SSA's Compassionate Allowance Initiative:

Improvements Needed to Make Expedited Processing of Disability Claims More Consistent and Accurate

GAO-17-625: Published: Aug 11, 2017. Publicly Released: Sep 6, 2017.

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What GAO Found

The Social Security Administration (SSA) does not have a formal or systematic approach for designating certain medical conditions for the Compassionate Allowance initiative (CAL). CAL was established in 2008 to fast track claimants through the disability determination process who are likely to be approved because they have certain eligible medical conditions. In lieu of a formal process for identifying conditions for the list of CAL conditions, SSA has in recent years relied on advocates for individuals with certain diseases and disorders to bring conditions to its attention. However, by relying on advocates, SSA may overlook disabling conditions for individuals who have no advocates, potentially resulting in individuals with these conditions not receiving expedited processing. Further, SSA does not have clear, consistent criteria for designating conditions for potential CAL inclusion, which is inconsistent with federal internal control standards. As a result, external stakeholders lack key information about how to recommend conditions for inclusion on the CAL list.

To identify disability claims for expedited CAL processing, SSA primarily relies on software that searches for key words in claims. However, if claimants include incorrect or misspelled information in their claims the software is hindered in its ability to flag all claimants with CAL conditions or may flag claimants for CAL processing that should not be flagged. SSA has guidance for disability determination services (DDS) staff on how to manually correct errors made by the software, but the guidance does not address when such corrections should occur (see figure). Without clear guidance on when to make manual changes, DDS examiners may continue to take actions that are not timely and may hinder expedited processing for appropriate claims, and this can also impact the accurate tracking of CAL claims.

Social Security Administration Process to Identify Disability Claims for Compassionate Allowance Initiative (CAL) Processing

Social Security Administration Process to Identify Disability Claims for Compassionate Allowance Initiative (CAL) Processing

SSA has taken some steps to ensure the accuracy and consistency of decisions on CAL claims, including developing detailed descriptions of CAL conditions, known as impairment summaries. These summaries help examiners make decisions about whether to allow or deny a claim. However, nearly one-third of the summaries are 5 or more years old. Experts and advocates that GAO spoke to suggested that summaries should be updated every 1 to 3 years. This leaves SSA at risk of making disability determinations using medically outdated information. In addition, GAO found that SSA does not leverage data it collects to assess the accuracy and consistency of CAL adjudication decisions. Without regular analyses of available data SSA is missing an opportunity to ensure the accuracy and consistency of CAL decision-making.

Why GAO Did This Study

SSA in October 2008 implemented CAL to fast track individuals with certain conditions through the disability determination process by prioritizing their disability benefit claims. Since then, SSA has expanded its list of CAL conditions from 50 to 225. GAO was asked to review SSA's implementation of CAL.

This report examines the extent to which SSA has procedures for (1) designating CAL conditions, (2) identifying claims for CAL processing, and (3) ensuring the accuracy and consistency of CAL decisions. GAO reviewed relevant federal laws, regulations, and guidance; analyzed SSA data on disability decisions for CAL claims from fiscal years 2009 through 2016 and on CAL claims with manual actions in fiscal year 2016; reviewed a nongeneralizable sample of 74 claim files with fiscal year 2016 initial determinations; and interviewed medical experts, patient advocates, and SSA officials in headquarters and six DDS offices selected for geographic dispersion and varied CAL caseloads.

What GAO Recommends

GAO is making eight recommendations including that SSA develop a process to systematically gather information on potential CAL conditions, communicate criteria for designating CAL conditions, clarify guidance for manual corrections on CAL claims, update CAL impairment summaries, and use available data to ensure accurate, consistent decision-making. SSA agreed with GAO's recommendations.

For more information, contact Kathryn A. Larin at (202) 512-7215 or larink@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: SSA agreed with this recommendation. In November 2017, SSA reported that it had revised the CAL website to provide an explanation of how to suggest a Compassionate Allowance initiative (CAL) condition and how the agency will evaluate suggestions. SSA also planned to sponsor a National Disability Forum in November 2017 to provide experts and patient organizations in the field of rare and debilitating diseases another opportunity to share research and suggestions for new CAL conditions. We will consider closing this recommendation when the agency provides evidence that it has utilized research that is directly applicable to identifying CAL conditions.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop a formal and systematic approach to gathering information to identify potential conditions for the CAL list, including by sharing information through SSA's website on how to propose conditions for the list and by utilizing research that is directly applicable to identifying CAL conditions.

    Agency Affected: Social Security Administration

  2. Status: Open

    Comments: SSA agreed with this recommendation and updated its Compassionate Allowance initiative (CAL) website to describe how the agency will keep stakeholders informed of their status in evaluating suggestions. Further, SSA reported in November 2017 that it plans to update the website to include information on process timeframes, including when stakeholders who have submitted a potential CAL condition for agency consideration can expect to hear from SSA. We will consider closing this recommendation once the agency has completed these website updates.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop formal procedures for consistently notifying those who propose conditions for the CAL list of the status of their proposals.

    Agency Affected: Social Security Administration

  3. Status: Open

    Comments: SSA agreed with this recommendation and stated that it has several relevant activities underway. SSA reported that it completed a survey of the disability determination services staff regarding several aspects of CAL in October 2017. SSA also plans to begin a quality review process to obtain feedback on CAL conditions and other issued raised by GAO's review. In addition, SSA plans to revise its website based on feedback from the survey and its quality reviews.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop and communicate internally and externally criteria for selecting conditions for the CAL list.

    Agency Affected: Social Security Administration

  4. Status: Open

    Comments: SSA agreed with this recommendation and reported that it completed a survey of disability determination services staff in October 2017 that included several questions about CAL policy, process, and conditions. SSA plans to analyze the survey results to identify opportunities to further refine its CAL selections. We will consider closing this recommendation when the agency provides evidence that it has used this disability determination services office feedback or other management data or research to refine the selection software for CAL claims.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should take steps to obtain information that can help refine the selection software for CAL claims, for example by using management data, research, or DDS office feedback.

    Agency Affected: Social Security Administration

  5. Status: Open

    Comments: SSA agreed with this recommendation and stated that it has two activities underway to assess opportunities to improve CAL procedures. SSA completed a survey of disability determination services staff in October 2017. The survey included several questions focused on how adjudicators understand and implement procedures for manually adding or removing CAL case flags. In addition, in fiscal year 2018, SSA plans to begin a special quality review process that focuses on CAL flag use. SSA reported that it will use results of the survey and quality reviews to improve CAL procedures.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should clarify written policies and procedures regarding when manual addition and removal of CAL flags should occur on individual claims.

    Agency Affected: Social Security Administration

  6. Status: Open

    Comments: SSA agreed with this recommendation. SSA plans to use results from its October 2017 disability determination services survey and fiscal year 2018 quality reviews of CAL flag use to assess why manual actions vary across disability determination services offices. SSA stated that these results may prompt the agency to conduct further data analysis or modify CAL procedures and training.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should assess the reasons why the uses of manual actions vary across DDS offices to ensure that they are being used appropriately.

    Agency Affected: Social Security Administration

  7. Status: Open

    Comments: SSA agreed with this recommendation and stated that the agency has drafted an internal business process document to ensure all impairment summaries are current. The business process identified how and when SSA will complete and document its review of an revisions to the CAL impairment summaries. SSA reported that it will implement the process once it has been finalized.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop a schedule and a plan for updates to the CAL impairment summaries to ensure that information is medically up to date.

    Agency Affected: Social Security Administration

  8. Status: Open

    Comments: SSA agreed with this recommendation and stated that it has drafted a protocol for an ongoing review of CAL allowances and denials. The plan is currently under review, and once finalized, SSA said they will review a nationally valid sample of CAL determinations on an ongoing basis. SSA said that it will share study results with policy and other internal stakeholders, as needed.

    Recommendation: To ensure expedited processing of disability claims through CAL is consistent and accurate, the Acting Commissioner of Social Security should develop a plan to regularly review and use available data to assess the accuracy and consistency of CAL decision-making.

    Agency Affected: Social Security Administration

 

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