We have determined that your condition is not severe enough to be considered disabling.  In deciding this, we considered the medical records, your statements, and how your condition affects your ability to work….Doctors and other people in the State agency who are trained in disability evaluation reviewed the evidence and made the determination based on Social Security law and regulations….

Now it turns out that these “doctors and other people” are not so well trained, nor is it likely that they spent more than a few minutes reviewing your file.

An article in today’s Wall Street Journal entitled Doctor Revolt Shakes Disability Program, the Journal describes a system where Social Security administrators are pressing consulting physicians to work faster and to process more files to deal with a growing claims file backup.

Consulting physicians, many of whom are retired doctors looking to earn extra money are being asked to evaluate medical records outside their areas of specialty (such as a case where a pediatrician was asked to review a complex small fiber neuropathy case, or where an eye doctor was asked to review an orthopedic case).  SSA has also cut the case consulting fee for these doctors from $90 per hour to $80 per hour.

As a result of these changes, consulting doctors are leaving the program, further stressing the system and increasing delays.  One former consulting physician recalled that he was fired when he refused to complete a report about a medical issue outside his area of specialization.

What does this internal upheaval at Social Security mean to you?  I think it is fair to say that any progress SSA has made in reducing delays will be difficult to maintain given the increasing number of filings and the difficulty that the agency has in training and deploying trained personnel.

In my office, I no longer assume that Social Security claims adjustors will have time to track down and request copies of my clients’ medical records, or that they will have time to read these records.   In my office, we are taking more responsibility to obtain these records and to summarize them for the adjudicators, consulting doctors and, ultimately the judges.  If I can make the decision-maker’s life a little easier by giving him a reason to approve my deserving clients’ cases, then everyone will benefit.

Mental health evaluations, by contrast, often help your case – perhaps because psychologists and psychiatrists are generally not biased from being part of an adversarial workers’ compensation system and because mental health professionals often see a need for on-going therapy for many that they see.   To put this another way, physical medicine doctors face insurance company pressure and financial incentive to fix a problem as fast as possible, whereas mental health professionals are not looking for a “cure” as much as they are looking for gradual improvement over time, and thus on-going visits.

I have read literally thousands of physical and mental health consultative examination reports and as a rule the mental health evaluation reports usually offer some help, while the physical medicine reports either hurt my client’s case or offer no conclusions at all.

You may be wondering why you are being scheduled for either a physical, a mental evaluation or both?   The Social Security law requires the Commissioner of Social Security (and by extension, the employees of the agency) to help “develop” your medical record.   Consultative evaluations, therefore, would satisfy SSA’s statutory requirement even when considering the claims of applicants who have little or no medical treatment (due to lack of money or other causes).

Appeals courts considering the nature of SSA’s obligations have held that that consultative evaluations do satisfy SSA’s statutory duties to develop a claimant’s record.   SSA, presumably hoping to avoid further court challenges, orders consultative examinations in almost every case, even those where there are extensive medical records.

Why, then, would SSA schedule you for a mental health evaluation when your injuries are physical, or vice versa?  This question was posed to me in an email from one of my blog readers:

I was severely injured (multiple spinous fractures, spinal compression fractures, hip fracture) in a catastrophic train accident in London, England while on a business there in November 2010. I underwent spinal surgery in February 2011. I’ve undergone physical therapy since surgery, but have not recovered from my injuries and I continue to suffer debilitating pain in my back, neck and etremeties. I was seeing a psychiatrist leading up to my surgery because I was suffering mental trauma from the accident. I stopped seeing the psychiatrist after the surgery, principally because it was too difficult for me to get around. I’ve filed for disability from the SSA. My case is presently under review. I’ve hired a company to represent me in my claim. I just received a call from my SSA case worker asking me if I would see their pshyciatrist. I said I had no objection to this. My question: I don’t know why I need to see a psychiatrist if my claim is based on my physical disability, not any mental disability. Also, how should I approach my interview with the SSA psychiatrist?

Here are my thoughts:  first, I don’t necessarily presume that anything done by Social Security is inherently grounded in reason or logic.   It is possible that the adjudicator evaluating your case refers every claimant to both a physical and a mental health evaluation.

It is also possible that the adjudicator saw the psychiatric records in your file and that your treatment had stopped, and wanted more development.

Realize that a disability adjudicator (and ultimately a judge) has to justify his decision to approve (or disapprove) a case in writing.  In your case, I suspect that the adjudicator is looking for additional reasons to approve your case in addition to the obvious physical issues present.

Although not applicable to you, I have seen cases where an individual is referred to a psychiatrist or psychologist if there are suggestions of malingering or drug seeking behavior, or if the physical impairments claimed are out of proportion to physical injuries suffered.

My guess is that in your case the adjudicator is attempting to fully develop your record and to tie up loose ends.

As far as what to expect, most psychiatric evaluations involve a series of tests for depression and anxiety – there is no way to prepare for these evaluations – just tell the truth and do your best at completing the tests.

After discussing with him the ways he could apply – either by phone, in person at his local Social Security office, or online at ssa.gov, he asked me what was going to happen after he started his application.  I explained that once his claim was opened, his file would be sent to a disability adjudicator and that he should expect to hear from the adjudicator to set up an in-person or telephone interview.

Today, I heard back from this gentleman asking another very good question about the initial application process.  I believe that he has been through his initial interview and that his claim is now being processed.   Since his question is relevant to just about everyone who files for benefits, I thought I would answer it in my blog rather than by an email.

The applicant told me that he had applied in person and that his adjudicator had scheduled him to meet with a private doctor for a medical exam.  Is this a good sign or not?  What should he expect at this meeting?  Here are my thoughts:

The exam that has been scheduled is called a “consultative examination.”   These examinations are conducted by doctors who have contracted with the Social Security Administration to do this kind of work for a designated fee.

The most common kinds of consultative evaluations are general physical exams, as well as mental health evaluations by psychologists.   Depending on where you live, there could be specialists (such as cardiologists, neuropsychologists, etc.) on the consultative examination panel.  Further, if your regular treating physician will handle a consultative evaluation for the payment offered, your doctor can also serve as the provider for this evaluation.

In my experience, physical consultative evaluations are usually a waste of time.  Often the doctors on the panel for physical exams are “industrial clinic” doctors who also perform independent medical examinations for insurance companies in workers’ compensation cases.  More often than not, these clinic doctors will find nothing wrong with you.

By contrast, the psychologists who perform consultative psychological examinations will often identify one or more mental health issues.  These issues may not be “disabling” but they can pay dividends later by eliminating categories of jobs and thus narrowing the judge’s questions to a vocational witness at your hearing.

My experience has been that most Social Security judges recognize the limitations of a one time consultative examination and they weigh the importance of the exam report accordingly.  I also find that some of the medical or mental health vendors do a poor job when completing their reports – as I have discussed at length on this blog, the main issue in any Social Security case relates to your capacity to work, and I read far too many consultative reports that do not discuss this threshold issue at all.

As far as preparing for a consultative examination, there is not much  you can do.  If you have x-rays, MRI reports or CT scan reports, bring them.  If you have supporting records from a treating doctor I would bring those as well.  If you don’t have any of this documentation, that is fine as well.

At this initial and reconsideration appeal level, you are not going to win, generally, unless your condition meets a listing.  The consultative evaluations make up part of the puzzle for a judge’s determination about your capacity to work but your treating doctor’s records, reports and statements of opinion carry far more weight.

Question:

What type of information does the CE (consultative examination) need to contain in order to substantiate my claim for disability?

Answer:

The CE is more or less a doctor’s appointment in which (typically) an independent medical examiner will conduct additional medical testing or assessment in order to help make your disability case file complete so that the SSA may be able to render a decision in your claim.What happens at the CE depends on what kind of testing (psychological, neurological, and so on) is required by the SSA. But since you have probably already had plenty of experience with doctors by this time, the CE shouldn’t necessarily hold any surprises.

In terms of information needed in the actual examination report, the following guideline is a comprehensive list of information needed to ensure that your claim is further processed without additional delay:

A physical description of the claimant; this is an additional tool to ensure that the medical records are those of the claimant and not those of another individual.

All medical history, physical examination, laboratory findings and diagnoses should be included. The report should be such that an independent reviewer is able to determine the nature, severity and duration of the impairment as well as the claimant’s ability to perform basic functions required in the simplest of jobs without requiring additional information. If the report is incomplete, the examiner will be contacted and a request to supplement the records and/or clarify will be made thus creating additional delay.

Include a narrative finding in the history and of the physical examination.

Conclusions following the CE must be consistent with all other medical documentation under consideration.

The report should not include an opinion as to whether the claimant is disabled under the law.

All CE reports must be reviewed and signed by the provider who performed the examination.

Well, I hope this covers everything you need to know about the CE. Feel free to share stories about your CE or ask additional questions about the consultative exam by leaving a comment below.

Question:

How does the SSA choose a consultative examination source? Is there a list that they choose from, or do I choose?

Answer:

First, as I mentioned in an earlier post, consultative examinations are those additional tests and/or examinations requested in order to aide in the disability determination process. When I say “qualified,” that means the source, usually a physician or specialist, is required to be licensed in the state in which the application is being made and to have extensive training and experience in the type of test and/or examination being requested. In many cases, the examiner performing the CE is not your physician, but an independent source contracted by the SSA.

You can be assured that if a consultative examination is requested in your matter, the individual who performs the examination has an extensive understanding of the SSA’s disability programs. He/she is well versed in the evidence needed in order to substantiate a diagnosis of any impairment that you may have. All treating sources are required to comply with any accreditation standards subscribed by the SSA. Likewise, any staff that assists with the CE must meet those strict requirements as well.

In most cases, great consideration is given to the location of the claimant when a treating source is selected. This provides the claimant with a degree of comfort, as he/she is not required to travel extensively in order to submit to the requested testing.

In regard to the second part of your query, the SSA has list of sources available to them for completing a CE. Again, this list is established based on those qualified sources meeting the requirements dictated. Sources are chosen based on appointment availability, ability to perform specific examinations and/or tests, and again, the locale in relation to the claimant.

Stay tuned for Part 3 of my mini-series on the Consultative Exam…

Question:

If the medical records I submitted with my claim are determined to be inadequate to make a disability determination, is there a possibility that additional information would be requested by the SSA on my behalf?

Answer:

The answer to your question is ‘maybe.’ If additional medical information is requested and/or a clarification is needed, your original treating source (physician, specialist, psychiatrist, etc.) is the first preferred source to contact. However, there is a second option available, which is the scheduling of a consultative examination (commonly known as a CE) through an independent source.

Again, your treating source is the preferred choice for additional examinations as long as the following requirements are met:

• Your treating source (physicians, specialist, psychiatrists, etc.) is qualified;
• He/she has access to the testing equipment required to perform the examination and/or requested testing;
• He/she is willing to perform the requested examination and/or tests for a set fee, established by the state in which you have made application in;
• He/she is able to furnish a complete report within a specified time limit

However, as mentioned above, there are provisions that allow for an independent source, that person other than the treating source, to conduct a consultative examination and any future testing. Those instances in which an independent source would be considered over a treating source are as follows:

• The treating source cannot or does not prefer to conduct the requested examination;
• Conflicts and/or inconsistencies exist in the claimant’s file which are unable to be rectified by going back to the treating source;
• The claimant prefers an independent source and presents a valid reason for doing so;
• The treating source is considered an unproductive source

So, when the SSA determines it necessary to schedule a CE, they will contact the independent source, schedule the appointment, and then notify you of the appointment date and time.

The types of additional testing and/or examinations requested are strictly limited to the additional evidence needed in order to render a decision on the claimant’s application for disability. Tests conducted outside of the needed information requested are not permissible unless the examination warrants additional testing. In this event, the treating source must have prior approval before conducting further tests.

Please stay tuned for Part 2 and Part 3 of this mini-series on the consultative exam.