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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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