Disability Programs:

SSA Consultative Medical Examination Process Improved; Some Problems Remain

HRD-86-23: Published: Dec 10, 1985. Publicly Released: Dec 12, 1985.

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In response to a congressional request, GAO reviewed the Social Security Administration's (SSA) management of consultative examinations (CE) in its disability programs. GAO evaluated: (1) SSA ability to ensure the quality and reliability of examinations and reports; (2) SSA controls to ensure the necessity and appropriateness of CE purchases; and (3) the operations of major volume providers nationwide.

Disability decisions are made by state disability determination services (DDS), which are regulated by SSA regional offices. If a claimant's treating physician is unavailable to provide evidence of medical impairment, CE are purchased from private medical sources. GAO found that: (1) increased SSA claims documentation requirements, emphasis on decisional accuracy, and continuing investigations of persons already receiving disability benefits increased the rate of CE purchasing; (2) as the demand for CE grew, states would purchase them from volume providers; (3) there were few substantive problems in on-site reviews of volume providers by state and federal teams; (4) SSA required states to establish CE management plans with oversight by SSA regional offices; (5) new SSA policies have provided better direction on physician standards and CE reporting requirements; and (6) states have increased their monitoring of CE providers. GAO also found that: (1) SSA did not specify how the states should structure their management systems to control the CE process; (2) SSA still lacks reasonable assurance that it obtains good quality medical examinations and reports and prevents the purchase of unnecessary examinations; and (3) some SSA regional offices have not reviewed their states' implementation plans and are not performing monitoring activities as SSA requires.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: SSA does not believe that it is appropriate to limit the ordering of CE to any predetermined waiting period. Instead, SSA required that all regional offices and the quality assurance branches conduct quarterly on-site reviews of DDS CE ordering, including case reviews, to prevent premature and unnecessary CE purchasing.

    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of Social Security to monitor DDS implementation of the new requirements to pursue treating-source evidence to determine if additional controls are needed to prevent premature and unnecessary CE purchasing.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: Revised regulations have not been officially signed.

    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of Social Security to issue a comprehensive review guide to SSA regional offices for use in conducting annual and uniform comprehensive reviews of states' CE management activities.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: The comprehensive medical evidence effectiveness plan includes a multifaceted review of state CE management plans to ensure a consistent nationwide system of reviews.

    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of Social Security to issue specific direction to SSA regional offices on how to conduct reviews of states' CE management plans and require them to reevaluate the plans to ensure that they have effective procedures for implementing each critical area of the CE process.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: Revised regulations have not been officially signed.

    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of Social Security to clarify SSA intent and provide specific direction to states on structuring systems for ongoing review of CE reports and require larger DDS to establish independent report review systems.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Implemented

    Comments: Revised regulations have not been officially signed.

    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of Social Security to require states that use volume providers to establish standards for controlling CE appointment scheduling and/or examination duration, preferably before the resumption of continuing disability reviews.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Implemented

    Comments: Revised regulations have not been officially signed.

    Recommendation: The Secretary of Health and Human Services should direct the Commissioner of Social Security to conduct a study to determine the effect of physician review of CE requests on the appropriateness of CE purchases and, if warranted, require that such reviews be mandatory for all DDS.

    Agency Affected: Department of Health and Human Services

 

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