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: Closed - Implemented

    Comments: In October 2017, SSA developed a clear, standardized, written business process for identifying potential CAL conditions, including sharing information through SSA's website on how to propose conditions for the list and by utilizing research directly applicable to CAL condition identification. In addition, SSA revised the CAL website to provide an explanation of how to suggest a CAL condition and how the agency will evaluate suggestions.

    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: Closed - Implemented

    Comments: SSA developed formal procedures for consistently notifying those who propose conditions for the CAL list of the status of their submitted conditions and began using them in October 2017. Specifically, the submitter will receive an acknowledgement letter, a status update, and notice of whether the condition will or will not be added to the CAL list. Further, SSA updated the CAL website to include a description of this review process.

    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: Closed - Implemented

    Comments: In October 2017, SSA completed development of a clear, standardized, written business process describing the methodology staff should use to identify potential CAL conditions. In addition, the agency updated the description of what a CAL condition is-a disease or condition that clearly meets Social Security's statutory standard for disability-on its internal and external websites.

    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: Closed - Implemented

    Comments: SSA completed a survey of disability determination services staff in October 2017 that included several questions about CAL policy, process, and conditions. As of August 2018, officials reported that they had analyzed the survey results and were incorporating the results into their refinement of the CAL selection software. Further, agency officials said that they were working with the National Institutes of Health to refine the selection software.

    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 the agency has begun to take steps to implement it. 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. Based on the survey results, SSA officials reported that as of August 2018, the agency has drafted revisions to the CAL instructions regarding when to manually add or remove CAL flags on individual claims. These instructions are currently under review. We will consider closing this recommendation when they have been finalized.

    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. As of August 2018, SSA had conducted a survey of disability determination services staff to help assess why manual actions vary across disability determination services offices. Based on the survey responses, SSA officials reported that they had drafted revisions to CAL instructions regarding when to manually add or remove CAL flags on individual claims. These instructions are under review. We will consider closing this recommendation when the instructions have been finalized.

    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: Closed - Implemented

    Comments: SSA developed a schedule and a plan for updating CAL impairment summaries to ensure that the summaries are medically accurate and up to date. The agency published 3 updated impairment summaries in September 2017, 74 in March 2018, 5 in August 2018, and 148 in December 2018. Going forward, the agency plans to update each summary every 1 to 3 years.

    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: Closed - Implemented

    Comments: SSA developed a plan for conducting annual quality reviews of CAL case decisions. SSA completed a quality review of their current processes for decision-making on CAL claims and determined that the national CAL performance accuracy was comparable to the national rate for Initial Quality Assurance performance accuracy for cases adjudicated in fiscal year 2018. Further, SSA officials said that they plan to use available data on an ongoing basis to improve the accuracy of CAL decisions.

    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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