Social Security Disability Insurance:

SSA Actions Could Enhance Assistance to Claimants with Inflammatory Bowel Disease and Other Impairments

GAO-05-495: Published: May 31, 2005. Publicly Released: May 31, 2005.

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Advocates for patients with inflammatory bowel disease (IBD) believe that the Social Security Administration's (SSA) process for determining eligibility for Disability Insurance (DI) may treat some claimants unfairly. As a result, claimants with IBD believe they are likely to be denied benefits at the initial decision and reconsideration levels, making it necessary for them to appeal to SSA's hearings level to have their claims allowed. This congressionally mandated study focuses on (1) how SSA evaluates claims involving IBD to establish disability under Title II of the Social Security Act and (2) what unique challenges claimants with IBD encounter when applying for DI benefits, and what actions, if any, SSA has taken to address these challenges.

SSA evaluates DI claims involving IBD just as it does all claims, using a five-step sequential evaluation process to determine whether: (1) the individual is working and earning an amount exceeding established thresholds, (2) the impairment or combination of impairments significantly limits a person's physical or mental ability to perform basic work activities, (3) the individual's impairment meets or equals a pre-established list of the medical criteria for impairments considered severe enough to prevent an individual from earning wages above the established threshold, (4) the claimant can return to previous work based on what the individual can still do in a work setting despite physical or mental limitations, or his or her "residual functional capacity," and (5) the claimant can do any work in the economy. As claims move through the five-step process, their assessment requires additional evidence and increasingly complex judgments on the part of adjudicators. For example, at step three, claimants with IBD who are diagnosed with Crohn's disease would meet the medical criteria if their weight fell below the minimum on SSA's weight table. In contrast, to determine the residual functional capacity of claimants with IBD at steps four and five, SSA adjudicators must assess claimants' mental and physical capacity and make judgments regarding allegations of pain and fatigue. Adjudicators at the initial, reconsideration, and hearings levels use the same five-step process, although differences exist between the levels that may affect decisions. For example, claimants may be represented by an attorney or nonattorney at the hearings level. While claimants with IBD are somewhat less likely to be allowed DI benefits than claimants with other impairments, their experiences applying for disability benefits are not unique, and SSA has efforts under way that may address some claimant concerns. When we analyzed DI decisions in 2003 by decision-making levels, we found that claimants with IBD, like many others, experienced lower allowance rates at the initial and reconsideration levels compared to the hearings level, although the difference between the levels was more pronounced for claimants with IBD. Lower allowance rates at the initial levels and higher allowance rates at the hearings level may reflect challenges that claimants with IBD share with many other claimants in applying for disability benefits. For example, both claimants with IBD and other claimants are unlikely to be allowed at step five of the process at the initial levels but not at the hearings level. SSA is pursuing efforts that may address some claimant concerns. For example, the agency is currently updating the medical criteria used for many impairments, including IBD, and is proposing changes to its decision-making process that may improve consistency between decision-making levels. SSA is also trying to improve claimants' understanding of the disability claims evaluation process, but lacks assurance that the majority of claimants who file in person or over the phone understand and provide information critical to SSA's assessment of their claims as part of steps four and five of the process.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: SSA has made significant changes to its disability web site in response to GAO's recommendations. Specifically, SSA has updated SS Online to include an explanation of all steps of the 5-step disability determination process and has added more detailed explanations, examples, and frequently-asked questions. Information concerning steps 4 and 5 of the sequential evaluation process, formerly available only to a claimant actually filling out a DI application, is now readily available online. These changes will help ensure that claimants are informed and ultimately will provide SSA with information critical to the complete assessment of their impairment at the earliest possible point in the decision-making process.

    Recommendation: To help ensure that claimants with IBD and other claimants are informed of and ultimately provide SSA with information critical to a complete assessment of their impairment at the earliest possible point in the decision-making process, SSA should update its Web site to include more accessible information that clarifies the type and importance of information that claimants must submit for steps four and five of the sequential evaluation process. SSA should also consider making the information currently in its interactive adult disability report--including instructions, explanations and examples--more readily available to all claimants on its Web site.

    Agency Affected: Social Security Administration

  2. Status: Closed - Implemented

    Comments: In response to this recommendation, SSA is updating the Adult Disability Starter Kit to reflect recent changes made to the SSA-3368. As part of the update, the agency is also considering adding information and/or instructions along with other suggestions to the Disability Starter Kit to address the importance of obtaining information from the disability applicant about steps four and five of the sequential evaluation process, as we recommended.

    Recommendation: To help ensure that claimants with IBD and other claimants are informed of and ultimately provide SSA with information critical to a complete assessment of their impairment at the earliest possible point in the decision-making process, SSA should update the Disability Starter Kit--which is provided to all claimants who apply by phone or in person--to include an explanation of the types and importance of information that claimants must submit for steps four and five of the sequential evaluation process. SSA should consider adding instructions, explanations, and examples that are currently available in the on-line form, to the extent that it is cost-effective to do so.

    Agency Affected: Social Security Administration

  3. Status: Closed - Implemented

    Comments: SSA agreed with this recommendation. SSA noted that each regional office website currently provides access to a "Disability Interview Guide" for the field office claims representative (CR) to use for the front-end interview process. SSA reiterated that it recognizes the need for (and has conducted) additional field office training regarding the disability interview process to better assist the DDSs in their determination process. SSA acknowledged that some, not all, field offices use the Disability Interview Guides. In addition, the DDS generally submits functional reports to applicants that address limitations in activities of daily living and symptom questionnaires to further address limitations.

    Recommendation: To help ensure that claimants with IBD and other claimants are informed of and ultimately provide SSA with information critical to a complete assessment of their impairment at the earliest possible point in the decision-making process, SSA should explore options for ensuring that field office and DDS staff appropriately explain and collect the types of information needed to assess how claimants' impairments impact their ability to work.

    Agency Affected: Social Security Administration

 

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