Source: https://www.federalregister.gov/documents/2007/09/06/E7-17533/amendments-to-the-quick-disability-determination-process
Timestamp: 2017-08-23 09:07:59
Document Index: 435745645

Matched Legal Cases: ['art 405', 'art 405', 'art 404', 'art 416', 'arts 404', '§\u2009404', 'art 404', 'art 405', 'art 416', '§\u2009404', '§\u2009404', '§\u2009404', '§\u2009404', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009405', '§\u2009416', '§\u2009416', '§\u2009416', '§\u2009416', '§\u2009416', '§\u2009416', '§\u2009416', '§\u2009416', 'art\n28', '§\u2009416']

A Rule by the Social Security Administration on 09/06/2007
This rule is effective September 6, 2007. State agencies outside of the Boston region must notify SSA of the date by which they will be ready to accept QDD referrals. That date should be no earlier than October 9, 2007 and must be no later than March 4, 2008. State agencies must be ready to process claims referred under this rule no later than March 4, 2008.
72 FR 51173
51173-51179 (7 pages)
E7-17533
Appendix to Subpart A of Part 405 [Amended]
https://www.federalregister.gov/d/E7-17533 https://www.federalregister.gov/d/E7-17533
We are making final the rule we proposed in the Notice of Proposed Rulemaking (NPRM) published in the Federal Register on July 10, 2007 at 72 FR 37496. We provide a summary of the provisions of the final rule below. We then provide a summary of the public comments and our reasons for adopting or not adopting the recommendations in the summaries of the comments in the section, “Public Comments.” The text of the final rule follows the preamble.
We are dedicated to providing high-quality service to the American public. When we announced changes in March 2006 to our administrative review process for initial disability claims, we explained that we expected that the changes would improve disability service. Our commitment to continuous improvement in the way we process disability claims did not end with the publication of those rules as we continually explore ways to improve service to some of the most vulnerable in our society. We nevertheless face significant challenges now and in the foreseeable future in our ability to provide the level of service that disability benefit claimants deserve because of the increased complexity of and growth in claims for those benefits. Consequently, we are making modifications to our administrative review process that will further help us provide accurate and timely service to claimants for Social Security disability benefits and supplemental security income payments based on disability or blindness.
In early spring 2006, we published a final rule in which we laid out changes to the administrative review process for initial disability claims. We expected that the changes would “improve the accuracy, consistency, and timeliness of decision-making throughout the disability determination process.” 71 FR 16424 (March 31, 2006). We planned a gradual roll-out of the changes so that we could test them and their effect on the disability process overall. As we explained then, “Gradual implementation will allow us to monitor the effects that our changes are having on the entire disability determination process.* * * We will carefully monitor the implementation process in the Boston region and quickly address any problems that may arise.” 71 FR at 16440-41. Having thoroughly reviewed the initial determination level of that process, we have concluded that we need to modify some of the changes made last spring.
The changes in the March 2006 final rule included establishing, in the Boston region, an initial-determination-level process to identify and accelerate the adjudication of the claims of persons who have a “high degree of probability” of being disabled, where there was an expectation that the claimant's “allegations will be easily and quickly verified * * *.” 20 CFR 405.101-.110 (2006). We refer to this as the Quick Disability Determination (QDD) process. Under QDD, a predictive model analyzes specific elements of data within the electronic claims file to identify claims where there is a high potential that the claimant is disabled and where evidence of the claimant's allegations can be quickly and easily obtained. Those claims are then sent to a separate QDD unit in the State agency, where experienced disability examiners review the claims on an expedited basis. The QDD process in essence is a workload triaging tool that helps identify, in an automated fashion, claims where the disability should be easy to verify.
This process has been working quite well. Because our experience with QDD has been very favorable, has proven to be of significant benefit to those claimants who have been affected by it, has been well-received by the State agencies in the Boston region, and has shown that there are no significant administrative costs associated with it, we are accelerating our implementation of the QDD process and extending QDD to all States. -
Nevertheless, in order to improve the efficiencies that we have seen by using the QDD process, we are modifying those aspects of the QDD process that have served as a barrier to the type of outstanding public service that we strive to provide. These modifications will give State agencies greater flexibility in managing their QDD workloads. Specifically, we are eliminating the requirement that QDD claims be Start Printed Page 51174adjudicated within 20 days of receipt in the State agency and removing the performance standard and sanction provisions related to that 20-day adjudication requirement. We also are eliminating the requirement that separate QDD units be established within the State agencies.
The QDD rules published in 2006 required the State agency to adjudicate any claim referred to it under QDD within 20 days of the date the claim was received in the QDD unit; any QDD claim not decided within this time frame had to be returned by the QDD unit for regular processing in the State agency. We are eliminating this 20-day requirement for three reasons. First, the early information concerning processing times for QDD claims is quite promising. The average QDD processing time for the Boston region State agencies has been approximately 12 days. For a large majority of the cases, they have processed claims selected for QDD in 9 days or less, and only a small minority of the claims exceeded the 20-day threshold. Given this experience, we are confident that the State agencies will continue to process the vast majority of QDD claims within 20 days. Eliminating the 20-day requirement will give the State agencies more flexibility in managing this workload.
Second, even where the processing time goes beyond 20 days, we believe disability claimants will be better served and the State agencies' resources will be better utilized by allowing the QDD examiner to complete the work on the claim, rather than requiring the examiner to return the claim for regular processing in the State agency.
Though we are eliminating the 20-day adjudication requirement to give State agencies greater flexibility, we still believe that State agencies should strive to adjudicate any claim referred under QDD within 20 days. We will gather data in order to monitor the performance of State agencies with these claims. SSA currently shares this information with appropriate oversight agencies and will continue to do so. We will consider broadly or selectively reinstituting a formal time deadline, if warranted.
Our second change to the QDD rules removes the requirement that State agencies create separate QDD units to handle the QDD claims we refer. Our intent when we created that requirement was to ensure that QDD claims were processed by individuals with the knowledge, training, and experience to effectively carry out the QDD function and to ensure that they could be held accountable for performing this important task. 71 FR at 16429. At the same time, we recognized the State agencies' need for flexibility in handling their workloads. 71 FR at 16429. Now that we have some experience with the QDD process, we believe the requirement of a separate QDD unit in each DDS is not necessary. Particularly in smaller States, we believe the requirement of a separate QDD unit may unnecessarily restrict the flexibility the State agency needs to best address its workloads. Therefore, we are eliminating the requirement that State agencies create a separate QDD unit. We will retain the existing requirement that all QDD claims be handled by designated disability examiners who have the knowledge, training, and experience to effectively carry out the QDD process. We believe this is sufficient to afford QDD cases the proper level of attention and accountability.
In light of these considerations, we are amending our regulations to require all State agencies that perform disability determinations for us to handle claims we refer to them under QDD and to remove from the QDD rules the 20-day performance standard and the separate unit requirements discussed above. In addition, because we are accelerating our nationwide roll-out of the QDD process independent of the other changes in the March 2006 final rules, we are moving the substantive QDD rules from part 405 of our regulations to part 404, subpart Q, and part 416, subpart J, which contain the provisions covering the State agency determination process.
State agencies within the Boston region are already processing cases under QDD, and the changes we are making to the QDD process will apply to those State agencies immediately. However, we recognize that State agencies newly affected by this accelerated roll-out of the QDD process will need a reasonable time to establish QDD procedures and make any needed software modifications. Some State agencies may also need time to satisfy collective bargaining obligations. Therefore, we are allowing the State agencies outside of the Boston region additional time to prepare for the implementation of the QDD process. Each newly affected State agency must notify us of the date by which the State agency will be ready to accept QDD referrals. That date should be no earlier than 30 days from the date of publication of this rule and must be no later than 180 days from its publication. We will not refer any claims to a State agency outside the Boston region for processing under QDD until the earlier of the date that agency has notified us it will be ready to accept and process QDD referrals or the date 180 days from the publication of this final rule.
In this rule we also are revising the provisions in parts 404, 405 and 416 of our regulations that describe the contents of the notices we send to inform claimants of our initial determinations on our claims. The current regulatory provisions, while not substantively inconsistent with one another, are phrased differently. In order to avoid any unintended suggestion that we apply different standards when drafting the notices to which these various sections apply, we are revising the language to be consistent in all three sections. We wish to emphasize that we are not in any way changing the substance of what must be in our notices of initial determination, but rather are simply adopting more uniform language based on the statutory requirements in sections 205(b)(1), 205(s) and 1631(c)(1)(A) of the Social Security Act (Act).
In the NPRM we published on July 10, 2007 (72 FR 37496), we provided the public with a 30-day period in which to comment. That comment period ended on August 9, 2007.
We received timely comments from 21 individuals and organizations. We carefully considered all the comments. Because some of the comments were lengthy, we have summarized the comments. In addition, some of the comments did not relate to the Quick Disability Determination process. We have provided responses to each significant issue raised by commenters that was within the scope of this rule.
Comment: Many commenters expressed support for the proposed expansion of the QDD process and indicated that it will help alleviate delays in receiving disability determinations. However, several commenters expressed a concern that accelerating decisions at the initial level will increase the pending caseloads at Start Printed Page 51175the subsequent levels of our administrative adjudicative process.
Response: We agree that improving our performance at the initial level, as these commenters recognized QDD would do, is only one part of the changes we need to make, and we want to assure the public that we are looking at a number of other areas as well. We have a number of initiatives underway, including proposals that will improve service at the reconsideration, hearings, and appeals levels of our administrative adjudicative process. We believe those other activities will address the commenters' concerns about processing times at the subsequent levels of our administrative process.
Comment: One commenter expressed concern that the predictive model is the sole method for identifying QDD claims. The commenter suggested allowing experienced disability examiners to refer cases for QDD processing based on their initial review of the claim.
Response: The QDD process is designed to take advantage of the technology now available to us to screen cases automatically and select for QDD processing those cases that involve a high potential that the claimant is disabled and that require evidence that can be easily and quickly obtained to support the claimant's allegations. We believe the predictive model that has been developed, and that we will revise as appropriate, will identify the appropriate cases for QDD processing. We therefore are not adopting the suggestion to let disability examiners or others involved in the claims-taking process select cases for QDD processing based on their own assessment of the case.
Comment: Several commenters expressed concern that eliminating the 20-day time limit for processing QDD claims would lessen the likelihood of quick determinations. These commenters also stated that it will be difficult to monitor State agency performance in the QDD process without any specific time limitations in the rule. Other commenters recognized the need to provide for additional time to obtain medical evidence without removing a claim from the QDD process. Some of these commenters suggested retaining the 20-day time limit and allowing one 20-day extension to complete the QDD process. Others suggested adding incentives for meeting the time frames and sanctions where time frames are not met. On the other hand, several commenters supported the proposal to eliminate the 20-day time limit and related sanctions. They reasoned that the processing times for QDD cases in the Boston region showed that State agencies are completing most QDD cases well before the 20-day limit, demonstrating that the time limit is not necessary. Some of these commenters believed eliminating the time limit would give State agencies greater flexibility to handle their workloads.
Response: We understand the concerns on both sides of this question. We have decided to eliminate the 20-day time limit, as proposed, for several reasons. First, we believe that the QDD processing results in the Boston region amply demonstrate that our partners in the State agencies share our commitment to processing these cases as quickly as possible. They have completed most QDD cases well before the 20-day limit, which indicates to us that the time limit was not the reason for their performance. Second, as we discussed earlier, the 20-day time limit has proven too short for some cases, leading to reassignment as non-QDD cases and additional work that could have been avoided by allowing the cases to remain with the QDD examiner. While some commenters suggested allowing the QDD examiner to obtain an extension of time in those cases, we believe the additional burdens of obtaining or justifying such an extension would needlessly divert the examiner's attention from adjudicating claims. Third, we anticipate that we may increase the percentage of cases selected for QDD as we gain more experience with it. As we increase that percentage, the additional cases will be those where the indicators for QDD are not as strong as the cases selected earlier, and where the adjudication of the claim will be more difficult. We reasonably expect that such an increase in the percentage of cases selected will lead to longer average processing times, and we believe we need the flexibility to continually adjust our process as we do this. Eliminating the 20-day rule gives us more flexibility. Therefore, we are eliminating the 20-day limit on processing QDD cases.
Our goal of processing QDD claims within 20 days remains, however. As noted above, we will gather data in order to monitor the performance of State agencies with these claims. SSA currently shares this information with appropriate oversight agencies and will continue to do so. We also will consider adding incentives and sanctions as part of possible future changes to the QDD process if we determine that such changes are necessary.
Comment: Three organizations representing State and Federal employees supported our proposed elimination of the requirement for separate QDD units, stating that the removal of that requirement would provide greater flexibility and efficiency. One commenter suggested that State agencies be required to have separate QDD units for 2 years to ensure that staff is fully trained and any local issues are addressed.
Response: We agree with the commenters who believed that the flexibility and efficiency gains for the State agencies of eliminating the separate QDD unit requirement outweigh the advantages of retaining the requirement. Because all QDD claims must be assigned to experienced disability examiners, we do not agree with the suggestion that a separate unit be required for 2 years for training or other purposes. Therefore, we are eliminating the separate unit requirement.
Comment: Our proposed rule requires that a medical or psychological consultant verify that the medical evidence in the file is sufficient to determine that, as of the alleged onset date, the individual's physical or mental impairment(s) meets the standards established by us for making a quick disability determination. Two commenters suggested that the experienced disability examiners who will handle QDD cases be given the authority to make the quick disability determination on their own if they decide that a medical or psychological consultant is unnecessary. Another commenter supported our requirement for medical or psychological consultant review in all QDD cases, stating that it maintains the medical integrity of the QDD decision.
Response: We believe that medical or psychological consultant involvement in the disability determination is a critical component of the QDD process and helps ensure the quality of the determinations. Therefore, we are not adopting the suggestion to allow disability examiners to make determinations without a medical or psychological consultant's involvement.
Comment: Commenters also suggested expanding the use of the Single Decision Maker (SDM) case processing model currently operating in 20 States. They stated that SDM performance data show quicker processing times while maintaining the quality of the determinations. One commenter asked that we clarify how QDD's requirement for involvement of a medical or psychological consultant will work in States currently using the SDM model.
Response: We are still evaluating the SDM model. It is premature to make any decisions about expanding it to other States. Under the SDM model generally, the decision maker is directed to make Start Printed Page 51176the disability determination “after any appropriate consultation with a medical or psychological consultant.” See 20 CFR 404.906(b)(2); 416.1406(b)(2). Because of the nature of the QDD process and the importance we are placing on the medical or psychological consultant's involvement in the QDD process, it is both “appropriate” and necessary in States operating under the SDM model for the decision maker to obtain the medical or psychological consultant involvement that is required by the QDD rules. We may revisit this question, however, during our evaluation of the SDM model.
Comment: One commenter believes that we should monitor the predictive model software to ensure that it selects only cases appropriate for QDD processing. The commenter also suggested expanding QDD “compassionate reviews” throughout the DDSs.
Response: As noted above, we agree with the need to monitor the predictive model software as part of our ongoing evaluation of the entire QDD process. We will make changes to the predictive model as data dictates. With regard to the comment on compassionate allowances, we recently published an advance notice of proposed rulemaking requesting public comments on the rules for compassionate allowances (72 FR 41649, July 31, 2007), and will consider any relevant comments we receive as we proceed with that initiative.
Comment: In the NPRM, we specifically requested comments on the lead time, if any, that State agencies outside the Boston region would need to implement these rules. We received only one comment on this question. That commenter, an organization that represents disability determination directors, suggested that most States could implement the QDD process within 30 days, even considering the need for systems changes, outreach to medical providers, and staff selection and training. The commenter acknowledged that States with specific collective bargaining obligations requiring negotiations for the designation of QDD adjudicators might need additional time to implement the QDD process.
Response: We appreciate the commenter's observations. Because the needs of individual State agencies may vary, particularly with regard to collective bargaining issues, we have provided in this final rule for additional time for State agencies outside the Boston region to become ready to accept QDD referrals. That lead time is provided in the DATES section of this final rule and discussed under the “Quick Disability Determinations” heading in the SUPPLEMENTARY INFORMATION section.
Comment: Four organizations representing individuals with disabilities expressed concerns about the QDD process in regard to low income claimants. They noted that to qualify for the QDD process, the claim must have a “high degree of probability that the individual is disabled” and the “individual's allegations will be easily and quickly verified.” They noted that many people with low incomes have difficulty obtaining ongoing medical care and, thus, may lack the readily available medical evidence to meet the QDD selection criteria. They urged us to consider ways to allow claims from such individuals to qualify for the QDD process.
Response: The ready availability of medical evidence to support the claimant's alleged disability is crucial to the QDD process. We recognize that some claimants may be disabled but, for financial or other reasons, will not have readily available medical evidence supporting their claim. In those cases, we expend considerable time and resources to get the medical evidence necessary to decide the claim, even to the extent of arranging for medical examinations at our expense. While we share the commenters' concerns for these claimants, we do not believe cases lacking the necessary medical evidence can benefit from the QDD process. Therefore, we will process these claims using existing procedures.
Comment: These same commenters urged us to expand the categories of claims that will satisfy the criteria of the predictive model and qualify for the QDD process. In particular, they suggested that more mental impairments be included in the QDD selection criteria.
Response: Our predictive model does not necessarily identify specific conditions, but rather considers a variety of factors, including medical history, treatment protocols, and medical signs and findings. We will continue to evaluate the predictive model and make appropriate changes as we gain more data and experience. We will consider the commenters' concerns during that process. However, the specific criteria of the predictive model are not prescribed by this rule, and therefore we are making no changes to this rule in response to this comment.
Comment: One commenter stated that we used inconsistent language in the preamble and in the proposed rule itself. The commenter correctly noted that in the proposed rule, in §§ 404.1619(a) and 416.1019(a), we referred to allegations being “easily and quickly verified.” However, the commenter stated that in the preamble, 72 FR at 37497, we referred to allegations that “can be quickly and easily obtained.”
Response: We agree that our choice of words should be consistent, and in this instance we believe it was. The preamble language actually refers to claims “where evidence of the claimant's allegations can be quickly and easily obtained.” That is, we must be able to “obtain” the evidence and “verify” the allegations.
We certify that this rule will not have a significant economic impact on a substantial number of small entities as it affects only States and individuals. Therefore, a regulatory flexibility analysis as provided in the Regulatory Flexibility Act, as amended, is not required.
Start List of Subjects Start Printed Page 51177
For the reasons set out in the preamble, we are amending subparts J, P and Q of part 404, subparts A, B and I of part 405, and subparts I, J and N of part 416 as set forth below:
§ 404.1503
7. Amend § 404.1602 by adding in alphabetical order a definition for “Quick disability determination,” to read as follows:
9. Add a new undesignated center heading following § 404.1618 and add new § 404.1619 to read as follows:
Start Printed Page 51178 Authority: Secs. 201(j), 205(a)-(b), (d)-(h), and (s), 221, 223(a)-(b), 702(a)(5), 1601, 1602, 1631, and 1633 of the Social Security Act (42 U.S.C. 401(j), 405(a)-(b), (d)-(h), and (s), 421, 423(a)-(b), 902(a)(5), 1381, 1381a, 1383, and 1383b).
§ 405.101
14. Amend § 405.101 by removing from the first sentence the phrase “, unless it makes a quick disability determination under §§ 405.105-.110,”.
§ 405.105
15. Remove and reserve § 405.105.
§ 405.110
16. Remove and reserve § 405.110.
17. Revise § 405.115 to read as follows:
We will mail a written notice of our initial determination to you at your last known address. The written notice will explain in simple and clear language what we have determined and the reasons for and the effect of our determination. If our determination involves a determination of disability that is in whole or in part unfavorable to you, our written notice also will contain in understandable language a statement of the case setting forth the evidence on which our determination is based. The notice also will inform you of your right to review by a Federal reviewing official and explain your right to representation. We will not mail a notice if the beneficiary's entitlement to benefits has ended because of his or her death.
18. Remove and reserve subpart I, consisting of §§ 405.801 through 405.850.
19. The authority citation for subpart I is revised to read as follows:
§ 416.903
20. Amend § 416.903 by removing the last sentence in paragraph (a).
21. The authority citation for subpart J continues to read as follows:
22. Amend § 416.1002 by adding a definition for “Quick disability determination,” to read as follows:
23. Amend § 416.1003 by revising paragraph (c)(2) to read as follows:
24. Add a new undesignated center heading following § 416.1018 and add new § 416.1019 to read as follows:
25. Amend § 416.1020 by adding a new paragraph (c) to read as follows:
27. Amend § 416.1403 by revising paragraphs (a)(22) and (a)(23) to read as follows:
Start Printed Page 51179 Start Amendment Part
28. Amend § 416.1404 by revising paragraph (a), removing paragraph (b) and redesignating paragraph (c) as paragraph (b).
[FR Doc. E7-17533 Filed 9-5-07; 8:45 am]