Social Security Disability Programs:
Clearer Guidance Could Help SSA Apply the Medical Improvement Standard More Consistently
GAO-07-8: Published: Oct 3, 2006. Publicly Released: Nov 2, 2006.
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The Social Security Act requires that the Social Security Administration (SSA) find an improvement in a beneficiary's medical condition in order to remove him or her from either the Disability Insurance (DI) or Supplemental Security Income (SSI) programs. GAO was asked to (1) examine the proportion of beneficiaries who have improved medically and (2) determine if factors associated with the standard pose challenges for SSA when determining whether beneficiaries continue to be eligible for benefits. To answer these questions, GAO surveyed all 55 Disability Determination Services (DDS) directors, interviewed SSA officials, and reviewed pertinent SSA data.
Each year, about 13,800 beneficiaries, or 1.4 percent of all the people who left the disability programs between fiscal years 1999 and 2005, did so because SSA found that they had improved medically. More beneficiaries leave because they convert to regular retirement benefits, die, or for other reasons--including having earnings above program limits. In addition, while continuing disability reviews (CDR) are SSA's most comprehensive tool for determining whether a recipient continues to have a disability, on average, 2.8 percent of beneficiaries were found to have improved medically and to be able to work following a CDR during this 7-year period. Several factors associated with the medical improvement standard (the standard) pose challenges for SSA when assessing whether beneficiaries continue to be eligible for benefits. First, limitations in SSA guidance may result in inconsistent application of the standard. For example, SSA does not clearly define the degree of improvement needed to meet the standard, and the DDS directors GAO surveyed reported that they use different thresholds to assess if medical improvement has occurred. Second, contrary to existing policy, disability examiners in a majority of the DDSs are incorrectly conducting CDRs with the presumption that a beneficiary has a disability rather than with a "neutral" perspective. Other challenges associated with the standard include inadequate documentation of evidence as well as the judgmental nature of medical improvement determinations. All these factors have implications for the consistency of CDR decisions. However, due to data limitations, GAO was unable to determine the extent to which these problems affect decisions to continue or discontinue benefits.
Recommendation for Executive Action
Status: Closed - Not Implemented
Comments: The Deputy Commissioner of Operations, Office of Disability Determination and the Office of Disability Programs (ODP) collaborated to provide guidance to the DDSs for adjudicating CDRs. Staff members prepared "Development of Medical Evidence for Continuing Disability Review Cases" to assist with adjudication guidance, which provides reminder items for continuing disability review development. SSA reported in 2009 that CDRs are currently being adjudicated in the DDSs and that a pilot in Missouri to test 200 CDRs in the electronic environment (eCDR) is near completion. The next step is to rollout eCDR to the rest of the state. It is not clear to GAO, however, whether the adjudication guidance clarifies what degree of improvement is required to meet the standard or when the use of exceptions to medical improvement is appropriate. As of FY11, SSA had not demonstrated that it sufficiently implemented this recommendation.
Recommendation: To ensure that SSA is able to consistently assess whether DI and SSI beneficiaries have improved medically, the Commissioner of Social Security should clarify guidance for assessing medical improvement when conducting CDRs. More specifically, SSA should clarify guidance concerning (1) what degree of improvement is required to meet the standard and (2) when the use of exceptions to medical improvement is appropriate. SSA should also work with DDSs to ensure that CDRs are conducted on a neutral basis, without a presumption that beneficiaries continue to have a disability.
Agency Affected: Social Security Administration