Letter to the Hon. Gene Dodaro - Chairman Larson Requests GAO Study on Quality of Medical Reviews in Social Security Disability Eligibility Determinations

Letter

Dear Mr. Dodaro,

The Social Security Administration (SSA) administers disability programs under Social Security and Supplemental Security Income (SSI) that provide a basic standard of living for people with the most severe and long-term impairments.

People apply for Social Security disability benefits at a financially perilous time: after the onset or worsening of a medical impairment has halted their ability to support themselves through work. To qualify, claimants must submit evidence of a medically determinable impairment that meets the Social Security Act's stringent eligibility standard. Accurate and prompt determinations are necessary to allow eligible people to access their benefits and gain relief from economic hardship.

SSA contracts with state Disability Determination Service (DDS) agencies to evaluate disability applications on behalf of SSA, in accordance with the Social Security Act and SSA's rules and policies. SSA pays all costs associated with making these determinations. DDS staff--generally a team of disability examiners and medical consultants--reviews medical and other evidence, obtains additional evidence as needed, and makes the initial and reconsideration disability determination.

Some state DDS offices contract with licensed physicians, who are not salaried DDS employees, to provide medical consultant services for the determination processes. Recent news reports revealed that Tennessee uses contracted medical consultants who are paid on a per-case basis, which apparently led to rushed reviews by a significant number of consultants. This has raised concerns about the quality of such reviews and could result in some people's disability claims being decided incorrectly.

Beyond Tennessee, little is known about the extent to which DDS offices in other states use contracted medical consultants, how these consultants are compensated and overseen, how quality is measured, and in what ways, if any, the use of contracted medical consultants affects determination accuracy. The stakes are particularly high because people who are incorrectly denied by a state DDS agency currently face an average wait of more than 18 months to appeal the denial at a hearing before an Administrative Law Judge.

Accordingly, I request that GAO conduct a study examining the following questions:

To what extent do state DDS offices use contracted medical consultants to review Social Security and SSI disability applications and make determinations? Also, among state DDSs that use contracted medical consultants, how do DDS contracts vary in terms of payment structure, consultant credentialing, or other qualifications?
What measures are in place--at the state DDS level and SSA level--to oversee the performance and qualifications of contracted medical consultants and to ensure accurate, high-quality reviews? Do the measures used for contracted medical consultants differ from the measures used for salaried DDS employees and if so, how?
What is known about whether the use of contracted medical consultants affects disability determination accuracy and whether differences in payment structure or qualification requirements affect accuracy?
Please also look at these questions with respect to the use of contracted psychological consultants to the extent applicable.

Sincerely.

Source