Social Security Disability: Collection of Medical Evidence Could Be Improved with Evaluations to Identify Promising Collection Practices
Published: 2008-12-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The timely collection of relevant medical evidence from providers, such as physicians and psychologists, is key to the Social Security Administration (SSA) process for deciding whether an estimated 2.5 million new claimants each year have impairments that qualify them to receive disability benefits. The initial determinations are generally made by state agencies called Disability Determination Services (DDSs). We evaluated: (1) the challenges, if any, in collecting medical records from the claimants' own providers and ways SSA and the DDSs are responding to these challenges; (2) the challenges, if any, in obtaining high-quality consultative exams and ways SSA and the DDSs are responding to these challenges; and (3) the progress SSA has made in moving from paper to electronic collection of medical evidence. We surveyed 51 DDS directors, visited 5 state DDSs, reviewed sample case files, and interviewed officials with SSA, DDSs, and associations for claimants and providers.
section_title: What GAO Found
paragraphs: Obtaining timely and complete medical records is a challenge to DDSs in promptly deciding disability claims, and DDSs have responded with additional provider contacts and adjustments to their payment procedures. Although DDSs pay most medical providers for medical records and SSA pays the DDSs to cover these expenses, 14 of 51 DDSs reported the percentage of requests for which they did not receive records was 20 percent or more in fiscal year 2007. In response to this challenge, all DDSs conduct follow-up with providers and claimants to urge them to provide records. Over half of the DDSs (34 of 51) have also implemented more timely payments for records and six increased the amount they pay. Although SSA evaluates DDS collection of medical records, it does not compile key data necessary to identify and share promising collection practices. Recruiting and retaining qualified providers is a challenge to obtaining consultative exams needed to supplement insufficient medical records. For example, 41 of 51 DDSs reported routinely asking claimants' own providers to perform these exams; yet 34 reported providers never or almost never agree to do so. DDSs directors in our survey believe that current payment rates account for some of the difficulty recruiting and retaining consultative exam providers. In response to these challenges, 32 DDSs rely on medical providers who specialize in performing disability evaluations, and 20 pay providers for time spent preparing for appointments claimants fail to attend. SSA evaluates evidence from consultative exams, but these evaluations and the data they yield are too limited to identify and share promising DDS practices. SSA has made progress moving to electronic collection of medical records, but faces challenges in fully implementing electronic retrieval and analysis of medical evidence. SSA now uses electronic images instead of paper copies of new claimants' records. Though SSA seeks to obtain all records electronically and provides options for online submission of records, only one large provider accounts for most of the records submitted online, and about half of all records received are on paper. To date, SSA has taken only limited action to identify and analyze the barriers providers face in using current electronic record submission options, and has not developed a strategy to address them. In the long run, SSA is participating in an advanced prototype to collect medical records in formats that can be searched and analyzed by electronically querying a hospital's records database and directly retrieving the claimants' records.

section_title: Letter
paragraphs: The Social Security Administration (SSA) has faced challenges for decades  in making accurate and timely decisions on whether claimants have  impairments that qualify them to receive disability benefits. Some  disability applicants whose claims are denied and appeal wait years for  their claims to be decided at the final administrative appeals level, which  can be a hardship. In fiscal year 2006, 30 percent of claims processed at  the hearings stage alone took 600 days or more. To help avoid such  hardships and improve its process, SSA Commissioners have emphasized  the need to make the right decision at the beginning of the process. The  prompt collection of relevant medical evidence is key to SSA’s process for  deciding each year whether about 2.5 million new claimants have  impairments that qualify them to receive disability benefits. SSA estimates  that in fiscal year 2007, disability cases prompted an estimated 15 million  to 20 million medical records requests sent to providers including  hospitals, physicians, psychologists, and community health centers. The  number of new claimants is expected to increase as the baby boom  generation ages. To promptly make consistent and accurate decisions on a  high volume of claims, SSA needs efficient and effective methods to  collect medical evidence, including records from claimants’ own medical  providers as well as consultative examinations and tests performed by  other medical providers.
To be eligible for disability benefits under SSA law, individuals must have  a medically determinable impairment that prevents them from engaging in  substantial gainful activity, and is expected to last at least a year, or result  in death. The initial determination of disability is generally made by  federally funded, SSA-authorized state agencies called Disability  Determination Services (DDS). DDSs help claimants collect medical and  other evidence of their impairments. When medical records obtained from  claimants’ own providers are inconclusive, DDSs obtain additional  evidence through consultative examinations. In most cases, DDSs pay  medical providers for the medical records and consultative exams at rates  set by the states within limits set by SSA, and SSA pays DDSs to cover  these expenses. SSA reported that in fiscal year 2007, it paid DDSs about  $1.7 billion dollars for their services, including $123 million for medical  records and $311 million for consultative examinations. SSA and DDSs are  working to transform what is largely a paper process into a computerized  one, as the medical community moves to electronic medical records.
To respond to your concern about the adequacy of medical evidence  collection in the disability determination process, we evaluated: (1) the  challenges, if any, in collecting medical records from the claimants’ own  providers and ways SSA and DDSs are responding to these challenges;   (2) the challenges, if any, in obtaining high-quality consultative exams and  ways SSA and DDSs are responding to these challenges; and (3) the  progress SSA has made in moving from paper to electronic collection of  medical evidence.
To address these topics, we conducted background research and  interviews with SSA, SSA Office of the Inspector General, and DDS  officials. We also spoke with representatives of professional associations,  including those representing people with disabilities; disability examiners;  physicians; representatives of claimants; and medical providers. We  conducted a Web-based survey of DDSs in all 50 states and the District of  Columbia concerning medical evidence collection for initial disability  decisions, including DDS practices for collection of medical records and  medical opinions from claimants’ own providers and from consultative  exam providers. To learn more about how DDSs collect medical evidence,  we reviewed a random, but nonprojectable, sample of 100 claim folders for  initial DDS disability determinations during fiscal year 2007; to document  the differences in medical evidence collection between the initial and  appeals levels, we reviewed a random sample of 50 administrative law  judges’ decisions and their associated claim folders. We conducted site  visits to DDSs in large and small states in various geographic regions that  purchased medical records for a relatively high or low percentage of  claimants, and that requested consultative examinations for a relatively  high or low percentage of claimants. Based on these criteria, we visited  California, Mississippi, New York, Vermont, and Wyoming. We also  analyzed SSA data concerning the disability determination process,  including SSA data on DDS cases, and quality assurance reviews of DDS  cases by SSA regional Disability Quality Branches. To assess progress in  moving from paper to electronic collection of medical evidence, we  reviewed SSA documents concerning SSA and the health industry’s efforts  and analyzed data compiled by SSA’s computer system regarding receipts  of evidence and discussed efforts to encourage electronic submission with  SSA and DDS officials, as well as medical providers. We conducted our  review between September 2007 and December 2008 in accordance with  generally accepted government auditing standards. Those standards  require that we plan and perform the audit to obtain sufficient, appropriate  evidence to provide a reasonable basis for out findings and conclusions  based on our audit objectives. We believe that the evidence obtained  provides a reasonable basis for our findings and conclusions based on our  audit objectives. For details concerning our scope and methodology, see  appendix I. For a summary of our review of randomly selected claim  folders from the initial claim and the administrative appeal levels, see  appendixes II and III, respectively.
subsections: section_title: Background
paragraphs: SSA administers two programs under the Social Security Act that provide  benefits to people with disabilities who are unable to work: Disability  Insurance (DI) and Supplemental Security Income (SSI). According to SSA  policy, to be eligible for either DI or SSI, an adult must be unable to engage  in “substantial gainful activity”—typically work that results in earnings  above a monthly threshold established each year by SSA—because of a  medically determinable physical or mental impairment that is expected to  last at least 12 months or result in death. Established in 1954, the DI  program provides monthly benefits to workers (and their spouses and  dependents) whose work history qualifies them for disability benefits and  whose impairment is disabling. In 2007, SSA paid about $99 billion in DI  benefits to about 8.1 million workers, spouses, and dependents. The  average monthly benefit was $1,004 for disabled workers. SSI is a means- tested income assistance program created in 1972 that provides a financial  safety net for people who are aged, blind, or disabled, and have low  incomes and limited assets. Unlike the DI program, SSI has no prior work  requirements. In 2007, SSA paid about $37 billion in SSI benefits. As of  December 2007 about 7.4 million recipients received an average monthly  benefit of $468. Some individuals with disabilities receive both DI and SSI  benefits if they meet both DI’s work history requirements and SSI’s income  and asset limits.
subsections: section_title: Disability Determination Process
paragraphs: The process to determine a claimant’s eligibility for SSA disability benefits  is complex, involving several state and federal offices. The disability  determination process, which is the same for DI and SSI claimants,  involves an initial determination of disability and provides up to two levels  of administrative review within SSA. A claimant first completes an  application, or claim, for DI or SSI benefits, which includes information  regarding illnesses, injuries, or conditions and a signature giving SSA  permission to request medical records from medical care providers. Once  the SSA field office staff verify that nonmedical eligibility requirements are  met, the claim is sent to the state’s DDS office for determination of  medical disability. If the claim is approved, a claimant will be notified and  will receive benefits, including limited retroactive benefits for some DI  claimants. Additionally, if the claim is approved, a claimant may become  eligible for Medicaid or Medicare health coverage. If the claim is rejected,  a claimant has 60 days to request that the DDS reconsider its decision. If  the DDS reconsideration determination concurs with the initial denial of  benefits, the claimant has 60 days to appeal and request a hearing before  an SSA administrative law judge (ALJ). A claimant may appeal an  unfavorable administrative law judge decision to SSA’s appeals council,  which includes administrative appeals judges and appeals officers and,  finally, to federal court. SSA and DDS officials (examiners and ALJs)  determine disability using a five-step sequential process based on evidence  such as medical findings and statements of functional capacity obtained  during the initial determination process and updated as necessary at each  appeal level. (See fig. 1.)
section_title: Development of Medical Evidence for Initial Determinations
paragraphs: Generally, SSA requires DDSs to develop a complete medical history for  each claimant for at least a 12-month period prior to the application. SSA  guidance directs DDSs to request records from all providers who have  treated or evaluated the claimant during this time period, except those  who treated only ailments clearly unrelated to the claimed impairment.  DDSs generally pay providers for records and SSA pays the DDSs to cover  these expenses. Each DDS determines its payment rates for medical and  other services necessary to make determinations, subject to certain  limits. DDSs request laboratory reports, X-rays, doctors’ notes, and other  information used in assessing the claimant’s health and functional  capability from many types of providers including: physicians or  psychologists; hospitals; community health centers; schools (for child  claimants); and Department of Veterans Affairs (VA), military, or prison  health care facilities. In addition to medical evidence, DDSs review  statements from the claimant or others about the claimant’s impairment  and ability to perform daily activities. SSA directs DDSs to make “every  reasonable effort” to help the claimant obtain medical reports, which SSA  defines as one initial medical records request and, if needed, one follow-up  request within 10 to 20 days, when providers have not responded, unless  experience with a particular provider warrants more time. DDSs allow a  minimum of 10 days after the follow-up request for the provider to reply.  When records indicate the claimant has been to other medical providers,  DDSs also contact those providers for records. Generally records are  placed in the claimant’s case record.
SSA regulations require that disability determinations place more, and in  some cases controlling, weight on the opinions of a claimant’s treating  providers. For example, a treating provider’s opinion about the nature  and severity of the claimant’s impairment should generally be given  controlling weight where their opinion is well supported by other  substantial evidence in a claimant’s case record.
In claims where the gathered medical and nonmedical evidence is  insufficient to support a disability determination, DDSs may order  consultative exams or tests. DDSs pay providers to perform these  examinations and SSA pays them to cover these costs. SSA regulations  require that payments to providers for consultative exams not exceed the  highest rate paid by federal or other state agencies for the same or similar  services. The regulation allows states to determine the rates of payment  and, as a result, DDS rates of payment for consultative exams vary  nationwide. SSA regulations specify the types of providers who may  perform these exams or tests, and require DDSs to recruit, train, and  oversee them. SSA regulations also state that the claimant’s own provider  is generally the preferred source for consultative exams if qualified,  equipped, and willing to perform the exams. (See fig. 2.)
section_title: Claimant
paragraphs: To support DDSs’ efforts to process claims quickly, SSA has established an  expedited process for claims in which a determination of disability is  likely. In September 2007, SSA implemented its Quick Disability  Determination process nationwide after testing it in the Boston region.  This process uses a computer model using certain key terms in the claim  file to identify claims for which a decision of disability is likely and  medical evidence establishing disability can be easily obtained. DDSs can  use expedited processes for these claims; for example, DDS staff in a  couple of states we visited explained how they request and receive  medical records for Quick Disability Determination cases by fax. SSA  reported, for fiscal year 2007, that the national average processing time for  all initial claims was 83 days. By comparison, during the pilot, the Boston  region decided Quick Disability Determination claims in an average of 11  days. SSA also has policies to expedite claims involving diseases such as  certain types of cancer that are terminal or otherwise so severe that they  clearly meet SSA’s definition of disability.
SSA performs a quality assurance review of a sample of more than 30,000  DDS decisions each year. SSA assesses the accuracy of the DDSs’  determination and the sufficiency of the documentation for the DDSs’  compliance with requirements for medical records collection and  consultative exams process. Decisional deficiencies occur when a  different determination should have been made, and documentation  deficiencies occur when additional documentation is necessary in order to  make the correct determination. SSA also collects extensive data on  spending for consultative exams and requires DDSs to routinely report  substantial budget, program operations, and management data to SSA.
section_title: Electronic Medical Record Collection
paragraphs: In 2004, President Bush called for widespread adoption of interoperable  electronic health records within 10 years and issued an executive order  assigning the coordination of the effort to the Department of Health and  Human Services. Under the department’s leadership, volunteer  organizations designated to develop standards for the health care industry  have prepared initial certification criteria for health information  technology such as electronic patient records and records management  systems. As businesses, providers decide when and whether to invest in  these certified systems. Another executive order in 2006 directs certain  federal agencies to “utilize, where available, health information technology  systems and products that meet recognized interoperability standards.”  HHS also has awarded several contracts related to health information  technology to address issues such as standardization, networking, and  privacy and security. SSA collection of medical evidence is affected by the  Health Insurance Portability and Accountability Act of 1996 (HIPAA)  which defines the circumstances in which an individual’s health  information may be used or disclosed. In addition, HIPAA’s security  provisions require entities that hold or transmit health information to  maintain reasonable safeguards to protect the information against  unauthorized use or disclosure and ensure its integrity and confidentiality.
section_title: DDSs Face Challenges Obtaining Medical Records from Claimants’ Providers
paragraphs: Determining eligibility for disability benefits is a complex, challenging  task. DDS officials identified obtaining records from claimants’ medical  providers as a major challenge to DDS examiners’ ability to quickly  compile the necessary evidence for disability determinations. DDSs cited  problems with the consistency of provider response to record requests,  both in timeliness and completeness of records submitted. DDSs have  responded to these challenges by conducting additional follow-up contacts  with medical providers and claimants, and more than half of the 51 DDSs  we surveyed reported adjusting their payment methods. Although SSA  routinely reviews DDSs’ compliance with medical records collection  requirements, SSA does not systematically identify and review the  effectiveness of promising DDS medical evidence collection practices.
subsections: section_title: Medical Providers Do Not Respond Consistently to DDS Requests for Records
paragraphs: DDS officials identified provider response to medical records requests as a  challenge in our survey of 51 DDSs. One DDS director reported in our  survey that more than 300 providers in the state were considered  “nonproductive” so that the DDS must send claimants who are patients of  those providers to consultative exams when evidence from other sources  is insufficient. One DDS director noted that public health clinics and  hospitals are overburdened providing patient care and that medical  records programs get short shrift. According to both DDS officials and  providers we interviewed, generating records for disability claims takes  lower priority than patient care and costs money for medical records staff  time and contracted copy services, for example. One DDS official told us  that some providers do not bill the DDS for records because the state’s  centralized payment system is slow and generates payments that are hard  to reconcile with invoices. Examiners in another state told us that some  providers refuse to submit requested records for claimants with unpaid  bills, or charge the claimants instead of the DDS. DDSs also can have  difficulty obtaining medical records when medical records are purged or  moved to another location, or when facilities close or are destroyed.
DDSs request records from all providers who have treated the claimant for  at least the 12 months preceding the application for benefits, except those  who treated only minor ailments clearly unrelated to the claimed  impairment or when the claimed disability began more recently. As a  result, the volume of records requested is high: 13 DDSs reported sending  over 200,000 requests in fiscal year 2007. Provider response to these  requests for medical records is inconsistent; some submit records to the  DDSs within 10 days, others never respond at all. Timeliness of medical  record receipt is a central concern because SSA tracks how long it takes to  process initial claims, and measures DDSs against regulatory performance  standards. SSA reported that the national average processing time for  initial claims was 83 days in fiscal year 2007. Although not all DDSs were  able to complete our survey question on the volume of medical record  requests and timeliness of provider responses, 32 of the 37 DDSs who did  provide numbers reported receiving responses for up to 40 percent of their  requests for medical records within 10 days. However, a substantial  number of requests for medical records go unfulfilled. As shown in figure  3, 14 DDSs received less than 80 percent of requested records. Another 14  DDSs did not provide sufficient data in response to our survey to calculate  the percentage of requests for which they received medical records.
DDS examiners request records from various types of providers including  physicians or psychologists in individual or group practices; hospitals;  community health centers; schools (for child claimants); and VA, military,  or prison health care facilities. As shown in table 1, DDS directors we  surveyed reported that some types of providers are more responsive to  medical records requests than others.
The task of obtaining a complete medical history is further complicated  when claimants do not identify all their medical providers when applying  for benefits. Almost all of the 51 DDS directors (48) we surveyed reported  that examiners at least sometimes identify providers who had not been  listed on the claimant’s application. Examiners may find out about  additional medical providers as they review the records in the file, for  example, and must generally request records from those providers. In our  review of 100 initial claim files, we identified 19 in which DDS examiners  requested records from providers who had treated the claimant but had  not been identified on the application.
In addition to contacting multiple providers, DDS examiners must develop  evidence for all of the claimed impairments, which can be numerous and  include both mental and physical conditions. During our site visits, DDS  claims examiners told us that claims involving mental impairments posed  particular documentation challenges, noting that some claimants with  mental impairments may have difficulty obtaining treatment or accurately  describing their medical histories. Furthermore, SSA regulations include  some specific requirements for collecting evidence of mental impairments.  For example, generally where there is indication of a possible mental  impairment, SSA regulations establish a special technique to be used when  evaluating the severity of mental impairments, which includes rating the  claimant’s degree of functional limitation in four broad functional areas  and recording the results of this evaluation on a standard document.
The opinions of providers with an ongoing treatment relationship with the  claimant are a particularly important source of evidence for disability  determinations. Treating providers’ opinions about the nature and severity  of the claimant’s impairment often are given great deference in SSA  regulations. Examiners must give controlling weight to treating providers’  opinions if they are not inconsistent with the other substantial evidence in  the case record and are well supported by medically acceptable clinical  and laboratory diagnostic techniques. Yet, of the 51 DDSs we surveyed,  none reported that half or more were willing to provide such opinion  statements, and 15 indicated that none or almost none were willing to  provide the statements. Almost all DDSs (48 of 51) reported asking for  treating sources’ opinion statements in their initial medical records  requests, but as table 2 shows, DDSs are not always successful at  obtaining those statements, even after multiple requests, and the  statements they receive are not always helpful in making their  determinations.
A good and useful MSS  both states a quantification of the  effects of the condition on the claimant’s ability to function and an explanation as to  how the assessment is supported by the evidence. These are rare. More often we  receive “less useful” MSS’s that only do the first part. Treating sources are generally OK  with just sending records or including a statement such as “the patient has severe  rheumatoid arthritis, remains under my care, and can’t return to work for the  foreseeable future.” When we get such an MSS, we either are left to refute it or return it  to the TS  for a better underlying analysis. This annoys them and  usually does not come to a beneficial or happy result.
DDS officials and providers described various reasons why treating  providers may be reluctant to submit medical source statements. Treating  providers may be concerned that submitting their medical opinion to the  DDS might interfere with the doctor-patient relationship, and they also  typically focus on diagnosis and treatment rather than evaluation of  functional ability. Providers also may have limited knowledge of SSA  standards or the physical or mental requirements for different types of  work.
section_title: Almost All DDSs Engage in Additional Follow-up Contacts to Encourage Provider Response; about Half Have Modified Their Payments
paragraphs: SSA regulations and guidance specify the timing of DDS requests for  medical records but leave the methods of contact up to each DDS. If it  does not receive records after one request, the DDS must make one  follow-up request within 10 to 20 days unless the provider is known to take  longer to respond. After that, the DDS must generally give the provider an  additional 10 days and then may send the claimant for a consultative exam  if needed. Requests by mail remain the most prevalent method for  requesting medical records, used at least very often by 42 of the 51 DDSs  surveyed. All use fax to some extent, with slightly more (27) reporting they  use fax at least often and 24 reporting using fax sometimes.
During our site visits, 6 of the 28 DDS examiners we interviewed told us  that some providers raise concerns about privacy or compliance with  HIPAA, for example, by insisting on a hard copy of the claimant’s signed  authorization to release medical records. According to SSA, hard-copy,  fax, or electronically transmitted versions of its official authorization form,  signed and dated by the claimant, all comply with relevant state and  federal laws and regulations, including HIPAA.
Once records are received, the DDS may need further contact with  providers to clarify ambiguities or request additional information. SSA  guidance require examiners to recontact a provider whose medical report  contains ambiguities, conflicts either internally or with other evidence, is  incomplete, or is not based on medically acceptable clinical and laboratory  diagnostic techniques. In addition, SSA guidance directs the DDS’s  examiners to recontact a treating provider if the report contains an  opinion on an issue reserved for SSA, such as whether the claimant is  disabled or has a condition that meets one of the medical listings, without  identifying the basis for that opinion.
If the initial recontact SSA requires is not successful, DDSs report  pursuing additional approaches to encourage providers to submit or  clarify records. These include making additional follow-up calls to  providers, their assistants, or medical records staff and asking claimants to  get in touch with their providers about sending in the records. In addition,  DDSs conduct outreach to emphasize the importance of submitting  medical records and contact providers to resolve questions about privacy.  Privacy of medical records came up frequently in our discussions of the  medical evidence collection process: DDS officials in each of the five  states we visited indicated that some providers relay concerns about  patient privacy and compliance with applicable protections.
DDS professional relations officers also supplement the examiners’  contacts via provider education and outreach to medical societies. If  information in the medical records requires clarification, DDS medical  consultants, such as physicians or psychologists, also may contact  providers directly. SSA guidance permits DDSs to obtain verbal  statements from treating providers, then send summaries of those  statements to the providers for their signatures to expedite the DDS  determination process.
In addition to following up with providers and claimants, more than half of  the 51 DDSs we surveyed reported modifying their payment methods for  medical records. To encourage provider response, 34 of the 51 DDS  directors surveyed reported taking steps to improve the timeliness of their  payments and 6 reported increasing their payment amounts. While only 30  DDS directors reported in our survey that their payment rates were high  enough to ensure adequate medical records collection, some DDS  directors commented that they had heard from some types of providers  that their rates were not adequate; psychologists or other specialty  providers, for example, reported that payments were adequate for some  types of providers but not others. Asked in the survey how their payment  rates compare with prevailing rates for medical records in their states, 3 of  the 51 DDSs reported that their payment rates were above prevailing rates  in their states, 19 reported that the rates were about the same, and 20  reported that their payment rates were below prevailing rates. Vermont’s  DDS instituted an incentive payment for prompt response because that  state prohibits providers from charging for providing copies of health care  records requested to support a claim or appeal under any provision of the  Social Security Act or any other federal or state needs-based program.
section_title: SSA Conducts Quality Assurance Reviews, but Does Not Gather Some Key Data on Varied DDS Approaches to Collecting Medical Records
paragraphs: While SSA conducts quality assurance reviews and collects data on  program operations from DDSs, it has not systematically evaluated the  effectiveness of the DDSs’ varied approaches to collecting medical  records. SSA regularly reviews DDSs’ compliance with requirements for  medical records collection as part of its quality assurance review of a  sample of more than 30,000 DDS decisions each year.
These reviews take place before the DDS determination is communicated  to the claimant, and SSA returns the claim to the DDS for additional work  if SSA reviewers find that additional medical evidence or analysis is  needed. These reviews assess both the accuracy of the DDSs’  determinations and the sufficiency of the documentation the DDSs  obtained. Decisional deficiencies occur when the DDS should have made a  different determination, and documentation deficiencies occur when  additional documentation is necessary in order to make the correct  determination. Errors related to the collection of medical evidence include  cases in which insufficient medical evidence was obtained to support the  DDS determination, for example, to establish that the claimant’s  impairment is severe or expected to last at least 12 months or result in  death.
SSA also requires DDSs to routinely report substantial budget, program  operations, and management data to SSA. While these data help SSA  oversee the DDSs, they may lack some key measures that SSA could use to  evaluate the effectiveness of different DDSs’ medical records collection  practices. For example, not all DDSs’ computer systems routinely track  the total number of requests they send and the timeliness of provider  responses. Of the 51 DDS directors we surveyed, 14 did not provide  complete responses on the number of medical record requests they sent  and received responses to, and others were able to provide only estimates.  The lack of consistent data on receipts of medical records from providers  limits SSA’s ability to evaluate the effectiveness of different DDSs’ medical  records collection activities—evaluations which could lead to wider  adoption of practices that are found to be successful and cost effective.
Nationally consistent data could help SSA assess whether some DDSs’  approaches are more effective than others or whether adoption of new  approaches, such as incentive payments for prompt provider response,  yields faster submission of records.
section_title: DDSs Face Challenges Recruiting and Retaining Qualified Consultative Exam Providers
paragraphs: Recruiting and retaining enough medical providers to conduct consultative  exams was frequently cited by DDS representatives as one of the main  challenges to medical evidence collection, in part because of provider  concerns about missed appointments or DDS payment rates for  consultative exams. Responses to these challenges include scheduling  consultative exams with medical providers whose practices focus  primarily on performing disability evaluations and adjusting payments, for  example, by paying providers for the time they spend preparing for a  consultative exam that a claimant fails to attend.
subsections: section_title: Recruitment and Retention of Consultative Exam Providers Is Difficult
paragraphs: We frequently heard from DDS directors, both during our site visits and in  response to our survey, about their difficulty finding medical providers to  conduct consultative exams. It is even difficult for DDSs to obtain  consultative exams from claimants’ treating physicians—the preferred  source for consultative exams according to SSA guidance and  regulations. For example, 41 of the 51 DDS directors we surveyed  reported that their offices routinely ask claimants’ treating providers if  they are willing to perform a consultative exam if needed, but 34 of these  directors reported that claimants’ treating providers are never or almost  never willing to perform these exams. According to DDS officials and  providers, reasons for this reluctance may include concern about  disrupting the doctor-patient relationship through involvement in the  disability claim and dissatisfaction with DDS payment rates. These  inquiries often are included in the requests for medical records sent by the  DDSs to claimants’ treating providers. For example, in our review of 100  claim files for initial disability determinations, 45 files contained one or  more requests for medical records that included an inquiry about the  providers’ willingness to perform a consultative exam. However, only 2  claimants’ files had records of consultative exams conducted by the  treating provider. In many cases, DDSs make this request in the form of a  yes or no question that accompanies their requests for medical records or  by asking providers to contact them if they would be interested in  performing a consultative exam. Often providers either indicate they are  not willing to perform a consultative exam or leave the question blank. In  some cases, the requests for records indicate that the absence of a  response will be interpreted as an indication that they are not interested.
One reason why the DDSs may face difficulty recruiting and retaining  consultative exam providers is the frequency with which disability  claimants miss their consultative exam appointments. DDS directors  reported in our survey that claimants fail to attend approximately 16  percent of consultative exam appointments on average, with 40 of the 51  directors providing this information. When asked the reason why  claimants fail to attend these appointments, DDS directors reported that  claimants sometimes miss appointments for reasons including  transportation challenges, unmet needs for someone to accompany the  claimant to the appointment, reluctance to take part in the exam, or  inability to attend due to a mental or physical health condition. Regardless  of the reason for claimants’ failure to attend scheduled exams, several  DDS examiners we spoke with identified missed consultative exams as a  major problem which may affect providers’ willingness to participate. If a  claimant misses an appointment, providers lose revenue if they are unable  to substitute another patient and cannot bill the DDSs for the missed  exam. When asked to what extent provider concerns about missed  consultative exam appointments posed challenges, almost half of DDS  directors (24 of 51) reported that such concerns posed challenges to a  great or very great extent, although some DDSs (20) reimburse providers  for time spent preparing for missed consultative exams.
Current payment rates also may contribute to the DDSs’ challenges  recruiting and retaining consultative exam providers who submit high- quality reports. Almost all DDS directors (50 of 51) reported that DDS fee  schedules posed a challenge, at least to some extent, to recruiting and  retaining a panel of highly qualified consultative exam providers. Several  DDS officials told us current consultative exam payment rates affect their  ability to recruit and retain consultative exam providers in their states. For  example, California DDS officials commented that current consultative  exam payment rates are below prevailing payment rates in the state.  Wyoming DDS officials also told us that payment rates pose challenges to  the recruitment of providers for Wyoming’s consultative exam provider  pool.
Consultative exam payment varies among DDSs nationwide. SSA  regulations require that payments to providers for consultative exams not  exceed the highest rate paid by federal or other agencies in the state for  the same or similar services. Within those parameters, DDSs vary in the  type of payment rates they use as benchmarks for consultative exams.  (See fig. 4.)
Many DDS directors (17 of 51) also indicated that in their opinion current  payment amounts in their states are not high enough to ensure that the  DDS receives timely, high-quality consultative exam reports. For those  DDSs, seven also reported that consultative exam reports only sometimes  demonstrated sufficient familiarity with the claimants’ medical records  and history to support the assessment.
section_title: Some DDSs Rely on High- Volume Consultative Exam Providers or Pay Providers for Preparing for Missed Appointments
paragraphs: Some DDSs have adopted responses to the challenge of recruiting and  retaining consultative exam providers by (1) relying on high-volume  providers whose practices focus primarily on performing disability  evaluations and (2) adjusting consultative exam payments. As shown in  figure 5, most DDSs (32 of 51) report they often use high-volume providers  to conduct consultative exams for claimants in their state. Twenty-nine  indicated that using these providers has a moderately positive or very  positive effect on the quality of the consultative exam reports they receive.
At least one DDS has taken the concept of high-volume consultative exam  providers one step further. The New York DDS expanded its use of high- volume consultative exam providers by hiring contractors to recruit  consultative exam providers and manage claimants’ appointments. New  York DDS officials reported that the majority of consultative examinations  now are conducted through these contractors in areas of the state covered  by contracts. As described to us by New York DDS officials, these  contracts provide for extensive training of new consultative exam  providers that can last several months, content and timeliness  requirements for exam reports, and quality assurance including surveys of  claimants and inspection of providers’ facilities.
Some DDSs have adjusted their payments for consultative exams to  address recruitment challenges in their states. For example, Wyoming  currently pays usual and customary rates that providers receive for similar  exams throughout the state. Wyoming DDS officials reported that they  make use of such a structure due to the sparse population and small  number of medical providers that service their state, approximately 1,000.  According to Wyoming DDS officials, a relatively small portion of these  providers are willing to perform consultative exams for the DDS and they  believe that without usual and customary payment, even fewer providers  would be willing to conduct them. In addition, many DDSs (20 of 51) pay  consultative exam providers for the time they spend preparing for exams  that claimants fail to attend, which may help DDSs retain their  consultative exam provider pool. Among those 20 DDSs reporting that  they offer such payments, the average payment provided was about $44.
Finally, DDSs engage in various activities to facilitate claimant attendance  at consultative exams. The most common activities reported are reminder  letters and telephone calls and reimbursement for travel costs (see table  3). Examiners at two of the DDSs we visited described arranging for  consultative exam providers to perform in-home evaluations for claimants  whose impairments kept them confined to their homes. Examiners noted  that “third parties”—family members or social workers listed as contacts  on the application for benefits—may help facilitate consultative exam  appointments, especially for claimants who are homeless or who have  mental or developmental impairments.
section_title: SSA Reviews Consultative Exams and DDS Decisions, but Does Not Evaluate DDS Practices to Address Recruitment and Retention Challenges
paragraphs: While SSA evaluates consultative exams as part of its quality assurance  review process and collects data on spending for consultative exams, it  has not evaluated the effectiveness of varied DDS responses to challenges  related to recruiting and retaining consultative exam providers. SSA  reviews consultative exams as part of its ongoing quality assurance  reviews of more than 30,000 randomly sampled initial disability  determinations. SSA reviewers assess the claim file for errors including  unnecessary consultative exams; consultative exam from an improper  source (such as failure to use a psychiatrist or psychologist to evaluate a  mental disorder); or incomplete, inadequate, or unsigned consultative  exam reports.
Despite these overall quality reviews, SSA officials indicated they were  unable to locate any studies SSA has conducted to evaluate the  effectiveness of varied DDS collection practices. By undertaking such  studies, SSA program managers could identify promising DDS practices to  recruit and retain consultative exam providers or evaluate their  effectiveness and potential for wider adoption and thereby improve  accountability by facilitating wider adoption of DDS practices with the  potential to help the agency achieve its service delivery goals, such as  making the correct decision early in the process. SSA currently does not  collect some information, such as nationally comparable data on missed  consultative exams, that could help SSA evaluate DDS practices that may  hold promise for improved recruitment and retention of consultative exam  providers in other states.
section_title: SSA Has Made Progress in Moving to Electronic Collection of Medical Records, but Faces Challenges Shifting to the Use of Electronic Medical Records
paragraphs: SSA’s transition from paper medical records to the use of electronic  images of medical records has increased opportunities for program  efficiencies and agency collaboration. SSA prefers and encourages  providers to submit medical records online, but it continues to receive a  little more than half of these records in paper form. SSA has only  conducted limited studies of the problems related to electronic submission  of medical records and has not taken additional steps necessary to  facilitate greater use of online submission options. In anticipation of the  medical community’s replacement of paper with uniform electronic  medical records, SSA is developing procedures to electronically request  and receive electronic medical records and analyze them in ways that are  expected to make the medical evidence collection process and disability  decision making more efficient.
subsections: section_title: Use of Electronic Images Enables SSA and DDSs to Collaborate More Efficiently
paragraphs: As a step toward automating its disability process, SSA has successfully  adopted the use of electronic images of medical records instead of paper  copies for new claimants. Electronic images of medical records—records  scanned, faxed, or uploaded into SSA’s computer database—are an  important step in SSA’s transition to an automated process, as these  images can be submitted, stored, and accessed electronically by  authorized staff from distant locations. Electronic medical evidence—even  in the form of electronic images—facilitates collaboration between SSA  and DDSs. For example, electronic files have enabled SSA to implement a  new process for resolving disagreements concerning DDS disability  decisions reviewed by SSA before initial decisions are finalized. Rather  than having SSA reviewers in each regional office review DDS decisions  only in that region, electronic access to records enables staff in other  regions and policy staff in SSA headquarters to review cases remotely. SSA  introduced this process to promote more nationally consistent  interpretations of SSA policy. Additionally, SSA and DDSs are able to shift  workloads from office to office without mailing records, which takes time  and increases the risk that records will be lost. However, SSA officials and  DDS directors told us electronic image records have limitations in that  they cannot be electronically analyzed and searched.
Almost all surveyed DDS directors (50 of 51) reported that having medical  records in electronic folders has increased productivity, but some  indicated that frustrations exist, such as some computer system usage  problems. For example, several DDS examiners told us they were  frustrated by occasional data system interruptions, due in part to  performance problems with SSA’s computer system. The SSA system  manages large amounts of data across multiple SSA and DDS computer  systems. Over half of DDS directors (27 of 51) reported that one of the  challenges to medical evidence collection was performance problems with  SSA’s integrated computer system, and most (38 of 51) reported that  improvement in the stability or responsiveness of the system would add a  great or moderate value to the DDSs’ medical evidence collection efforts.
section_title: SSA Has Made Progress in Developing Options for Submitting Records Electronically, but More than Half Are Still Submitted on Paper
paragraphs: One of SSA’s goals is to receive all medical records electronically. SSA  maintains several avenues for providers to submit medical evidence  online, and nearly all DDS directors (48 of 51) reported that DDS outreach  to providers very often addressed options for electronic submission.  Some providers, however, have told DDS officials they find SSA’s online  submission options inconvenient, difficult to use, or beyond their technical  expertise. For example, many providers do not use SSA’s Electronic  Record Express Web site to submit records, although it was designed to  provide an efficient option for submitting medical records. This Web site  limits the number of files that can be sent at one time, which is  problematic for large providers such as big hospitals or medical centers.  Additionally, infrequent users must call a designated DDS official to reset  expired passwords if too much time has passed between submissions.  SSA officials told us some providers opt to pay a commercial service to  submit medical records, because the service provides for the submission  of many files at once, which can be a more efficient option for providers of  large volumes of medical records. SSA has recently deployed its own tool  for submission of many files at once, called Webservices, but to use this  option, medical providers must develop their own software interface to  SSA’s Web site. Although SSA provides some technical support, some  providers may still find this option beyond their technical expertise. As of  November 2008, only two medical record providers were using  Webservices. SSA officials noted that additional providers have expressed  interest in using WebServices but the agency temporarily limited its use to  these two because of limits on the system’s capacity that it intends to  resolve after a planned upgrade.
DDS professional relations officers at a 2007 conference of the National  Association of Disability Examiners noted various difficulties they face  encouraging providers to use SSA’s Web site for submitting evidence  online. In order to use online options for submitting medical records to  SSA, some providers with electronic medical record systems may either  need to convert files or print and scan them. In some cases, providers may  find this too time consuming to be feasible. Although some providers have  registered as Web site users, the difficulties encountered were enough to  make them stop using it. A DDS professional relations officer said that  they were getting so many calls from providers having problems with the  Web site that they had to designate someone to handle the calls. On the  other hand, the Mississippi DDS had early success encouraging providers  to use the Web site by contracting with a former SSA official who provided  detailed “start to finish” guidance on how to use the Web site.
SSA held conferences in two cities in March 2008 to give its Web site users  an opportunity to express their concerns, and made some modifications to  the Web site in July 2008, but SSA has conducted only limited study of the  problems with electronic submission of medical records or analyzed the  barriers various groups of providers face using the site (such as small- and  medium-volume users), and they have not developed a strategy for  overcoming these barriers. The agency has made progress responding to  some user concerns, for example, by enabling claimants’ representatives  to view clients’ folders online, but SSA has not developed a strategy to  address the concerns of other user groups.
SSA’s efforts to realize its electronic submission goal also are hindered by  the uneven pace of the medical community’s acceptance of electronic  records. Despite a presidential call for widespread adoption of electronic  health records by the year 2014, the Robert Wood Johnson Foundation  estimated that less than one-fifth of responding U.S. physicians (17  percent) had at least basic electronic health records and only about 4  percent had fully functional electronic records systems.
Nationwide, in September 2008, SSA received 52 percent of records for  disability claims on paper, 21 percent through online submission, and 27  percent by fax. (See fig. 6.) One large provider accounts for most of the  records SSA receives online. In September 2008, 57 percent of online  submissions came from this large medical record copy service. We found  variation among the DDSs in the percentages of records received online.  In September 2008, 13 DDSs received more than 25 percent of records  online while another 11 DDSs received less than 10 percent. DDSs varied  in the percentage of records received by electronic fax, with 10 DDSs  receiving less than 15 percent of records by fax, and 5 DDSs receiving  more than 50 percent. Although providers have submitted an increasing  share of records via fax and online over the last few years, the growth in  nationwide use of online submission options has slowed in recent  months.
section_title: SSA Is Beginning to Transform Its Process with Computer-to-Computer Requests and Receipts of Records in Uniform Formats
paragraphs: While encouraging providers to submit medical records electronically  speeds the collection of medical evidence, SSA is participating in  preliminary tests of new computer processes that are expected to bring  substantial additional efficiencies. With these new procedures, SSA  computers request and receive electronic medical records directly from  providers’ computers—records in uniform formats that SSA’s computer  system can search and use to begin analysis of the claimant’s condition.  The electronic images of medical records they currently use are not as  suited for analysis as are electronic medical records in uniform formats.
For example, currently, DDS examiners cannot electronically search a  record or file for particular diagnoses and test results. Instead they must  review all the medical records—hundreds of pages of records in some  cases—in order to find the pertinent evidence. Most surveyed DDS  directors (32 of 51) reported that options for submitting medical evidence  in these new formats would be of great or very great value. In its strategic  plan for fiscal years 2008 to 2013, SSA established a goal to transform its  medical evidence collection process by automatically requesting and  receiving electronic medical records through a nationwide health  information network. This network is expected to enable medical  providers to securely exchange electronic medical records in uniform  formats. This will enable SSA to automatically search and analyze the  records at the start of the disability determination process. Software will  flag medical records that contain references to diagnoses and tests  specified in SSA’s medical listings, and thus help examiners promptly  determine whether claimants have impairments that qualify as disabilities.
To help encourage the use of these processes, SSA is working with other  agencies and health providers to develop electronic methods to request,  receive, and analyze electronic medical records. For example, SSA and a  Boston hospital have launched a prototype effort by which SSA  electronically queries the hospital’s computer and retrieves the hospital’s  electronic medical records for specific claimants. SSA plans to expand  the Boston initiative to additional providers in the future. However,  industry standards and protocols need to be further developed before this  process can be replicated widely. For example, standards have only  recently been developed for the document format used in the Boston  initiative called the “continuity of care document.” This format is an  electronic exchange standard for sharing patient summary information. In  addition, challenges remain in electronic authorization procedures  designed to protect the privacy of patients’ health records, as we have  reported in previous reports and testimonies.
section_title: Conclusions
paragraphs: The collection of medical evidence in the disability determination process  poses many challenges. The DDSs are operating in a high-volume  environment and must balance reasonable efforts to obtain complete  medical information with the need for timely determinations. Medical  providers have constraints on their time and resources as well, and  typically focus on diagnosis and treatment rather than assessment of  functional ability. The difficulties some DDSs have in obtaining requested  medical records and ensuring that claimants attend consultative exams  suggest opportunities for continued improvement in the medical evidence  collection process. Some DDSs have independently developed varied  approaches to respond to these challenges; and all DDSs might benefit  from learning from one another and testing and adopting some of these  approaches, as appropriate. SSA, however, currently lacks some important  data necessary to evaluate these approaches and identify promising  practices, which might be shared to promote more timely and complete  collection of relevant medical evidence by all DDSs.
Meanwhile, SSA efforts to improve the use of consultative examinations  and the collection of medical records proceed as the medical community  undertakes a major transformation from paper to computer records. With  a presidential goal of widespread adoption of electronic medical records  by 2014, increasing numbers of providers may have certified electronic  records systems capable of fulfilling DDS records requests in electronic  formats. As a high-volume user of these records, SSA has incentives to  keep pace with industry standards. As such, the prospect of electronically  requesting and receiving medical records being explored by SSA and a  Boston hospital, and in the development of the nationwide health  information network, among other projects, holds promise for achieving  even greater efficiencies in medical evidence collection for disability cases  in the long run. In the near term, SSA has opportunities to realize greater  efficiencies in the collection of medical evidence by encouraging providers  to submit records online, saving both time and money by dispensing with  inefficient copying and scanning. SSA has taken measures to improve its  online submission options, but some providers continue to face difficulties  using them and utilization remains limited. Reasons for this are unknown,  even to SSA. An evaluation that studies the utilization of SSA’s online  submission options, identifies barriers to wider usage, and develops  strategies to address these barriers, may help SSA identify cost-effective  ways to encourage wider use of online submission methods, especially as  more providers begin to use electronic medical records.
section_title: Recommendations for Executive Action
paragraphs: To foster timely and effective collection of medical evidence for disability  determinations, we recommend that the Commissioner of SSA identify  DDS medical evidence collection practices that may be promising,  evaluate their effectiveness, and encourage other DDSs to adopt effective  practices where appropriate. As a part of these evaluations, the  Commissioner should work with the DDSs to find cost-effective ways to  gather consistent data on the effectiveness of DDS medical evidence  collection activities. Such data should include key indicators, such as the  proportion of requests that yield medical records, the timeliness of  medical record receipts, and how frequently claimants fail to attend  consultative exams.
To achieve a more timely and efficient collection of medical records by  encouraging medical evidence providers to submit records electronically,  until the nationwide health information network is in operation, we  recommend that the Commissioner of SSA conduct an evaluation of the  limited utilization of its online submission options. This evaluation should  include an analysis of the needs of small, medium, and large providers;  identify any barriers to expanded use; and develop strategies to address  these barriers.
section_title: Agency Comments
paragraphs: We provided a draft of this report to officials at SSA for their review and  comment. In its comments, SSA agreed with our findings and  recommendations. Specifically, SSA noted the need for consistent  nationwide data but indicated that this is complicated by fact that each  DDS uses one of 5 separate case processing systems. To address this  limitation, SSA plans to include consistent management data in its  common disability case processing system, currently in the planning stage  with implementation to begin in 2011. The agency also described current  and planned activities to identify and address barriers to electronic  submission of data. SSA’s comments are reproduced in appendix IV.
We are sending copies of this report to the Commissioner of SSA and  others who are interested. The report is also available at no charge on  GAO’s Web site at http://www.gao.gov.
Please contact me on (202) 512-7215 if you or your staffs have any  questions about this report. Other major contributors to this report are  listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine how Disability Determination Services (DDS) and the Social  Security Administration (SSA) collect medical evidence, we used four  primary sources of information: (1) a survey of the 51 DDSs including all  50 states and the District of Columbia; (2) in-depth interviews and site  visits with 5 states; (3) a review of 100 randomly selected initial claims  files and 50 claim files at the appeals level; and (4) analysis of SSA data  concerning disability determinations. To assess progress in moving from  paper to electronic collection of medical evidence, we reviewed SSA  documents concerning SSA and the health industry’s efforts and analyzed  data compiled by SSA’s computer system regarding receipts of evidence  and discussed efforts to encourage electronic submission with SSA and  DDS officials, as well as several medical providers.
subsections: section_title: GAO Survey of DDS Directors on Collection of Medical Evidence for Initial DDS Disability Decisions
paragraphs: Our survey of DDSs addressed the timeliness of provider responses to  DDS requests for medical records, practices and challenges associated  with collecting medical records, practices and challenges associated with  obtaining consultative exams, outreach to the medical provider  community, and SSA and DDS initiatives associated with medical evidence  collection. We pretested the complete survey questionnaire at four of the  five DDSs we visited during our site visits and tested selected questions  during our fifth DDS site visit. We revised our questionnaire following  these pretests, incorporating suggestions and feedback from DDS and SSA  regional office officials who reviewed the draft questionnaire during these  pretests. In May 2008, we sent confidential access information to each of  the 51 DDS directors in the 50 states and the District of Columbia. We  received a response from all 51 of these directors, for a 100 percent  response rate.
We analyzed the survey responses and present selected results in our  report. In a few instances, we include results only from DDSs that  submitted complete responses and computed national totals from DDS- supplied information. For example, we limited our analysis of DDS  responses to questions about receipt of requested medical records to the  37 DDSs that provided the numbers of requested records received within  10 days, 11 to 20 days, 21 to 30 days, more than 30 days, and the number  not received. Several DDSs responded to some, but not all of these  questions, and other DDSs did not respond to any of these questions.  Some of the DDSs estimated their responses while others indicated they  were able to compute the information about medical record requests and  receipts from their database. One DDS director indicated that the number  of records not received included provider responses indicating that the  requested records were not available. Another indicated that the number  the DDS provided for records not received included instances in which the  DDS received records for which no payment was due. Checking with DDS  directors in our site visit states, we determined that some of these DDSs  used these same approaches, but others did not. In addition, we enforced  skip patterns that were published in the survey.
section_title: State DDS Site Visits
paragraphs: We visited DDS in five states—California, Mississippi, New York, Vermont,  and Wyoming—to gain a more detailed understanding of the medical  evidence collection process, related challenges, and the availability of  relevant data. At each of the DDSs we visited, we typically met with the  DDS Director, Professional or Medical Relations Officer, and the  Information Technology Specialist(s). SSA regional office representatives  joined us for some meetings as well. We also met individually with several  experienced claims examiners selected by the DDS directors in each state.  In addition to describing their collection practices and challenges, DDS  officials provided valuable feedback on the content and organization of  our questionnaire on medical evidence collection in advance of its release  to DDS directors in all 50 states and the District of Columbia. In California  and New York, we visited two of those states’ multiple DDS branch offices:  Sacramento and Oakland, California; and Albany and Manhattan, New  York. During each of these branch office visits we also spoke with  experienced claims examiners. The information we obtained from each  DDS we visited provided useful context to DDS operations and detailed  examples of DDS responses to challenges, but information from these site  visits is not intended to describe the operations of all DDSs.
We consulted a variety of factors in determining which DDSs to visit  including geographic diversity, size, type of administrative computer  processing system used, and SSA-provided performance data. These  performance data included productivity, accuracy, percentage of claims  with at least one invoiced medical record, percentage of all medical  records received electronically, and percentage of claims with at least one  consultative exam. We selected DDSs with both high and low indicators  on these measures to illustrate examples of states with a variety of  different medical evidence collection practices. The information we  obtained at our site visits is illustrative and not intended to reflect the  experiences of DDSs in other states. Table 4 presents some of the  indicators we consulted in selecting the five DDSs to visit.
section_title: Reviews of Random Samples of Claimants’ Folders
paragraphs: To obtain more detailed information about the medical evidence collection  process, we reviewed two sets of randomly selected, but not projectable,  samples of case files: (1) 100 initial disability claims files—electronic  folders containing documentation of the disability determination for  individual disability claimants and (2) 50 folders for claims decided at the  administrative law judge level (ALJ) or appeal. For results from these  reviews, see appendixes II and III.
To select these 100 initial disability claims folders, we reviewed all DDS  decisions during fiscal year 2007 for Supplemental Security Income (SSI)  and Disability Insurance (DI) disability benefits and excluded  reconsiderations, continuing disability reviews, reopenings, and informal  remands. For administrative purposes, we also excluded records that SSA  maintained using paper records, rather than certified electronic folders. In  order to avoid overrepresentation of claimants who filed for both SSI and  DI simultaneously (30 percent of DDS initial decisions in fiscal year 2007),  we eliminated duplicate listings of these claimants in our data set. We then  randomly selected 100 cases from among the approximately 2.3 million  cases in the selected data set.
These folders contained copies of SSA and DDS forms used in the  development of the case including documentation for both DI and SSI  claims. These documents often included medical evidence received from  physicians and other providers, claimant and third-party assessments of  the claimant’s functional abilities, reports from providers of consultative  exams of the claimant, forms providing evaluations of the evidence by  DDS medical consultants, DDS forms for obtaining medical source  statements from providers, forms and letters used to request medical and  nonmedical evidence, evidence submitted by the claimant or his or her  authorized representatives, and documents related to the disability  determination such as SSA form 831, and Personal Decision Notices and  similar notices for denied claims.
Similarly, to select a sample of cases decided by SSA ALJ hearings offices,  we obtained from SSA an extract of SSA’s Case Processing and  Management System data set managed by SSA’s Office of Disability  Adjudication and Review. We selected records for decisions by the ALJ  hearing offices during the first 6 months of fiscal year 2008 concerning  initial claims for SSI and DI disability benefits that had been denied at the  DDS initial level. Some had been appealed to the DDS (a  “reconsideration”) or to the federal reviewing official, while others were  appealed directly to the SSA ALJ hearing office. We also excluded records  for which SSA had paper records, rather than certified electronic folders.  We randomly selected 50 of these records. SSA staff prepared a CD for  each case folder. These electronic folders provided documents compiled  by SSA and the DDS during the initial determination, as well as additional  documents compiled subsequently, including those obtained during  reconsideration of the initial decision by the DDS, documents provided by  authorized representatives of the claimant, copies of medical evidence  concerning treatment and examinations after the initial determination,  medical source statements, an interrogatory, a deposition, and ALJ  decision documents.
section_title: Analysis of SSA Data
paragraphs: To obtain more detailed data concerning DDS collection practices and to  examine variations among DDSs, we obtained from SSA and analyzed a  variety of computerized data. These included data for  initial and reconsideration filings received, decided, and pending at year  end;  filings approved and denied; filings for which one or more medical evidence of record was purchased; filings for which one or more consultative exam was requested;    expenditures for purchase of medical records and consultative exams;    errors in DDS initial determinations identified by SSA quality assurance  the results of evaluations of medical records collected and consultative  exam reports by SSA quality assurance reviewers; and  responses to medical records obtained via methods, including paper and  faxed submissions, and online submission options such as SSA’s  Electronic Records Express Web site.
We used these data to summarize and compare how DDSs display these  data graphically. We also used these data to provide additional information  concerning the initial claim case files described above. To conduct limited  tests of the reliability of these data we obtained copies of 831 data and  Case Processing Management System data from SSA and compared results  provided by SSA with results from our analysis of these data sources.
section_title: Appendix II: Selected Results from Analysis of 100 Randomly Selected Initial Disability Cases
paragraphs: The following tables provide selected findings from our review of 100  randomly selected cases for claimants with initial DDS determinations in  fiscal year 2007.
section_title: Appendix III: Medical Evidence Collection Process at the Administrative Hearing Level
paragraphs: The process for collecting medical evidence at the administrative hearing  level typically differs from the process at the DDS level. If the claimant for  disability benefits is dissatisfied with the DDS’s initial decision, he or she  can appeal. In many cases the initial appeal is a request for a  reconsideration by the DDS. Then, if is the claimant is not satisfied with  the DDS decision, he or she can appeal and request a hearing before an  administrative law judge (ALJ), who will review the case in light of the  evidence gathered by the DDS as well as additional evidence obtained.  The responsibility for providing evidence to support the appeal falls on the  claimant. A claimant may be represented by an attorney or other  representative, to collect the additional evidence on his or her behalf. If  necessary evidence is not provided, the ALJ must attempt to fully and  fairly develop the evidence. Most claimants who appeal to an SSA hearings  office are represented by attorneys or others who enter into agreements  with SSA providing payment to the representative, which may be from a  specified proportion of awarded retroactive disability benefits in cases  where claimants win their appeal.
SSA requires ALJs to conduct a prehearing review of all evidence and  determine whether additional development is needed. Claimants’  representatives may submit updated medical records. If the ALJ is unable  to obtain adequate evidence, the ALJ also can request consultative exams  or tests. Similarly, if additional evidence is needed, the ALJ may have an  independent medical expert review the file and answer written  interrogatories, or testify at the hearing. Some ALJs ask the DDS to gather  additional evidence on their behalf. Others have SSA hearings office staff  gather evidence for the hearing. ALJs have additional options to obtain  opinion evidence from claimants’ providers, including sending  interrogatories or questionnaires, requesting testimony at the hearing, and,  under certain circumstances, issuing administrative subpoenas. Claimants’  representatives told us that letters describing the possibility of such  subpoenas are sometimes sent, but subpoenas are rare.
As part of SSA’s continuing efforts to reduce the backlog of claims at the  hearing level, it has implemented the Medical Expert Screening Initiative  Business Process. This is a new pre-hearing initiative to identify disability  claimants whose impairments are most likely to meet the requirements for  disability with a pre-hearing interrogatory sent to medical experts. If the  medical expert responses to the interrogatories show that a fully favorable  decision may be made on the record, without the need for additional  evidence or a hearing, the case is referred to an attorney adjudicator in  that hearing office to issue the decision, if warranted.
ALJs and DDSs use the same definition of disability, but use different  administrative guidance. SSA guidance for DDSs is included in SSA’s  Program Operations Manual System. Its counterpart for ALJs is called the  Hearings, Appeals, and Litigation Law Manual.
To obtain information on how medical evidence is collected at the ALJ  hearing level, we reviewed electronic copies of 50 claims that were  decided at the appeals level during the first half of fiscal year 2008. Claims  were randomly selected from all decided initial disability claims  nationwide which had a certified, fully electronic folder. The small sample  size means that the information we obtained from these selected cases  cannot be considered representative of all cases at the appeals level, but it  provides examples of how medical evidence is collected at the appeals  level. These included 34 fully favorable decisions, 1 partially favorable  decision (a changed date for onset of the claimant’s disability), and 10  unfavorable decisions. In 4 cases, the case was dismissed or the claimant  withdrew. The tables below summarize results from our review of these  cases:  ALJs often gather nonmedical as well as medical evidence to reach a  decision. They typically observe the claimant during the hearing, in- person, or by video conference. One ALJ wrote, for example,  “Furthermore, the state agency consultants did not adequately consider  that the claimant’s statements concerning the intensity, persistence and  limiting effects of these symptoms are generally credible.” Hearings also  sometimes involve evidence from vocational experts—experts in assessing  a claimant’s ability to perform various jobs. In 3 of the 50 cases reviewed,  the ALJ cited medical-vocational rules as the basis of their decision. By the  time the cases we reviewed were decided by the SSA hearings office,  medical evidence had typically been added that was not available at the  time of the initial DDS decision. In most of these cases, the claimant’s  representative collected the new evidence and submitted it to SSA. Often  this included evidence from sources that had not provided medical  records at the initial DDS level. In several cases the representative  obtained a medical source statement from a source that had not previously  submitted one, but had provided medical records. In 12 cases, evidence  indicated that the claimant’s condition proved more prolonged than the  DDS expected.
section_title: Appendix IV: Comments from the Social Security Administration
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Michael J. Collins, Assistant  Director; Benjamin P. Pfeiffer; Susan L. Aschoff; Alexander G. Galuten;  Catherine M. Hurley; Karen A. Jarzynka; Katherine N. Laubacher; Jennifer  R. Popovic; Suzanne C. Rubins; Meghan H. Squires; Vanessa R. Taylor;  Rachael C. Valliere; and Walter K. Vance, made key contributions to this  report.
section_title: Related GAO Products
paragraphs: Social Security Disability: Management Controls Needed to Strengthen  Demonstration Projects. GAO-07-331. Washington, D.C.: September 26,  2008.
Federal Disability Programs: More Strategic Coordination Could Help  Overcome Challenges to Needed Transformation. GAO-08-635.  Washington, D.C.: May 20, 2008.
Social Security Disability: Better Planning, Management, and Evaluation  Could Help Address Backlogs. GAO-08-40. Washington, D.C.: December 7,  2007.
High Risk Series: An Update. GAO-07-310. Washington, D.C.:   January 2007.
Disability Programs: SSA Has Taken Steps to Address Conflicting Court  Decisions, but Needs to Manage Data Better on the Increasing Number of  Court Remands. GAO-07-331. Washington, D.C.: April 5, 2007.
Social Security Administration: Agency Is Positioning Itself to  Implement Its New Disability Determination Process, but Key Facets  Are Still in Development. GAO-06-779T. Washington, D.C.: June 15, 2006.
Electronic Disability Claims Processing: SSA Is Proceeding with Its  Accelerated Systems Initiative but Needs to Address Operational Issues.  GAO-05-97. Washington, D.C.: September 23, 2005.
Social Security Administration: More Effort Needed to Assess Consistency  of Disability Decisions. GAO-04-656. Washington, D.C.: July 2, 2004.
Social Security Disability: Commissioner Proposes Strategy to Improve  the Claims Process, but Faces Implementation Challenges. GAO-04-552T.  Washington, D.C.: March 29, 2004.
Electronic Disability Claims Processing: SSA Needs to Address Risks  Associated with Its Accelerated Systems Development Strategy.  GAO-04-466. Washington, D.C.: March 26, 2004.
Social Security Administration: Strategic Workforce Planning Needed to  Address Human Capital Challenges Facing the Disability Determination  Services. GAO-04-121. Washington, D.C.: January 27, 2004.
SSA Disability Decision Making: Additional Steps Needed to Ensure  Accuracy and Fairness of Decisions at the Hearings Level. GAO-04-14.  Washington, D.C.: November 12, 2003.
Electronic Disability Claims Processing: Social Security  Administration’s Accelerated Strategy Faces Significant Risks.  GAO-03-984T. Washington D.C.: July 24, 2003.
Social Security Disability: Efforts to Improve Claims Process Have  Fallen Short and Further Action is Needed. GAO-02-826T. Washington,  D.C.: June 11, 2002  Social Security Disability: Disappointing Results from SSA’s Efforts to  Improve the Disability Claims Process Warrant Immediate Attention.  GAO-02-322. Washington, D.C.: February 27, 2002.
SSA Disability Redesign: Actions Needed to Enhance Future Progress.  GAO/HEHS-99-25. Washington, D.C.: March 12, 1999.