the claimant's case. SSA, however, instructs DDSs to include lists of all medical sources that respond to DDS requests, whether or not they provided medical evidence. SSA does not instruct staff to distinguish between sources that provide medical evidence and those that do not. Moreover, the notices typically go so far as to state that the denial was based on input received from specific providers, even those who could not produce any records. Thus, applicants may lack information needed to follow up with specific providers who may have relevant records.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-09-183R, Social Security Disability: Improving Notices to Denied Claimants
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GAO-09-183R:
United States Government Accountability Office:
Washington, DC 20548:
January 9, 2009:
The Honorable Michael J. Astrue:
Commissioner:
Social Security Administration:
Subject: Social Security Disability: Improving Notices to Denied
Claimants:
Dear Commissioner Astrue:
On December 17, 2008, we issued a report concerning our findings on the
Social Security Administration's (SSA) collection of medical evidence
in the disability determination process.[Footnote 1] In the course of
our review, an issue arose that was outside the scope of our work but
is important to how SSA communicates its disability determinations to
claimants. During this review, we examined a limited random selection
of electronic folders for initial disability determinations for fiscal
year 2007. The folders included notices sent to each denied claimant to
explain the reasons for the denial of their claim and the evidence used
to make the determination.[Footnote 2] Our findings related to these
notices and current SSA policy regarding them is the subject of this
report. This report also contains a recommendation that warrants SSA
management's consideration.
Results in Brief:
Notices sent to denied claimants may provide inconsistent and sometimes
misleading information about the evidence obtained. Our review of a
sample of electronic folders with initial determinations revealed, in
some cases, that notices provided claimants with a confusing list of
reports from medical sources that did not clearly indicate the medical
evidence the Disability Determination Services (DDS) used to reach its
determination. In response to DDS requests for medical records, some
providers responded that they have no records, either for the
individual or the period in question. In some cases, the notice sent to
these claimants may include only those providers who actually submitted
medical records. However, some notices include all providers who
responded to the medical records request. By also including those
providers who responded that they have no records, without
distinguishing between these varied responses, SSA is providing
additional information that may confuse claimants.
Federal regulations require that notices providing an unfavorable
determination to a claimant discuss, in understandable language, the
evidence used to reach a determination on the claimant's case. SSA,
however, instructs DDSs to include lists of all medical sources that
respond to DDS requests, whether or not they provided medical evidence.
SSA does not instruct staff to distinguish between sources that provide
medical evidence and those that do not. Moreover, the notices typically
go so far as to state that the denial was based on input received from
specific providers, even those who could not produce any records. Thus,
applicants may lack information needed to follow up with specific
providers who may have relevant records.
We are recommending that SSA modify its guidance to require that
notices to denied claimants identify medical sources in a manner that
clearly distinguishes (1) sources that provided requested medical
evidence, (2) sources that responded to the request but did not provide
evidence, and (3) sources that did not respond. In written comments on
a draft of this report, SSA indicated general agreement with our
findings and our recommendation. It noted, however, that implementing
the recommendation will require more study and some changes to computer
systems.
Scope and Methodology:
To obtain detailed information about the medical evidence collection
process and how the evidence collected is described in notices, we
reviewed 100 randomly-selected initial disability claims--electronic
folders containing documentation of the disability determination for
individual disability claimants.
To select the 100 initial disability claims, we reviewed all initial
DDS determinations during fiscal year 2007 for Supplemental Security
Income (SSI) and Disability Insurance (DI) disability benefits and
excluded reopenings and informal remands.[Footnote 3] For
administrative purposes, we also excluded records that SSA maintained
using paper, rather than certified electronic folders. In order to
avoid overrepresentation of claimants who filed for both SSI and DI
simultaneously (an estimated 30 percent of DDS initial determinations),
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 data set.[Footnote 4]
These folders contained copies of SSA and DDS forms used in the
development of each case, including documentation for both DI and SSI
claims. The folders often included medical evidence the DDS received
from physicians and other providers; claimant and third-party
assessments of the claimant's functional abilities; reports from
providers of consultative exams; 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 claimants or
their authorized representatives; and documents related to the
disability determination, such as SSA Form 831 and notices for denied
claims. We compared medical providers' responses to requests for
medical evidence and their discussion of evidence in the notices.We
conducted our review between November 2008 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 our
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.
Notices to Denied Claimants Provide Inconsistent and, in Some Cases,
Misleading Information about the Evidence Obtained:
Our review of a sample of electronic folders for initial determinations
revealed, in some cases, that DDS notices provided the claimant with a
list of medical sources that did not clearly indicate the medical
evidence the DDS used to reach its determination. In response to DDS
requests for medical records, some providers indicated that they had no
records for the individual or the period in question. Although this was
a response to the request, no records were actually provided. In some
cases, the notice the claimant received included only those providers
who submitted medical records. However, in other cases, the notices
also included providers who responded that they had no records, and the
notices did not disclose or distinguish between these varied responses.
Among the 100 electronic folders we reviewed, there were 34 in which
one or more sources provided no record responses. In 24 of these cases,
the claimant received a less than fully favorable determination, and
SSA sent a notice listing the medical sources on which the DDS based
its determination. In several of these cases (9 of 24), this list
included medical sources that provided no record responses, rather than
evidence concerning the claimant's conditions, without distinguishing
these from responses that included medical records. In the other cases,
however, the lists of reports received did not include the providers
who responded that they did not have the requested evidence. In some
cases, the notices indicated that they had sought but failed to obtain
reports from other sources. There were also examples where the notice
included a source when something other than medical evidence was
received by the DDS. This includes one case where a request letter was
returned by the Post Office and another case where the source indicated
that they would not provide records until the claimant signed an
authorization to release records.
SSA Procedures for Notices Fail to Require Easily Understandable
Disclosure of the Evidence:
Federal regulations require that notices reporting a determination
unfavorable to the claimant discuss, in understandable language, the
evidence SSA used to reach a determination on a claimant's case. SSA,
however, instructs DDSs to list medical sources that respond, whether
or not they provided evidence. Federal regulations require that if
SSA's determination is in whole or in part unfavorable to the claimant,
the written notice will contain, in understandable language, a
statement of the case setting forth the evidence on which the
determination is based.[Footnote 5] Similarly, SSA's Program Operations
Manual System directs that when a totally or partially unfavorable
disability determination is made, the determination notice must contain
a statement of the case written in understandable language discussing
the evidence and stating the determination and the reasons for it.
[Footnote 6] SSA directs staff, when creating personalized disability
explanations, to list all medical and nonmedical sources that
responded, but not to list unresponsive sources.[Footnote 7] We
requested clarification of these policies, and a response from SSA's
Office of Disability Policy stated that the notices should include a
list of all medical and nonmedical sources that responded to the
request for medical evidence, regardless of the content of the
response. SSA believes it is important that the claimant is aware that
the DDS received a response from a provider supplied by the claimant.
Therefore, SSA includes in the notice a list of all providers who
responded to requests for information, even those who responded that
they had no records for the claimant or that they had no records for
the period specified, without distinguishing between the various
responses. If they did not include all providers who responded to
requests for records, SSA believes the claimant might think SSA did not
contact a source provided by the individual.
We agree that a list of medical sources that excludes those sources
that indicated they did not locate evidence may leave the claimant
wondering whether SSA contacted the source. However, including those
sources without specifying that these sources did not provide medical
evidence fails to provide claimants a transparent and understandable
discussion of the evidence. By distinguishing between the different
sources and the content of their responses, SSA could provide claimants
clearer, more understandable information about the evidence on which
SSA's determination was based and, perhaps, better inform a claimant's
decision whether to request an appeal.
Recommendation for Executive Action:
In order to provide claimants clearly understandable information
concerning the evidence used as a basis for SSA's denial of their
disability claims, we are recommending that SSA modify its guidance to
require that notices to claimants identify medical sources in a manner
that clearly distinguishes (1) sources that provided requested medical
evidence, (2) sources that responded to the request but did not provide
evidence, and (3) sources that did not respond.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, which are reprinted in
enclosure I, SSA indicated general agreement with our findings and our
recommendation. It noted, however, that implementing the recommendation
will require more study and some programming changes in DDSs' legacy
computer systems. SSA noted that it is working with DDSs toward a
single system to replace these legacy systems, which would make it
easier to make the necessary changes:
This report is intended for use by the management of SSA. We are also
sending copies to interested congressional committees. The report is
also available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov]. If you or your staff have any questions concerning
this report, please contact me at (202) 512-7215 or bertonid@gao.gov.
Michael J. Collins, Assistant Director; Benjamin P. Pfeiffer; Susan L.
Aschoff; Alexander G. Galuten; Suzanne C. Rubins; Meghan H. Squires;
Vanessa R. Taylor; and Walter K. Vance, made key contributions to this
report. Contact points for our Offices of Congressional Relations and
Public Affairs may be found on the last page of this report.
Sincerely yours,
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
Enclosure:
[End of section]
Enclosure: Comments from the Social Security Administration:
Social Security:
The Commissioner:
Social Security Administration:
Baltimore, MD 21235-0001:
December 29, 2008:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 G St., NW:
Washington, D.C. 20548:
Dear Mr. Bertoni:
Thank you for the opportunity to review and comment on the draft
correspondence, "Social Security Disability: Improving Decision Notices
to Denied Claimants" (GAO-09-183R). We appreciate the Government
Accountability Office's efforts in conducting this review. Our response
to the correspondence findings and recommendation is attached.
Please let me know if we can be of further assistance. You may direct
staff inquiries to Ms. Candace Skumik, 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
Correspondence, "Social Security Disability: Improving Decision Notices
To Denied Claimants" (GAO-09-183R):
In general, we support your findings and recommendation. Currently, a
personalized decision notice (PDN) is required for a denial, partially
favorable allowance, or closed period of disability, and must include a
list of all medical and non-medical sources that responded to the
request, regardless of the content of their response. We have also
placed a renewed emphasis on improving the clarity of our notices. On
July 3, 2008, I announced the creation of the Office of Notice
Improvement and Authentication. This office is dedicated to improving
notice accuracy and clarity. We issue nearly 350 million notices each
year, and each notice is an opportunity to communicate more effectively
with the American public. We are committed to making our letters and
notices more direct and easily understood.
As indicated in your report, we have an obligation when denying a
disability claim to provide a written notice which "contains in
understandable language a statement of the case setting forth the
evidence on which our determination is based." [See 20 CFR 404.904 and
416.1404(a) (Notice of the initial determination)]
However, the situation is different during other stages of the process.
Hearing decisions discuss the evidence that formed the basis for the
administrative law judge's (AU) conclusions. The Appeals Council (AC)
does not routinely undertake medical development; rather, the AC may
give the claimant/representative the opportunity to submit additional
evidence. Therefore, the claimant knows what evidence has been
supplied. Moreover, the Office of Disability Adjudication and Review
(ODAR) acknowledges in the AC notice any additional evidence that is
received. Thus, the situation at the initial disability determination
and reconsideration levels is different than the adjudications at the
ALJ and the AC levels.
While we generally agree with your recommendation to improve written
notices at the initial disability determination and reconsideration
levels, we note that you examined electronic folders containing initial
disability determinations. You recommend that we modify guidance on
"personal decision notices and similar notices." Although "decision
notice" is the term used in your draft letter, please note that we use
the term "decision" when referring to adjudications by ALJs and the AC,
and use the term "determination" when referring to determinations at
the initial and reconsideration levels. Therefore, we suggest a
clarification in the draft letter because you refer in the draft
specifically to the regulations for "determinations," not `"decisions,"
and you reviewed only notices for initial disability "determinations."
Our response to your specific recommendation is as follows.
Recommendation:
In order to provide claimants clearly understandable information
concerning the evidence used as a basis for the Social Security
Administration's (SSA) decision to deny their disability claims, we
recommend that SSA modify its guidance to require that personal
decision notices and similar notices to claimants identify sources in a
manner that clearly distinguishes: 1) sources that provided requested
medical evidence; 2) sources that responded to the request, but did not
provide evidence; and 3) sources that did not respond.
Comment:
We agree in principle, but the operational and resource constraints
described below will influence our efforts in this area. Claimants
should receive a clear understandable explanation of the basis for a
disability determination that is not fully favorable. However, while we
agree that the PDN should provide more information concerning the
responsiveness of the medical sources, the practical aspect of
implementing this recommendation requires more study. A modification of
current policy that instructs the examiner not to include information
about non-responsive medical sources would require a thorough
examination of the genesis of the policy, the legal implications of
disclosure, and the impact on the State agency's relationships with the
medical provider community. The recommended changes would also require
some programming of the States' legacy systems. Currently, the policy
of only identifying medical sources by name and date of receipt fits
well with the automated systems' generation/propagation of the list of
providers for the notice. We could implement this recommendation
provided the automated propagation for the provider information from
the legacy systems could be over-ridden or amended to manually show
which one of the three situations applied. In addition, we are working
with the State DDSs toward a single system that would replace their
legacy systems and make it easier to make this type of change. However,
this change will require working with all 50 States and a considerable
investment of IT funds. We will explore these issues and continue to
work towards modifying and standardizing our procedures. We are
confident that we will be able to produce a product that will allow a
clear, concise explanation of the actual evidence obtained and used in
our determination, as well as the attempt to obtain evidence from all
medical sources listed by the claimant.
[End of section]
Footnotes:
[1] GAO, Social Security Disability: Collection of Medical Evidence
Could Be Improved with Evaluation to Identify Promising Collection
Practices, [hyperlink, http://www.gao.gov/products/GAO-09-149]
(Washington, D.C.: Dec. 17, 2008).
[2] The folders for initial determinations we reviewed included notices
identified as "personal decision notice" or "notice of disapproved
claim."
[3] Reopenings are cases returned due to an error or receipt of
additional evidence. Informal remands are cases returned to the DDS
when SSA determines there is a strong likelihood that the earlier DDS
determination will be reversed.
[4] Although we randomly selected cases to review, our sample of 100
cases does not provide a basis for inferring the prevalence of these
cases in the population of 2.3 million initial disability
determinations during fiscal year 2007.
[5] 20 C.F.R. §§404.904, 416.1404(a).
[6] DI 26530.001.
[7] DI 26530.020(B)(1).
[End of section]
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