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Social Security Eliminates “Treating Source” Rule – What does this Mean for You?

Effective March 27, 2017, Social Security has changed its long-standing policy about how it treats medical records and opinion evidence form your treating physician. Prior to March 27, 2017, evidence from your treating physicians would be given “controlling weight” by a Social Security adjudicator or judge.

Now, records and opinions from your long time treating doctors will be given no special weight. Instead, medical opinions from your treating doctor, consultative doctors and even non-examining medical consultants will be evaluated equally based on “persuasiveness.”

What does this change mean to you?

At first glance, this rule change seems to make no sense at all. Clearly a physician who has treated you for 10 years would have a more educated opinion about your capacity for work than a consultative doctor who met you once 2 years ago for 45 minutes, or a Social Security in house doctor who only knows you through his review of your medical records.

And, yes, there is a danger that a judge who has made up his mind not to approve your case will now have an easier time justifying a denial of your case. Continue reading →

Claim Review Doctors at Social Security Overworked, Underqualified and Underpaid

Social Security medical review system under strainIf you have received a claim denial notice from Social Security, you are familiar with the language used in these denials:

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.

Continue reading →

Why does Social Security Want You to See a Psychiatrist if You Have a Physical Injury?

psychiatric testingAt some point in your Social Security disability case – usually during the initial application evaluation, but possibly later – Social Security will send you out for a “consultative examination” with one or more doctors.   In my experience, the physical medicine consultative evaluations are fairly useless – Social Security tends to contract with “industrial clinics” who handle worker’s compensation claims and those reports often minimize symptoms.

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). Continue reading →

What to Expect When Social Security Schedules You for a Medical Exam?

social security consultative examinationEarlier this month I received an email asking about initial application procedures from a gentleman who had visited my Georgia disability web site.   This person had not yet applied and he wrote to ask me what he should expect when he did apply.

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. Continue reading →

The Consultative Exam (CE): Part 3

Hello and welcome to the final installment of my 3-part mini-series on the Social Security Disability consultative examination (CE).  Part 1 is here and Part 2 is here.  In this final post, I discuss what can you can expect at a CE and what kind of information that the CE will need to contain to substantiate your disability claim.

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.

The Consultative Exam (CE): Part 2

Hello and welcome to Part 2 of my 3-part mini-series on Social Security Disability consultative exams (CE).  Part 1 is here.  In this post, I discuss how an independent medical examiner is chosen by the SSA for the purposes of conducting a CE.

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.

Click here for Part 3 of my mini-series on the Consultative Exam…

The Consultative Exam (CE): Part 1

I have been asked a few questions which relate to the Consultative Examination (CE), which is basically a doctor’s appointment sometimes scheduled on your behalf by the SSA if they feel that additional medical testing/evidence is required to help them render a decision in your case. In this and the following two posts, I will answer questions about the consultative exam and explain in further detail what you can expect at the CE.

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.

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