Appendix VII Process Change Recommendations That Were Outside the Parameters....................................................95
Introduction
A claimant for disability benefits from the Social Security Administration faces a lengthy, bewildering process. An initial decision from SSA will likely take
more than three months. Anywhere from 16 to 26 employees will handle the claim before the initial decision is reached. If that decision is a denial, and the
request for reconsideration is also denied, chances are the claimant will hire an attorney. It will likely be an additional eight months or more before a
response on the hearing is received, and even longer before a check is issued or eligible dependents' benefits are paid. As many as 45 employees could
handle the claim.
If the claim for benefits is approved after a hearing, the claimant will view the SSA disability application process as one which requires jumping through
lengthy bureaucratic hoops. Dealing in person or on the telephone with SSA field office staff and, possibly, the State disability determination service (DDS)
staff at the initial and reconsideration levels, the claimant must appear at a hearing and finally talk to a person in a position to make a decision on the
claim. The claimant will rate SSA employees as courteous and knowledgeable, but the disability determination process as bureaucratic and unresponsive.
Congress agrees with this assessment; in May 1991, the House Ways and Means Committee cited SSA for an excellent job of delivering retirement benefits, but
gave SSA a failing grade for the way it processes applications for disability benefits, with Chairman Dan Rostenkowski stating, "...those who are unfortunate
enough to become disabled find their problems compounded by inefficiencies at SSA."
SSA employees reiterate this belief, as illustrated in the following statement by a claims representative, "I wish we could stop shuffling all this stuff back
and forth. I don˛t really know what the DDS is looking for, so I try to do the best generic job I can on these forms."
The report of the National Performance Review reflected Administration concern by directing SSA to "Improve Social Security disability claims processing to
better serve people with disabilities..."
SSA has reached a critical juncture; disability claims receipts at the initial claims and appeals levels have reached all time highs˛Fiscal Year (FY) 1995
claims requiring a disability determination will increase 69 percent over FY 1990 levels; appeals workloads will increase 75 percent over FY 1990 receipt
levels; employees in field offices, DDSs and hearing offices are overburdened despite recent significant increases in productivity. As an agency, SSA must vie
for scarce administrative resources in an era of spending limitations and competing social spending priorities. The ability of SSA to cope with further
workload increases is questionable; it is clear that only radical change can address the disability service delivery problems facing the Agency today.
SSA is meeting this challenge with an unprecedented effort to reengineer the entire disability process˛from the point a potential claimant first contacts the
Agency to file for disability benefits, through the disability allowance or final administrative appeal. Reengineering the disability process involves asking the
question, "Given what we know about technology and resources available to us today, how can we best design a disability process for the 1990s and
beyond?" This report will answer that question by proposing a radical redesign of disability program policies and procedures, to ensure dramatic
improvements in the way the entire process works and is managed to serve the American public.
The report represents the collective efforts and recommendations of the 18-member Disability Reengineering Team, composed of Federal and State DDS
employees, operating under the auspices of the Director of the SSA Process Reengineering Program, and the SSA Executive Steering Committee formed to
provide advice to the Commissioner on the disability reengineering process change proposal development.
The Executive Steering Committee provided the following parameters for the disability reengineering proposal: "Every aspect of the process except the
statutory definition of disability, individual benefit amounts, the use of an administrative law judge as the presiding officer for administrative hearings and
vocational rehabilitation for beneficiaries is within the scope of this reengineering effort."
The recommendations in this report represent the Team proposal to SSA for reengineering the disability process; this is not a final SSA proposal. The
Commissioner of SSA asks interested parties to comment on the proposal within the next 60 days. The Team looks forward to receiving comments from the
community concerned with The delivery of disability benefits.
Current Process
The procedures in the current process have not changed in any significant way since the Social Security Disability Insurance (DI) program began in the
1950s, a time when caseloads, demographic characteristics of claimants, types of disabilities, and available technology were radically different.
In the 1970s, Congress federalized State programs of cash assistance to the aged, blind and disabled into the Supplemental Security Income (SSI) program
and added this to the responsibilities of SSA. SSA then adopted the DI disability determination procedures for SSI blind and disabled claims.
Overview
A claim must now pass through from 1 to 4 decisional paths within SSA to receive a favorable disability decision. The initial claim, reconsideration,
administrative law judge (ALJ) hearing and Appeals Council review levels all involve multi-step uniform procedures for evidence collection, review, and
decisionmaking.
The process starts at the initial level when an individual first applies for DI or SSI disability benefits on the basis of a disabling physical or mental
condition. An individual calls the national toll-free telephone number and is referred to a local SSA field office or visits or calls one of 1,300 local field
offices to apply for benefits. Field office personnel asst with application completion, obtain detailed medical and vocational history and screen nonmedical
eligibility factors. Field office personnel forward the claim to 1 of 54 State disability determination services where medical evidence is developed and a final
determination is made regarding the existence of a medically determinable impairment which meets the definition of disability.
After possible quality assurance review in the DDS or in the SSA regional Disability Quality Branch, the claim is returned to the field office. Thirty-nine
percent of these claims were paid in FY 1993; denials are retained pending possible appeal. Allowed DI claims are sent to one of 7 processing centers (which
include the Office of Disability and International Operations and the 6 Program Service Centers) for final processing and storage, as well as adjudication of
claims for dependents. Allowed SSI claims remain in the field office for payment and retention.
An initial claim currently takes an average of 100 days to process from the time it is filed until a final decision is made according to SSA's computer-based
processing time measurements. However, a better understanding of how long the process takes from the claimant's perspective comes from a 1993 study
conducted by SSA˛s Office of Workforce Analysis, which showed that an average claimant waits up to 155 days from the initial contact with SSA until
receiving an initial claim decision notice. Sixteen to 26 employees will handle the claim during this period.
An appeal of the initial decision can be made within 60 days of the denial notice. Reconsiderations were requested on 48 percent of denied claims in FY
1993. The local field office receives the request, updates the information, and forwards the claim file to the DDS for review, possible medical development,
and final medical decision. The determination is made by a different adjudicative team than the one that made the initial determination.
After possible quality assurance review in the DDS or in the regional Disability Quality Branch, about 14 percent of these claims are returned to the field
office for payment, and forwarding to the processing centers, while the remaining denials are forwarded to the field office for retention, pending a request
for a hearing before an ALJ. The average reconsideration itself takes about 50 days according to SSA's computer-based processing time reports˛however,
according to the Office of Workforce Analysis study, a claimant has now been involved with the SSA process for roughly 8 months from the point of initially
contacting the Agency, and up to 36 different employees could have handled the claim.
Within 60 days of receiving an unfavorable reconsideration decision, a claimant can request a hearing before an ALJ In FY 1993, about 75 percent of all
reconsideration denials were appealed to ALJs. At this point, a claimant has usually retained an attorney or other representative to assist in pursuing the
claim for benefits. About 75 percent of all claimants retain a representative at the hearing. The local field office receives the request for hearing and
forwards it with the claim file to one of 132 local SSA hearings offices. Hearing office personnel review the file for possible additional development, conduct a
hearing, and render a final decision.
Allowed DI claims are sent to a processing center for final action and storage, as well as adjudication of claims for dependents. Allowed SSI claims are
returned to the local field office for income and resource development, and payment. Denied claims are forwarded to the Appeals Council for retention in case
a request for review is filed. The hearing process itself takes about 265 days according to computer-based reports. However, according to the Office of
Workforce Analysis study, a claimant has been dealing with SSA for over a year and a half at this point in the process.
If still dissatisfied with an unfavorable decision, a claimant or representative has 60 days to request a review of the ALJ decision by the Appeals Council.
About 23 percent of hearing decisions are unfavorable and forwarded to the Appeals Council pending possible appeal. The Appeals Council considers about 18
percent of all ALJ dispositions, including cases it reviews on its own motion.
Requests for Appeals Council review are typically received directly from the claimant's representative. The Appeals Council may either deny review, issue a
decision, or remand the claim to an ALJ. The Appeals Council remands claims to the ALJ level about 27 percent of the time for subsequent development and
decision. Denied claims, representing about 70 percent of the Appeals Council dispositions, are held in the Appeals Council for possible appeal to Federal
District court.
Allowed DI claims are sent to a processing center for final action and storage, as well as adjudication of claims for dependents. Allowed SSI claims are
returned to the local field office for income and resource development, and payment. According to processing time reports, this part of the process takes on
average about 100 days; however, according to the Office of Workforce Analysis study, a claimant has spent almost 2 years dealing with SSA since initially
contacting the Agency.
Trends
The current disability process served SSA and the public well for a number of years. However, over the last several years, as workloads have increased
dramatically, the current process has been placed under increasing stress. The upward trend in the number of claims for benefits SSA has received is
reflected as follows:
The growth in claims and benefits awarded is reflected in increases in the number of beneficiaries SSA pays and the growth in Federal program outlays over
recent years.
The increase in workload has occurred concurrently with
significant downsizing activity in SSA and staffing fluctuations in the State DDSs.
Even with the downsizing, the total costs for processing initial disability and appeals determinations (excluding the costs for processing the Sullivan v.
Zebley court case) remain enormous ˛ more than half of the total administrative costs (including DDS costs) for SSA in FY 1993 were devoted to this task.
Despite these funds, and despite directing a larger percentage of the SSA resources toward disability initial claims and appeals processing in recent years,
average processing times for initial claims, as well as appeals, have escalated dramatically since 1988.
At least part of the increase in processing time results from the time added as the claim moves from one employee or facility to another (handoffs), and
waits at each employee's workstation to be handled (queues). As workloads increase, the amount of time a claim waits at each processing point grows.
"Task time" is the time employees actually devote to working directly on a claim, rather than the total amount of time it takes for a claimant to receive a
final decision. Based on the Office of Workforce Analysis study, a claimant can wait as long as 155 days from the first contact with SSA until receiving an
initial claim decision notice˛of which only 13 hours of this is actual task time. The same study reveals a claimant can wait as long as 550 days from that
initial contact through receipt of the hearing decision notice˛of which only 32 hours is actual task time.
The Team's research revealed that the problems of queues, handoffs, and task time are compounded by problems with the way SSA takes claims, collects
evidence, and determines disability. These problems are discussed in the following section.
Research Summary and Analysis
Overview of Methodology and Findings
The Team's methodology called for extensive site visits and interviews with members of the disability community. Team members visited 421 locations in 33
States and conducted over 3,600 interviews. Almost 2,900 of these involved front-line employees, managers and executives. The interviews provided insights
into the problems confronting the disability program and recommendations for solving these problems. The Team conducted an additional 111 interviews by
telephone.
The Team also interviewed over 750 parties external to SSA˛members of the medical, legal, advocate and interest group community˛for their views. Finally,
the Team has analyzed the results of focus groups involving disability claimants and the general public in order to determine what SSA customers experience
and expect from the disability process.
The information collected from these activities resulted in the framework for the analysis and recommendations that follow. At a minimum, the Team was
determined to address the most pressing problems identified by SSA employees, claimants, and other interested parties. Not surprisingly, all three groups
were in general agreement regarding many of the problems with the SSA disability process. All agreed that the current fragmented process takes too long to
provide applicants a decision, and leaves them confused about who has responsibility for their claim, and puzzled about the status of their claim during
various points in the process. Additionally, nearly all believe that many claimants can and should assume more responsibility for submitting evidence and
pursuing their claim.
Most view the reconsideration step as little more than a rubber stamp of the initial determination, creating additional work for employees and yet another
bureaucratic obstacle for claimants and their representatives. Some believe a face-to-face interview with the decisionmaker is vital to reaching a fair,
accurate determination; others believe just as strongly that the decision should be reached on the basis of a paper review, and that a face-to-face interview
can lead to subjective decisions that are not based on objective criteria.
Higher allowance rates at the ALJ level lead to the perception that different adjudicative standards apply at the initial and appeals levels. The public, in
particular, believes that it is necessary to hire an attorney to maneuver through this process, and voices resentment at having to do so. Quality reviews and
Appeals Council reviews are often mentioned as areas where opportunities exist for improving current processes.
The Case for Change
The Public and Third Parties Find the Current Process Confusing
Many applicants enter the SSA disability process uninformed about the process itself and the definition of disability. They are unaware of the criteria for
establishing disability and the evidence they will be required to submit. Even third parties and advocate organizations, often more knowledgeable than the
general public about SSA procedures, experience difficulty obtaining meaningful information about the status of their client's claims finding that they often
are transferred from one employee to another.
Disability claimants face a "one size fits all" approach to the intake and processing of their claim, finding themselves answering questions they believe are
intrusive and irrelevant to their claim. Front-line employees currently devote hours to completing forms and obtaining information which may not be
necessary for a finding of disability. If the claim is approved, whether at the initial or appellate level, claimants and their representatives, as well as
front-line employees, are concerned about the complicated procedures and length of time it takes to effectuate payment and entitle eligible dependents.
Evidence Collection and Decision Methodology Pose Problems
The collection of medical evidence presents problems as the case is developed in the DDS. Medical providers who have treated the claimant often do not
understand the requirements for establishing disability, and find the forms for the collection of medical evidence confusing. In order to compensate for poor
or missing medical evidence, DDSs purchase consultative examinations, devoting substantial resources to scheduling, purchasing, and processing these
examinations.
Once the medical evidence has been collected, the methodology used to reach a decision on the case is complex and controversial. Criteria originally
developed to identify and evaluate cases simply and rapidly have grown increasingly complex as a result of court decisions and changes in medical
technology. Today's 330 different vocational rules, which have been added to SSA's regulations since 1980, can lead to varying interpretations resulting in
inconsistent decisions.
Claimants and their representatives have learned their chances for a favorable decision improve if they appeal their claim to an ALJ. A variety of factors
may be contributing to this. The facts of many cases change over time as a claimant's condition changes. ALJs often have access to information not
considered at lower levels in the process because earlier decisionmakers are not as likely to have face-to-face interaction with the claimant. Finally, the
fragmented nature of SSA's policy making, policy issuance, training and review apparatus all reinforce the differences.
The Fragmented Process Contributes to Difficulties
The fragmented nature of the disability process is driven by and exacerbated by the fragmentation in SSA's policy making and policy issuance mechanisms.
Policy making authority rests in several organizations with few effective tools for ensuring consistent guidance to all disability decisionmakers. Different
vehicles exist for conveying policy and procedural guidance to decisionmakers at different levels in the process. While the standards for disability
decisionmaking are uniform, they are expressed in different wording in the various policy vehicles.
Training on disability is not delivered in a consistent manner, nor is it provided simultaneously to disability decisionmakers across or among levels in the
process. Mechanisms for reviewing application of policy among levels of the process are fragmented and inconsistent. Review of DDS decisions is heavily
weighted toward allowances; no systematic quality assurance program is in place for hearing decisions although the opportunity for feedback from the
appeals council or court cases is heavily weighted toward denials.
The organizational fragmentation of the disability process creates the perception that no one is in charge of it. SSA measures the process from the
perspective of the component organizations involved, rather than the perspective of the claimant. Multiple organizations (field offices, DDSs, hearings offices,
Appeals Council operations, and processing centers) have jurisdiction over the claim at various points in time, with each line of authority managing toward
its own goals without responsibility to the overall outcome of the process. Additionally, the impact of one component's work product on other components is
not measured, further contributing to the fragmentation of the process. Each component's narrow responsibilities reinforce a lack of understanding among
component employees of the roles and responsibilities of other employees in different components.
Customer Research and Demographics
Customer Research
The National Performance Review report, released in the fall of 1993, calls upon agencies to establish customer service standards equal to the best in the
business to guide their operations. Federal agencies are encouraged to identify "the customers who are, or should be served by the agency," and survey
these customers "to determine the kind and quality of services they want and their level of satisfaction with existing services."
SSA customers include the individuals who file for social security or supplemental security income disability benefits, or who are potential filers for these
benefits. They were surveyed through a series of 12 focus groups conducted throughout the country last fall. Participants represented a demographically
diverse cross-section of current claimants, including those who had been initially denied, and who filed for a reconsideration or hearing; new beneficiaries;
and the general public. Two focus groups were conducted with non-English speaking participants.
Focus group participants were quick to offer their frank opinions; the general view was that they:
wait too long for a decision˛this is the most common complaint; the claim process is a struggle characterized by stress, fear, and the anger associated with
running out of funds;
do not understand the program or process˛what happens to the claim after initial contact with SSA is unclear, they view SSA multiple requests for medical
information with skepticism, do not understand their decision and believe it was reached arbitrarily;
want more information and personal contact˛while they would prefer to deal with one person for all claim business, their major preference is to receive
accurate, consistent information from all SSA sources and to be provided substantive status reports on their claim;
view the initial and reconsideration denials as bureaucratic precursors to final approval at the ALJ level˛they believe the process is designed "to make you
go away".
resent the need for attorney assistance to obtain benefits˛the process should not be so complicated that an attorney is needed; and
want more active involvement in pursuit of their claim˛they want to make their case directly to the decisionmaker, and would personally obtain needed
additional evidence to speed the decision on their claim.
Demographics
Changes in demographics of the general population and in SSA's claimant population present challenges as well as opportunities for SSA as it focuses on
claimant needs and reengineers its disability determination process.
American society has changed dramatically since the DI program began in the 1950s. This is reflected in an increased demand for SSA˛s services, changes
in the characteristics of claimants seeking benefits, and complexities in claim related workloads and processes.
The demographic character of the SSA disability claimant population has changed as well. The enactment of the SSI program in the 1970's added individuals
who have sketchy work histories, increased the number of individuals filing based on disabilities such as mental impairments, and provided for eligibility of
disabled children. Additionally, the requirements of the SSI program added complex and time consuming development of non-disability eligibility factors such
as income, resources and living arrangements. The 1990 U.S. Supreme Court decision, Sullivan V. Zebley, resulted in increased claims for children; children
comprised 21 percent of all SSI claims in 1992, up from 11 percent in 1988. Claims for homeless individuals and others with special needs have increased in
recent years. These claimants require significant intervention and assistance to navigate the disability claims process.
A trend in the general population which is reflected in SSA's disability claimant population is the increased number of people in the United States for whom
English is not the native language. Recent national Census data indicate that 1 in 7 people speak a language other than English in the home; this is an
increase of almost 38 percent in the last 10 years. SSA will need to accommodate the special communication needs of these claimants in its ongoing claimant
contacts and in public information vehicles.
Forty percent of claimants filing for disability benefits and polled in a recent SSA survey had filed for or received benefits from Aid to Families with
Dependent Children, welfare or social services within the past year. Approximately three-fourths of them were awarded this assistance and three-fourths of
those awardees were still receiving benefits when they applied for disability benefits. SSA has the opportunity to develop productive relationships with these
entities to improve the processing of disability claims for mutual customers.
Technological advances such as personal computers, facsimile machines, electronic mail, and videoconferencing are increasingly available to our claimants,
their representatives, medical providers and other third parties involved in the disability process. SSA can take advantage of these capabilities to offer
expanded service options and to modernize evidence collection.
New Process
Overview
A claimant for disability benefits under the proposed process will be provided a full explanation of SSA's programs and processes at the initial contact with
SSA. The claimant and third parties will be able to assist in the development of the claim, deal with a single contact point in the Agency, and request a
personal interview with the decisionmaker at each level of the process. Additionally, if the claimant requests a hearing, the issues and evidence to be
addressed at the hearing will be focused, the responsibilities of representatives clarified and, if the claim is approved, the effectuation of payment to the
claimant, eligible dependents and the representative streamlined.
The new process will result in a correct decision at the initial level by simplifying the decision methodology, providing consistent direction and training to
all decisionmakers, enhancing the collection and development of medical evidence, and employing a single quality review process across all levels.
A single claim manager will handle most aspects of the initial level claim, thus eliminating many steps caused by numerous employees handling discrete parts
of the claim (handoffs) and the time lost as the claim waits at each employee's workstation to be handled (queues). This will reduce the time needed to
rework files and redevelop information from the same medical sources. Levels of appeal will be combined and improved, reducing the need to redevelop
nonmedical eligibility factors after a favorable decision because less time will have elapsed since initial filing.
The proposed process will enable the current work force to handle an increased number of claims, freeing the most highly skilled staff (physicians and
ALJs) to work on those cases and tasks that make the best use of their talents, and targeting expenditures for medical evidence to those areas most useful
in determining disability.
Employees will perform a wider range of functions, using their skills to their full potential, enabling them to meet the needs of claimants and minimize
unnecessary rework. The proposed process will facilitate employees' ability to do the total job by providing technology and the support to use that
technology.
The New Process ˛ A Brief Description
Under the proposed process, the number of appeal steps will be reduced and opportunities for personal interaction with decisionmakers will be increased. At
the initial claim level, the claimant will be offered a range of options for filing a claim, pursuing evidence collection, and conferring with a decisionmaker,
using various modes of technology to interact with SSA. At the hearing level, the claimant will have an additional opportunity to participate in a personal
conference and meet with a decisionmaker.
A Disability Claim Manager Will Handle Initial Disability Claims Processing
Claimants initially will deal almost exclusively with a disability claim manager˛a front-line employee knowledgeable about the medical and nonmedical factors of
entitlement˛responsible for making the initial determination, with technical support if necessary, to allow or deny the claim.
The disability claim manager will determine the level of development needed to make a disability decision using a simplified determination methodology; relying on
evidence submitted by or through the efforts of the claimant (whenever the claimant is able to do this); requesting medical evidence or a functional assessment; or
referring complex medical questions to a medical consultant for expert advice and opinion, if necessary. The disability claim manager will contact the claimant if the
decision on a claim appears to be a denial. The claim manager will explain the situation including the evidence that was considered, and offer the claimant an
opportunity to submit additional information as well as an option for an interview in-person or via telephone, before the claim is formally denied.
All initial claims will be subject to a randomly selected postadjudicative national sample review designed to determine whether disability policies are being properly
applied. Extensive ongoing training will enable adjudicators to consistently issue correct decisions. By the time the initial decision is issued, the claim will have been
handled by seven or eight employees.
An Adjudication Officer Will Prepare the Claim for a Hearing
A claimant wishing to appeal an unfavorable initial decision to an ALJ will continue to have 60 days to file a request for a hearing. The disability claim manager will
assist the claimant with the request, and forward the claim to an adjudication officer. The adjudication officer will be responsible for explaining the hearing process
to the claimant, as well as conducting personal conferences, preparing claims, and scheduling hearings. The adjudication officer will have the authority to allow the
claim at any point prior to the hearing that sufficient evidence becomes available to support a favorable decision.
An ALJ Will Conduct the Hearing
The ALJ will conduct the hearing and issue the decision. At any point in the process where the claim is approved, it will be returned to the claim manager for
payment effectuation, whether the claim is DI, concurrent, or SSI. Denied claims will be forwarded to the Appeals Council, for retention in the event of civil action. At
this point, an average claimant will have been dealing with SSA for approximately five months from the first contact with the Agency. A total of up to 14 employees
will have been involved with the process during this entire period.
An ALJ decision will be the final decision of the Secretary, subject to judicial review, unless the Appeals Council reviews the ALJ decision on its own motion. The
Appeals Council will conduct reviews of ALJ allowances and denials prior to effectuation, at its discretion, and on its own motion. The Appeals Council will also review
all claims in which a civil action has been filed, and decide whether the ALJ decision should be defended as the final decision of the Secretary. If a claim is selected
for own motion review, a total of 17 employees will have been involved in the process from first claimant contact with SSA through Appeals Council review.
Claimants Will Receive World-Class Service
The time from a claimant's first contact with SSA until issuance of a final initial decision, will be reduced from an average of 155 days (as cited in SSA's Office of
Workforce Analysis study) to less than 40 days, enhancing SSA's capacity to provide world-class service. Available employees will be able to process a greater number
of claims, and devote more time to each claimant, providing more personalized service.
The time from a claimant's first contact with SSA until issuance of a hearing decision, will be reduced from an average of a year and a half (as cited in SSA's Office
of Workforce Analysis study) to approximately 5 months.
Summary of Differences
Process Entry:
Current Process: Claimant has limited or no program information available prior to entry . New Process: Claimant has program information, starter application and
means to gather evidence before entry.
Current Process: Files by mail, telephone, or in-person.
New Process: Claimant files by mail, electronically, telephone or
person evidence before entry.
Claims Intake
Current Process: Interview with claims representative trained only in nondisability aspects of program. New Process: Interview with claim manager trained in
disability and nondisability aspects of program.
Current Process: Multiple contacts with different claims Specialists. New Process: Single point of contact for all claims processing.
Disability Decision Methodology (Adult)
Current Process: 5-step sequential evaluation; engaging in substantial gainful activity,
Severe impairment, Meets or equals the Listings of Impairments, Able to do past relevant work,
Able to do other work (using the "Grid"). New Process: 4-step approach: Engaging in substantial gainful activity, Medically determinable impairment, Impairment is
in Index of Disabling, Impairments (No medical equivalence or assessing function), Able to perform substantial gainful activity ("Grid" eliminated).
Disability Decision Methodology (Child)
Current Process: 4-step sequential evaluation: Engaging in substantial gainful activity, Severe impairment, Meets or equals Listings of Impairments, Comparable
severity. New Process:
4-step approach; Engaging in substantial gainful activity, Medically determinable impairment,
Impairment is in Index of Disabling Impairments (No medical equivalence or assessing function),
Comparable severity.
Evidentiary Development
Current Process: SSA takes responsibility for obtaining medical evidence. New Process: Claimant is a partner in obtaining medical evidence.
Current Process: SSA obtains detailed clinical and laboratory findings in all claims. New Process: SSA obtains evidence necessary to decide issues in the claim.
Current Process: SSA uses objective findings, medical opinion, and other evidence to assess a claimant's residual functional capacity. New Process: SSA, working
with medical experts, develops standardized instruments and criteria for measuring a claimant's functional
ability.
Initial Disability Determination
Current Process: Disability specialist and physician team decide claim based on paper review. New Process: Claim manager decides claim after appropriate consultation
with physician. New Process Claimant has opportunity for personal predenial interview .
Reconsideration
Current Process: Paper review by different disability specialist and physician team. New process: Reconsideration eliminated.
Administrative Law Judge Hearing
Current Process: Process Hearing request must be filed within 60 days of reconsideration. New Process: Hearing request must be filed within 60 days of initial
determination.
Current Process: ALJ is responsible for overseeing all prehearing development. New Process: Adjudication officer oversees prehearing development.
Current Process Prehearing conference is held in limited circumstances. New Process: Personal conference is mandatory if claimant is represented.
Appeals Council Review
Current Process: Claimant requests Appeals Council review and the Appeals Council may consider new evidence. New Process: Appeals Council reviews claim only on
its own motion; review is limited to the record before the ALJ.
Current Process: Appeals Council action is a prerequisite for judicial review. New Process: Appeals Council action is not a prerequisite for judicial review.
Quality Assurance
Current Process: Quality measurements focus primarily on end of line disability decision accuracy; quality is not consistently measured at all levels of administrative
review. New Process: Quality assurance will address customer satisfaction, employee education/performance, and error prevention; end of line reviews will measure
quality of the entire adjudicative process
Process Integrity
Current Process: Adjudicative standards and policies are available through a variety of instructional vehicles. New Process: A single policy book will be used by all
adjudicators at all levels of administrative review.
Current Process: Consistent training is not provided to disability decisionmakers. New Process: Ongoing training will be provided to all disability decisionmakers and
support personnel.
Detailed Description of New Process
Process Entry and Intake
SSA Will Customize Its Disability Claims Entry and Intake Processes to Maximize
Access, Efficiency, Accuracy, and Personal Service
The disability claims entry and intake processes will reflect the SSA commitment to
providing world-class service to the public. The hallmarks of the process will be
accessible, personal service that ensures timely and accurate decisions. SSA will
work to make potential claimants better informed about the disability process and
fully prepare them to participate in it. SSA will also be flexible in providing modes
of access to the claims process that best meet the needs of claimants and the third
parties who act on their behalf. SSA will provide claimants with a single point of
contact for all claims-related business. Finally, SSA will ensure that the disability
decisionmaking process promotes timely and accurate decisions.
SSA Will Make Information About Its Disability Programs Available to Potential
Claimants Prior to Entry Into the Process
SSA will make available to the general public comprehensive information packets
about the Disability Insurance (DI) and Supplemental Security Income (SSI)
disability programs. The packets will include information about the purpose of the
disability programs; the definition of disability; the basic requirements of the
programs; a description of the adjudication process; the types of evidence needed
to establish disability; and the claimant's role in pursuing a claim.
SSA will make disability information packets commonly available in the community,
both at facilities frequented by the general public (libraries, neighborhood
resource centers, post offices, the Department of Veterans Affairs offices, and
other Federal government installations) and at facilities frequented by potential
claimants (hospitals, clinics, other health care providers, schools, employer
personnel offices, State public assistance offices, insurance companies, and
advocacy groups or third party organizations that assist individuals in pursuing
disability claims). SSA studies have shown that claimants frequently rely on advice
from their physicians and from State public assistance personnel in deciding
whether to file a claim for disability benefits. Therefore, SSA will make a special
effort to target its public information activities at these and other known sources
of referrals for claims. SSA will also make the disability information packets
available electronically.
In addition to comprehensive program information, the packets will describe the
types of information that a claimant will need to have readily available when the
individual files a claim. It will also contain two basic forms: the first, designed for
completion by the claimant, will include general identifying information and will
serve as the claimant's starter application for benefits; the second, designed for
completion by the treating source(s), will request specific medical information about
a claimant's alleged impairments. SSA will encourage claimants to review the
information in the packet and have the basic forms completed prior to telephoning
or visiting an SSA office to apply for disability benefits. Claimants filing will be
encouraged to immediately submit starter applications to protect the filing dates
for benefits. The starter application will serve as a claim for both programs, but it
will include a disclaimer should the claimant want to preclude filing for benefits
based on need (i.e., SSI).
SSA Will Permit Claimants to Choose the Mode of Entry Into the Process That Best
Meets Their Individual Needs
The disability claims entry process will be multi-faceted, allowing claimants the
maximum flexibility in deciding how they will participate in the process. Claimants
may choose to enter the disability claims process by telephoning the SSA toll-free
number, electronically, by mail, or by telephoning or visiting a local office.
Claimants may also rely on third parties to provide them assistance in dealing with
SSA. Finally, claimants may formally appoint representatives to act on their behalf
in dealing with SSA. SSA field managers will also have the flexibility to tailor the
various service options to their local conditions, considering the needs of client
populations, individual claimants, and the availability of third parties who are
capable of contributing to the application process.
If an individual submits a starter application by mail or electronically, SSA will
contact the claimant to schedule an appointment for a claims intake interview or, at
the claimant˛s option, conduct an immediate intake interview by telephone.
If an individual telephones SSA to inquire about disability benefits, the SSA
contact will explain the requirements of the disability program, including the SSA
definition of disability, and provide a general explanation of evidence requirements.
The SSA contact will determine whether the individual has the disability
information packet, and mail it or advise the claimant regarding possible means of
electronic access. If an individual indicates a desire to file a claim at that time,
the SSA contact will complete the starter application available on-line as part of
the automated claims processing system to protect the claimant's filing date and
schedule an appointment for a claims intake interview. The interview may be in
person or by telephone at the claimant's option. If the individual has no medical
treating sources, the SSA contact will annotate this information within the on-line
claim record.
If a claimant visits an SSA office, the SSA contact will refer the claimant for an
immediate claims intake interview or, at the claimant's option, complete the starter
application and schedule a future appointment for an intake interview.
In all cases, appointments for claims intake interviews will be made available within
a reasonable time period, generally 3 to 5 working days, but no later than two weeks.
Local management will determine how to best accommodate claimant's needs in
learning about the disability process and completing a claims intake interview.
Depending on an individual's circumstances, such accommodation may involve:
referral to the nearest location for obtaining an information packet which can then
be mailed in; an immediate telephone or in-person interview; arranging for an
on-site visit from an SSA representative; or referral to appropriate third parties
who can provide assistance. Additionally, depending on the nature of the
individual's disability, SSA may encourage the individual to file in person when it
appears that a face-to-face interview will assist in the proper claims intake and
development. Face-to-face interviews, when considered necessary by either the
claimant or SSA, can also be accomplished via videoconferencing. In any case, SSA
will make every reasonable effort to meet the needs of the claimant in completing
the application process.
Similarly, local managers will modify the claims entry and intake process to provide
maximum flexibility for representatives who act on behalf of claimants or third
parties who can assist claimants in completing the application process. Such
accommodations may include, but are not limited to: 1) using automated means to
interact with SSA to protect a claimant's date of filing (e.g., telephone, fax, or
E-mail); 2) providing appointment slots for third parties to accompany claimants to
interviews or to provide assistance during telephone claims on a claimant's behalf;
3) out-stationing SSA personnel at a third-party location to obtain applications
and/or medical evidence, when appropriate; and 4) providing "open appointment"
scheduling to permit claimants to contact SSA within a flexible band of time.
Interested third parties will be encouraged to participate in the development of
claims by becoming certified by SSA to do so.
Local managers will also conduct outreach efforts that are designed to meet the
needs of hard-to-reach populations or assist those individuals unable to access the
SSA claims process without considerable intervention. As appropriate, outreach
efforts may be facilitated through videoconferencing, teleconferencing or other
electronic methods of obtaining and processing claims information to provide timely
service despite claimants' geographic or social isolation.
A Disability Claim Manager Will Be Responsible for a Disability Claim from Intake
Through Payment
A disability claim manager will have responsibility for the complete processing of
an initial disability claim. The disability claim manager will be a highly-trained
individual who is well-versed in both the disability and nondisability aspects of
the program and has the necessary knowledge, skills, and abilities to conduct
personal interviews, develop evidentiary records, and adjudicate disability claims
to payment. However, the disability claim manager will also be able to call on other
SSA resources such as medical and technical support personnel to provide advice
and assistance in the claims process.
The disability claim manager will rely on an automated claims processing system
that will permit the disability claim manager to: gather and store claims
information; develop both disability and nondisability evidence; share necessary
facts in a claim with SSA medical consultants and specialists in nondisability
technical issues; analyze evidence and prepare well-rationalized decisions on both
disability and nondisability issues; and produce clear and understandable notices
that accurately convey all necessary information to claimants.
The disability claim manager will be the focal point for claimant contacts
throughout the claim intake and adjudication process. The disability claim manager
will explain the disability program to the claimant, including the definition of
disability and how SSA determines if a claimant meets the disability requirements.
The disability claim manager will also convey what the claimant will be asked to do
throughout the process; what the claimant may expect from SSA during this
process, including anticipated timeframes for decision; and how the claimant can
interact with the disability claim manager to obtain more information or assistance.
The disability claim manager will advise the claimant regarding the right to
representation and provide the appropriate referral sources for representation.
The disability claim manager will also advise the claimant regarding community
resources, including the names of organizations that could help the claimant
pursue the claim. The goal will be to give claimants access to the decisionmaker
and allow for ongoing, meaningful dialogue between the claimant and the disability
claim manager.
Claims Intake and Development Will Be Directed at Reaching a Decision in the Most
Timely and Accurate Manner
The disability claim manager will conduct a thorough screening of the claimant's
disability and nondisability eligibility factors. If the claimant appears ineligible for
either disability program based on the claimant's allegations and evidence
presented during the claim intake interview, the disability claim manager will
explain this to the claimant. If the claimant decides not to file a claim, the
disability claim manager will give the claimant an informal denial notice.
If the claimant decides to file, the disability claim manager will complete
appropriate application screens from the automated claims processing and decision
support system. Impairment-specific questions will assist the claim manager in
obtaining information that is relevant and necessary to a disability decision. Based
on the claimant's statements and the evidence that is available at that interview,
the disability claim manager will determine the most effective way to process the
claim. If the evidence is sufficient to decide the claim, the disability claim manager
will take necessary action to issue a decision and, if necessary, effectuate
payment. The disability claim manager will determine what additional evidence is
required to adjudicate the claim and will take steps to obtain that evidence. Such
steps may include asking the claimant to obtain further medical or nonmedical
evidence where feasible, requesting medical evidence directly from treating
sources, or ordering further medical evaluations.
The disability claim manager will decide whether to defer nondisability development
(e.g., requesting SSI income and resource information, or developing DI
dependents' claims) or do it simultaneously with development of the disability
aspects of the claim. In making this decision, the disability claim manager will take
into account the type of disability alleged, evidence and other information
presented by the claimant, and other relevant circumstances, e.g., terminal illness,
homelessness or difficulty in recontacting the claimant. Because the disability claim
manager maintains ownership of the claim throughout the initial decision-making
process, the disability claim manager will be in the best position to choose the
most efficient and effective manner of providing claimants with timely and accurate
decisions while meeting claimants' individual service needs.
Although the disability claim manager will be responsible for the adjudication of an
initial claim, the disability claim manager will call in other staff resources, as
necessary. With respect to disability decisionmaking, the disability claim manager
will, in appropriate circumstances, refer claims to medical consultants to obtain
expert advice and opinion. Similarly, other staff resources will be called upon for
technical support in terms of certain claimant contacts and status reports;
development of nondisability issues including auxiliary claims or representative
payee issues; and payment effectuation. However, the disability claim manager will
make final decisions on both the disability and nondisability aspects of the claim.
Claimants Will Be Partners in the Processing of Their Disability Claims
Throughout the disability claims process, SSA will encourage claimants to be full
partners in the processing of their claims. To the extent that they are able,
claimants and their families and other personal support networks will actively
participate in the development of evidence to substantiate their claim for disability
benefits. SSA will provide assistance and/or engage third party resources, when
necessary and appropriate. SSA will keep claimants informed of the status of their
claims, advise claimants regarding what additional evidence may be necessary, and
inform claimants what, if anything, they can do to facilitate the process.
At the completion of the claims intake interview, the disability claim manager will
issue a receipt to the claimant that will identify what to expect from SSA and the
anticipated timeframes. It will also identify what further evidence or information
the claimant has agreed to obtain. Finally, it will provide the name and telephone
number of the disability claim manager for any questions or comments which the
claimant may have.
SSA Will Recognize That Some Third Parties Can Develop Complete Application
Packages
Certain third party organizations may be willing to provide a complete disability
application package to SSA. Based on local management's assessment of service area
needs and the availability of qualified organizations, SSA will certify third party
organizations who are capable of providing a complete application package,
including appropriate application forms and medical evidence necessary to
adjudicate a disability claim. In such claims, SSA will permit the third party to
identify potential claimants, screen for disability and nondisability criteria, and
contact SSA to protect the filing date. The third party will interview the claimant;
complete all applications and related forms; obtain completed treating source
statements; and obtain additional medical evaluations, when appropriate. Using
procedures agreed on with local management, the third party will submit claims for
adjudication by a disability claim manager. The disability claim manager may elect
to contact the claimant for the purpose of verifying identity or other
claims-related issues, as appropriate. SSA will monitor such third parties to ensure
that quality service is provided to claimants and to prevent fraud.
Claimants Will Have the Opportunity for a Personal Interview Before SSA Makes an
Initial Disability Denial Decision
When the evidence does not support an allowance, the disability claim manager will
provide the claimant an opportunity for a personal interview before issuing the
initial denial determination. The interview will be in person, by videoconference, or
by telephone, at the claimant's option and as the disability claim manager
determines is appropriate under the circumstances. In appropriate circumstances,
the predenial interview may follow the initial intake interview. The purpose of the
predenial interview will be to advise the claimant of what evidence has been
considered and to identify what further evidence, if any, is available that bears on
the issues. If such further evidence exists, the disability claim manager will advise
the claimant to obtain the evidence or, as appropriate, assist the claimant in
obtaining it.
Initial Disability Decisions Will Use a "Statement of the Claim" Approach
The initial disability determination will use a "statement of the claim" approach.
The statement of the claim will set forth the issues in the claim, the relevant facts,
the evidence considered, including any evidence or information obtained during the
predenial interview, and the rationale in support of the determination. The
statement of the claim not only reflects the SSA commitment to fully explaining the
basis for its action but also recognizes that claimants need clear information about
the basis for the determination to make an informed decision regarding further
appeal.
Much of the information that will provide the basis for the statement of the claim
will be available on-line as part of the automated claims processing and decision
support system. Adjudicators will create the statement of the claim and whatever
supplementary information is necessary for a legally sufficient notice to the
claimant based on the information in the decision support system. For allowance
decisions, the statement of the claim will be more abbreviated than for denial
decisions; however, it will contain sufficient information to facilitate quality
assurance reviews and/or continuing disability reviews. The statement of the claim
will be part of the on-line claim record and will be available to other adjudicators
as the basis and rationale for the Agency action, if the claimant seeks further
administrative review.
Disability Decision Methodology
The Methodology for Deciding Disability Claims Will Promote Consistent, Equitable,
and Timely Disability Decisions
SSA must have a structured approach to disability decisionmaking that takes into
consideration the large number of claims (2.7 million initial disability decisions in
FY 1994) and still provides a basis for consistent, equitable decision making by
adjudicators at each level. The approach must be simple to administer, facilitate
consistent application of the rules at each level, and provide accurate results. It
must also be perceived by the public as straightforward, understandable and fair.
Finally, the approach must facilitate the issuance of timely decisions.
The cornerstone of any approach is, of course, the statutory definition of
disability. Under the statute, disability (for adults) means the: "...inability to
engage in any substantial gainful activity by reason of any medically determinable
physical or mental impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period of not less than 12
months...An individual shall be determined to be under a disability only if his
physical or mental impairment or impairments are of such severity that he is not
only unable to do his previous work but cannot, considering his age, education,
and work experience, engage in any other kind of substantial gainful work which
exists in the national economy..." (223(d) of the Social Security Act)
The decision-making approach is the foundation on which SSA will base the claim
intake process and evidence collection. The focus will be, first, to establish a solid
medical basis for documenting that an individual has a medically determinable
physical or mental impairment. Second, once the evidence establishes a medically
determinable impairment, SSA will use additional medical findings to provide a solid
link between the disease entity and the loss of function caused by the
impairment(s).
Disability Decisionmaking for Adult Claims Will Be a Four-Step Evaluation Process
The disability decision methodology will consist of four steps that are based on the
statutory definition of disability. They are:
Step 1-
Is the individual engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2-
Does the individual have a medically determinable physical or mental impairment?
If no, deny.
f yes, continue to Step 3*.
Step 3-
Does the individual have an impairment that is included in the Index of Disabling
Impairments?
If yes, allow*.
If no, continue to Step 4.
Step 4-
Does the individual have the functional ability to perform substantial gainful
activity?
If yes, deny.
If no, allow*.
*An impairment must meet the duration requirement of the statute; a denial is
appropriate for any impairment that will not be disabling for 12 months.
Step 1 ˛ Engaging in Substantial Gainful Activity
Any individual who is engaging in substantial gainful activity will not be found
disabled regardless of the severity of the individual˛s physical or mental
impairments. If a claimant is performing substantial gainful activity at the time a
claim is filed, SSA will determine that the claimant is not disabled based on the
demonstrated ability to engage in substantial gainful activity.
Under the current process, in determining whether a claimant is performing or has
performed substantial gainful activity, SSA generally considers the amount of the
claimant's earnings, less any impairment-related work expenses. However, there are
several threshold levels of earnings that need to be considered and, depending on
the actual amount earned, SSA evaluates whether a claimant˛s work is comparable
to that of unimpaired individuals in the community who are doing the same or
similar occupations, or whether the work is substantial gainful activity based on
prevailing pay scales in the community.
Under the new process, SSA will simplify the monetary guidelines for determining
whether an individual (except those filing for benefits based on blindness) is
engaging in substantial gainful activity. In making this determination, SSA will
evaluate the work activity based on the earnings level that is comparable to the
upper earnings limit in the current process (i.e., $500). A single earnings level will
simplify the evidentiary development necessary to evaluate work activity and
establish the appropriate onset date of disability.
SSA will continue to exclude impairment-related work expenses in evaluating
whether a claimant's earnings constitute substantial gainful activity. SSA will
continue to use separate earnings criteria to evaluate the work activity of blind
individuals as in the current process.
Step 2 ˛ Medically Determinable Impairment
Because the statute requires that disability be the result of a medically
determinable physical or mental impairment, the absence of a medically determinable
impairment will justify a finding that the individual is not disabled.
Under the current regulations, SSA considers, as a threshold matter, whether an
individual has a medically determinable impairment or combination of impairments
that is "severe." A severe impairment is defined as one that significantly limits the
individual˛s physical or mental abilities to do work activities such as walking,
standing, sitting, hearing, seeing, understanding, carrying out, or remembering
simple instructions, using judgment, etc.
Under the new approach, SSA will consider whether a claimant has a medically
determinable impairment, but will no longer impose a threshold severity
requirement. Rather, the threshold inquiry will be whether the claimant has a
medically determinable physical or mental impairment. To establish the presence of
a medically determinable impairment, evidence must show an impairment that results
from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.
SSA will continue to evaluate the existence of a medically determinable impairment
based on a weighing of all evidence that is collected, recognizing that neither
symptoms nor opinions of treating physicians alone will support a finding of
disability. There must be medical signs and findings established by medically
acceptable clinical or laboratory diagnostic techniques which show the existence of
a physical or mental impairment that results from anatomical, physiological, or
psychological abnormalities which, in the opinion of the Secretary, could reasonably
be expected to produce the symptoms or substantiate any opinion evidence
provided. Depending on the nature of a claimant's alleged impairments, SSA will
consider the extent to which medical personnel other than physicians can provide
evidence of a medically determinable impairment.
There will be an exception to the requirement that evidence include medically
acceptable clinical and/or laboratory diagnostic techniques. This will occur when,
even if SSA accepted all of the claimant's allegations as true, SSA still could not
establish a period of disability; under these circumstances, SSA will not require
evidence to establish the existence of a medically determinable impairment. For
instance, if a claimant describes a condition as one that will clearly not meet the
12-month duration requirement, (e.g., a simple fracture), SSA will deny the claim
on the basis that even if the allegations were medically documented, SSA could not
establish a period of disability.
Step 3 ˛ Index of Disabling Impairments
If an individual has a medically determinable physical or mental impairment
documented by medically acceptable clinical and laboratory techniques, and the
impairment will meet the duration requirement, SSA will compare the claimant's
impairment(s) against an index of severely disabling impairments. In contrast to
the Listing of Impairments in the current regulations, the index will contain fewer
impairments and have less detail and complexity. The index will describe
impairments that will result in death or impairments that are so debilitating that
any individual would be unable to engage in substantial gainful activity regardless
of any reasonable accommodations that an employer might make in accordance with
the Americans with Disabilities Act. The index will be designed to be equitable,
easy to understand, and consistent with the statutory definition of disability.
The index will function to quickly identify severely disabling impairments; the
index will not attempt to describe ideal medical documentation requirements for
each and every body system as occurs with the current Listings. The index will
consist of descriptions of specific impairments and the medical findings that are
used to substantiate the existence and severity of the particular disease entity.
The index will not attempt to measure the functional impact of an impairment on
the individual; functional impact will be considered at Step 4 in the process. The
medical findings in the index will be as nontechnical as possible and will exclude
such things as calibration or standardization requirements for specific tests and/or
detailed test results (e.g., pulmonary function studies or electrocardiogram
tracings). The index will be simple enough so that laypersons will be able to
understand what is required to demonstrate a disabling impairment in the index.
Additionally, SSA will draw no inferences or conclusions about the effect of a
claimant's impairments on his or her ability to function merely because a claimant's
impairment(s) does not meet the criteria in the index. Finally, SSA will no longer
use the concept of ."medical equivalence." in relation to the index, as it now uses
in applying the Listing of Impairments.
Step 4 ˛ Ability to Engage in Any Substantial Gainful Activity
In the final step in determining disability, SSA will consider whether an individual
has the ability to perform substantial gainful activity despite any functional loss
caused by a medically determinable physical or mental impairment. If an individual
retains the ability to perform substantial gainful activity, then an individual does
not meet the statutory definition of disability.
Presently, there are no generally accepted measurement criteria for determining an
individual's ability to function in relation to work-related activities. Currently, SSA
assesses residual functional capacity by analyzing the objective medical findings
and other available evidence and translating this information into functional loss
and residual capacity for work activities.
Additionally, there are also no definitive sources for identifying the physical and
mental requirements of "baseline" work functions that are required to engage in
substantial gainful activity. SSA currently relies on the Department of Labor
definitions regarding the physical and mental demands of work in the national
economy, and relies on related reference sources and independent experts
regarding the existence of particular occupations and jobs in the national economy.
Under the new process, SSA will define the physical and mental requirements of
substantial gainful activity and, will measure as objectively as possible whether an
individual meets these requirements. How SSA will achieve this is described in the
following sections.
SSA Will Develop Instruments That Provide A Standardized Measure of Functional
Ability
Under the current process, SSA relies on available clinical and laboratory findings,
treating source opinions, the claimant's description of his or her abilities and
limitations, and third party observations of the claimant's limitations in determining
the claimant's residual functional capacity. Residual functional capacity is the
claimant's remaining capacity for work activities despite the limitations or
functional loss caused by his or her impairments.
Under the new process, SSA will develop, with the assistance of the medical
community and other outside experts from public and private disability programs,
standardized criteria which can be used to measure an individual's functional
ability. These standardized measures of functional ability will be linked to clinical
and laboratory findings to the extent that SSA needs to document the existence of
a medically determinable impairment that results from anatomical, physiological, or
psychological abnormalities which could reasonably be expected to produce the
functional loss. However, extensive development of all available clinical and
laboratory findings is not necessarily effective in evaluating an individual's
functional ability to perform basic work activities.
Functional assessment instruments will be designed to measure, as objectively as
possible, an individual's abilities to perform a baseline of occupational demands
that includes the principal dimensions of work and task performance, including
primary physical, neurophysical, psychological, and cognitive processes. Examples
of task performance include, but are not limited to: physical capabilities, such as
sitting, standing, walking, lifting, pushing, pulling; mental capabilities, such as
understanding, carrying out, and remembering simple instructions; using judgment;
responding appropriately to supervisors and co-workers in usual work situations;
and responding appropriately to changes in the routine work setting; and postural
and environmental limitations. Functional assessment instruments will be designed
to realistically assess an individual's abilities to perform a baseline of occupational
demands.
SSA will be primarily responsible for documenting functional ability using the
standardized measurement criteria. In the near term, SSA will solicit functional
information from treating medical sources, other nonmedical sources, and from
claimants in a manner that is similar to the current process. In the future, the
standardized measurement criteria will be widely available and accepted so that
functional assessments may be performed by a variety of medical sources,
including treating sources. The SSA goal will be to develop functional assessment
instruments that are standardized, that accurately measure an individual's
functional abilities and that are universally accepted by the public, the advocacy
community, and health care professionals. Ultimately, documenting functional ability
will become the routine practice of physicians and other health care professionals,
such that a functional assessment with history and descriptive medical findings
will become an accepted component of a standard medical report.
The prospect of universal health coverage may offer a unique opportunity for SSA
to work with the public and private sector to develop standards that both can
use. For example, medical insurance payors (whether public or private) may want
some way of measuring the effectiveness and necessity of treatment that is
prescribed by the individual's treatment source; SSA will want these same types of
measures to determine how well an individual is able to function despite his or her
impairment(s). Similarly, if all individuals have treating sources under universal
health coverage, SSA can expect that complete functional assessment measurements
will be readily available from a treating source. Finally, universal health coverage
may enable SSA to access medical records from health care providers who may be
operating under some contractual or other relationship with Federal agencies
and/or a statutory requirement that health care providers cooperate in providing
evidence as a condition of receiving Federal funds.
SSA will use the results of the standardized functional measurement in conjunction
with a new standard that SSA will develop to describe basic physical and mental
demands of a baseline of work that represents substantial gainful activity and that
exists in significant numbers in the national economy.
SSA Will Identify Baseline Occupational Demands That Represent Substantial Gainful
Activity
Under the current regulations, after assessing a claimant's residual functional
capacity, SSA evaluates whether the claimant can meet the physical and mental
demands of his or her past relevant work. Past relevant work is usually work that
a claimant performed in the last 15 years.
If the claimant is unable to perform his or her past work, SSA then evaluates
whether the claimant can perform other work in the national economy. In making
this decision, SSA relies on medical-vocational guidelines (the "Grid"). The Grid
rules represent major functional and
vocational patterns and reflect the analysis of various vocational factors (age,
education and work experience) in combination with the claimant's residual
functional capacity (which is used to determine the claimant's maximum sustained
work capacity for sedentary, light, medium, heavy or very heavy work).
In promulgating the Grid rules, SSA has taken administrative notice of the
existence of unskilled jobs that exist in the national economy at the various
functional levels. Therefore, when all the findings of fact regarding a claimant's
functional ability and vocational factors coincide with the corresponding criterion
of a rule, the existence of other work in the national economy is conclusively
established. However, if any finding of fact does not coincide with the criterion of
a rule, the rules can only provide a framework for decisionmaking. In these
situations, adjudicators must consult vocational resources or obtain expert
testimony to resolve the question of whether other work exists in the national
economy that the claimant can perform.
Under the new approach, SSA will conduct research and, working in conjunction
with outside experts, will specifically identify the activities that comprise a
baseline of occupational demands needed to perform substantial gainful activity. In
the current process, an example of comparable "baseline" criteria are the
functional requirements of unskilled, sedentary work. In establishing the functional
activities that comprise an appropriate baseline of occupational demands, SSA will
ensure that: 1) the functional activities are a realistic reflection of the demands of
occupations that exist in significant numbers in the national economy; 2) the
occupations are those that can be performed in the absence of prior skills or
formal job training; and 3) the baseline of occupational demands that becomes the
standard for evaluating the ability to perform substantial gainful activity considers
any reasonable accommodations that employers are expected to make under the
Americans with Disabilities Act.
The Effect of Age on Ability to Perform Substantial Gainful Activity
The effect of aging on the ability to perform substantial gainful work is very
difficult to measure, especially in the context of today's world when individuals are
living longer than preceding generations. Despite this change, the demographic
characteristics of those preceding generations continue to provide the framework
for disability decisionmaking because SSA's approach for deciding disability has
changed little since the inception of the DI program.
The statute recognizes that age should be considered in assessing disability on the
assumption that the ability to make a vocational adjustment to work other than
work an individual has previously done may become more difficult with age. In
determining the impact of age, recognition should be given to the changes that
occur with each succeeding generation. Accordingly, in the new process, SSA will
establish age criterion in relation to the full retirement age. The full retirement
age will gradually increase over time, based on the recognition that succeeding
generations can expect to remain in the workforce for longer periods than the
preceding generation.
In applying age criterion under the new process, an individual who falls within
the prescribed number of years preceding the full retirement age will be
considered as "nearing full retirement." In establishing what the prescribed
number of years should be, SSA will conduct research and consult with outside
experts on the relationship between age and an individual's ability to make
vocational adjustments to work other than work the individual has done in the
recent past.
SSA will rely on the age of the individual in relation to the full retirement age to
decide which of two decision paths to follow as described in the next two sections.
Individuals Who Are Not Nearing Full Retirement
For an individual who is not nearing full retirement, SSA will compare the
individual˛s functional abilities against the functional demands of the baseline
work. SSA will no longer rely on the medical-vocational guidelines and/or expert
testimony to identify whether work exists in the national economy that the claimant
can perform.The ability to perform the baseline work will represent a realistic
opportunity to perform substantial gainful activity that exists in significant
numbers in the national economy and a finding of disability will not be
appropriate.
However, anyone, regardless of age, who cannot perform the baseline work will be
considered unable to engage in substantial gainful activity, and a finding of
disability will be justified. The range of work represented by less than the
baseline will be considered so narrow that despite any other favorable factors,
such as young age or higher education or training, an individual would not be
expected to have a realistic opportunity to perform substantial gainful work in the
national economy.
For individuals who are not nearing full retirement, the ability or inability to
perform previous work is not a significant factor. These individuals should be
capable of making a vocational adjustment to other work, as long as they are
functionally capable of performing the baseline work.
Individuals Who Are Nearing Full Retirement
For individuals who are nearing full retirement, SSA will compare the individual's
functional abilities against the functional demands of the individual's previous
work. Individuals nearing full retirement age can not be expected to make a
vocational adjustment to work other than work they have performed in the recent
past. However, consistent with the statute, if an individual, even one nearing full
retirement age, is capable of performing his or her previous work, SSA will find
that the individual is not disabled.
For those individuals who have no previous work, SSA will compare the
individual's functional abilities to the baseline work, and a finding of not disabled
will be appropriate if the individual is capable of performing the baseline work. In
such claims, the fact that the individual has no previous work is usually not
related to the existence of his or her impairment(s), and a finding of disability will
not be appropriate for these individuals if they retain the capacity for the
baseline work.
The Effect of Education on Ability to Perform Substantial Gainful Activity
The statute also recognizes that education may play a role in an individual's
ability to perform substantial gainful activity. Experience demonstrates that
educational level alone, i.e., the numerical grade level that an individual has
attained may not be a good indicator of ability to function. Education is generally
completed in the remote past when compared to the age at which the majority of
disability claimants file for benefits. Completion of a certain educational level in
the remote past, without any practical application of that education in recent work
activity, has no positive effect on an individual's ability to perform substantial
gainful activity.
In relying on standardized functional assessments, SSA will be measuring both the
individual's physical and mental abilities, and education will be appropriately
reflected in the assessment of an individual's cognitive abilities. However, further
evaluation of a claimant's educational level will not be required because, in
establishing the functional activities that comprise an appropriate baseline of
occupational demands, SSA will not assume that individuals have prior skills or
significant formal job training. Thus, additional formal education will have little
impact on an individual's ability to perform the baseline of occupational demands.
SSA Will Rely on Medical Consultants to Provide Necessary Expertise in the
Decisionmaking Process
SSA will continue to rely on medical consultants to provide expert advice and
opinion regarding medical questions and issues that will arise in deciding disability
claims. Disability adjudicators at all levels of the administrative review process will
call on the services of medical consultants to interpret medical evidence, analyze
specific medical questions, and provide expert opinions on existence, severity and
functional consequences of medically determinable impairments. If a medical
consultant is called on to offer expert advice and opinion, the medical consultant
will provide a written analysis of the issues and rationale in support of his or her
opinion. The written analysis will be included in the record and will be considered
with the other medical evidence of record by disability adjudicators at all levels of
administrative review. Additionally, medical consultants will assist in the training of
other consultants and disability adjudicators; contact other health care
professionals to resolve medical questions on specific claims; perform public
relations and training with the medical community; and participate in SSA quality
assurance efforts.
Childhood Disability Methodology
As with adults, SSA must have a structured approach to disability decisionmaking
in childhood claims that takes into consideration the relatively large number of
claims and still provides a basis for consistent, equitable decisionmaking by
adjudicators at all levels of administrative review. The approach for childhood
claims must also derive from the statute. Under the statute,
An individual will be considered to be disabled for purposes of this title if he is
unable to engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to result in
death or which has lasted or can be expected to last for a continuous period of
not less than 12 months (or in the case of a child under the age of 18, if he
suffers from any medically determinable physical or mental impairment of
comparable severity). (1614(a)(3)(A) of the Social Security Act)
Disability Decisionmaking For Childhood Claims Will Be a Four-Step Evaluation
Process
The disability decision methodology for childhood claims will consist of four steps
that are based on the statutory definition of disability.
As with adults, the approach is one that provides accurate decisions that can be
achieved efficiently and cost-effectively, primarily by ensuring that documentation
requirements are directed toward the ultimate finding of disability. The four steps
are:
Step 1˛
Is the child engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2 ˛
Does the child have a medically determinable physical or mental impairment?
If no, deny.
If yes, continue to Step 3*.
Step 3 ˛
Does the child have an impairment that is included in the Index of Disabling
Impairments?
If yes, allow*.
If no, continue to Step 4.
Step 4 ˛
Does the child have the functional ability to perform activities that are comparable
to an adult's ability to engage in substantial gainful activity?
if yes, deny.
If yes, allow*.
*An impairment must meet the duration requirement of the statute; a denial is
appropriate for any impairment that will not be disabling for 12 months.
Step 1 ˛ Engaging in Substantial Gainful Activity
Any child who is engaging in substantial gainful activity will not be found
disabled regardless of the severity of his or her physical or mental impairments.
The guidelines for determining whether a child is engaging in substantial gainful
activity will be identical to the guidelines for adults. Although the issue of work
activity will arise infrequently in childhood claims, the step is warranted for two
reasons: 1) the approach for adults and children should be as similar as possible;
and 2) as a child approaches age 18, it is increasingly likely that work activity
may be an issue.
Step 2 ˛ Medically Determinable Impairment
Because the statute requires that disability be the result of a medically
determinable physical or mental impairment, the absence of a medically determinable
impairment will justify a finding that a child is not disabled. To establish the
presence of a medically determinable impairment, evidence
must show an impairment that results from anatomical, physiological, or
psychological abnormalities which are demonstrable by medically acceptable clinical
and laboratory diagnostic techniques.
The same guidelines and rules that apply for adults will apply equally for
children. SSA will continue to evaluate the existence of a medically determinable
impairment based on a weighing of all evidence that is collected, recognizing that
neither symptoms nor opinions of treating physicians alone will support a finding
of disability. There must be medical signs and findings established by medically
acceptable clinical or laboratory diagnostic techniques which show the existence of
a physical or mental impairment that results from anatomical, physiological, or
psychological abnormalities which, in the opinion of the Secretary, could reasonably
be expected to produce the symptoms or substantiate any opinion evidence.
SSA will use the same exception for evidence collection in childhood claims that will
be applied in adult claims. If a child has a medically determinable physical or
mental impairment that is not an exception to further development, SSA will then
evaluate whether the impairment(s) is included in the index of disabling
impairments.
Step 3 ˛ Index of Disabling Impairments
If a child has a medically determinable physical or mental impairment documented
by medically acceptable clinical and laboratory techniques and the impairment will
meet the duration requirement, SSA will compare the child's impairment(s) against
an index of disabling impairments. As with adults, the index for childhood claims
will function to quickly identify severely disabling impairments; the index will not
attempt to describe ideal medical documentation requirements for each and every
body system.
The index for childhood claims will consist of descriptions of specific impairments
and the medical findings that are used to substantiate the existence and severity
of the particular disease entity. As with adults, the childhood index will not
attempt to measure the functional impact of an impairment on the child; functional
impact will be considered at Step 4 in the process. The medical findings in the
index will be as nontechnical as possible and will be simple enough so that
laypersons will be able to understand what is required to substantiate a disabling
impairment in the index. As with adults, SSA will draw no inferences or conclusions
about the effect of a child's impairments on his or her ability to function merely
because a child's impairment(s) is not included in the index. Additionally, SSA will
no longer use the concept of "medical equivalence" or functional equivalence in
relation to the childhood Index.
Step 4 ˛ Comparable Severity to Adult Ability to Engage in Substantial Gainful
Activity
In evaluating disability in adults, SSA will evaluate an individual's functional
ability to perform work-related activities consistent with the ability to engage in
any substantial gainful activity. The difficulty with evaluating childhood claims is
the standard against which any functional measurement criteria are compared. For
older children, it is relatively easy because at some age (somewhere between 14
and 18) the standard approaches the adult standard, i.e., ability to engage in
substantial gainful activity. However, for younger children, the standard can be
more difficult to describe. Under the current process, SSA uses a standard that
measures the degree to which a child engages in age-appropriate activities which
corresponds fairly well with developmental milestones for different age categories.
However, the difficulty with this approach is that it may not appropriately define
how much functional loss or interference with growth and maturity is comparable
to inability to perform any substantial gainful activity.
Consistent with the adult approach, SSA will develop baseline criteria for a child's
activities that are comparable to an adult's ability to perform substantial gainful
activity. In establishing a baseline of functional activities, the functional abilities
for a child will represent a realistic comparison to an adult's ability to work.
Functional Assessment Instruments
Consistent with the approach for adult claims, SSA will develop, with the assistance
of the medical community and educational experts, standardized criteria which can
be used to measure a child's functional ability. These standardized measures of
functional ability will be linked to clinical and laboratory findings to the extent
that SSA needs to document the existence of a medically determinable impairment
that results from anatomical, physiological, or psychological abnormalities which
could reasonably be expected to produce the functional loss.
These functional assessment instruments will be designed to measure, as
objectively as possible, a child's abilities to perform a baseline of functions that
are comparable to the baseline of occupational demands for an adult. SSA will
conduct additional research to specifically identify activities that are comparable to
those that comprise a baseline of occupational demands needed to perform
substantial gainful activity by adults.
SSA will be primarily responsible for documenting functional ability using the
standardized measurement criteria. Ultimately, the course of documenting and
developing for the functional abilities for childhood claims will mirror the adult
approach.
Comparability Standard
SSA will develop realistic standards which represent activities that are comparable
to an adult's ability to engage in substantial gainful activity. The standards will
focus on a skill acquisition threshold designed to measure broad areas of skill that
are required to ultimately develop the ability to engage in substantial gainful
activity. If the child is progressing satisfactorily in the development of these
skills, then the child will not have an impairment of comparable severity and SSA
will not find the child disabled.
Evidentiary Development
SSA's Ability to Issue Timely and Accurate Disability Decisions Depends on the
Efficient Collection of Quality Medical Evidence SSA's ability to provide timely and
accurate disability decisions depends to a significant degree on the quality of
medical evidence it can obtain and the speed with which it can obtain it. The
medical evidence collection process accounts for a considerable portion of the total
time involved in processing disability claims.
Traditionally, the procurement of medical evidence has involved multiple, often
repetitive, requests for information from a variety of health care providers. Health
care providers believe that these requests burden them with far too much
paperwork and offer far too little in the way of compensation for the time
invested. Conversely, adjudicators often find that this evidence is primarily
treatment-oriented and fails to provide the highly specialized clinical information
required by the current Listings, or the functional information that is frequently
necessary at various points in disability decision-making process. Health care
professionals, particularly physicians, readily concede that their training is
oriented towards diagnosis and treatment, not the assessment of function. Thus,
the timely collection of medical information depends to a significant degree on
health care providers who have only a tangential interest and understanding of
the disability program, its requirements, and, most importantly, the vital role that
health care providers' information has in the disability decision process.
Evidence Collection Will Focus on Core Diagnostic and Functional Information
Necessary to a Disability Decision
The goals of the evidence collection process will be to focus requests for evidence
on the critical diagnostic and functional assessment information necessary for a
disability decision and to form a new partnership with the sources of this
information so that it can be obtained in the most efficient, cost-effective manner.
Medical evidence development will be driven by the four-step approach SSA will
use to decide disability. Two of the core elements of that approach are: 1)
identifying an individual's medically determinable impairments (including those that
meet the Index of Disabling Impairments criteria); and 2) assessing the functional
consequences of those impairments. SSA will develop medical evidence that is
sufficient to satisfy the core elements but target evidentiary development so that
SSA obtains only the evidence that is necessary to reach an accurate decision on
the ultimate question of disability.
Treating Sources Will Be the Preferred Sources for Medical Evidence
SSA will give primary emphasis to obtaining medical information from treating
sources by way of brief, but specific, diagnostic information regarding an
individual's medically determinable impairments and the functional consequences of
those impairments. Treating source statements will include diagnostic information
about a claimant's impairments, the clinical and laboratory findings which provide
the basis for the diagnosis, onset and duration, response to treatment, and the
functional limitations that can reasonably be linked to the clinical and laboratory
findings. SSA will develop, in conjunction with the appropriate health care
professionals and other public and private disability programs, standardized
criteria which can be used to measure, as accurately and objectively as possible,
an individual's functional ability. SSA will also seek health care providers'
assistance in educating the medical community on the clinical application of these
instruments. Once developed and universally accepted as the appropriate standard
by the medical community, the standardized measurement criteria will be widely
available. If a standardized functional assessment is available from a treating
source, SSA will obtain that information and accept it as probative evidence. SSA
may also request that the treating source or another examining source perform the
standardized functional assessment at SSA expense.
SSA Will Use a Standardized Form to Request Medical Evidence From Treating
Sources
SSA will develop a standardized form which effectively tailors the request for
evidence to the specific diagnostic and functional assessment information necessary
to make a disability decision. The standard form will also be available in electronic
form to permit treating sources to submit evidence electronically. Standardizing
requests for evidence in this manner will facilitate the participation of claimants,
representatives and third parties in the evidence collection process.
The form will permit treating sources to provide necessary diagnostic and
functional assessment information on a single document. In appropriate
circumstances, SSA will accept a treating source's statement on the standardized
form as to these issues without resorting to the traditional, wholesale procurement
of actual medical records. Depending on the nature and extent of an individual's
impairments and treating sources, statements from multiple medical sources may be
appropriate. In completing standard forms, treating sources will certify that they
have in their possession the medical documentation referred to in the statement
and that said documentation will be promptly submitted at the request of SSA. The
certification approach is consistent with evidence collection methods used by
private disability insurance carriers, which request specific medical records in
individual claims, as appropriate to the individual circumstances, or at random as
part of a quality assurance program. SSA will monitor treating source completion of
the standardized forms and verify evidence when appropriate.
SSA Will Provide Incentives for Treating Sources to Cooperate in the Development
of Medical Evidence
SSA will acknowledge the value of treating source information by establishing a
national fee reimbursement schedule for medical evidence. Additionally, the fee
reimbursement schedule will utilize a sliding-scale mechanism to reward the early
submission of medical information. A national, sliding-scale fee schedule will
provide incentives for treating sources to cooperate in the evidentiary development
process and invest quality time to provide medical certifications on behalf of their
patients.
SSA will focus professional educational efforts and medical relations outreach at
the local and/or regional level to ensure that treating sources are kept informed
of program requirements and made aware of specific evidentiary needs or problems
as they arise in the adjudication process.
SSA Will Use Consultative Examinations When There is No Treating Source Able or
Willing to Provide Necessary Evidence or There Are Unresolved Conflicts in the
Record
If a claimant has no treating source, or a treating source is unable or unwilling to
provide the necessary evidence, or there is conflict in the evidence that can not
be resolved through evidence from treating sources, SSA will refer the claimant
for an appropriate consultative examination. Because the standardized measurement
criteria for assessing function will be widely available, consulting sources will be
able to perform functional assessments that, in the absence of adequate treating
source information or where there are unresolved conflicts in the evidence, will be
considered probative evidence. Depending on the service area, SSA will consider
contracting with large health care providers to furnish consultative examinations
for a specified geographic location.
As part of an ongoing training and medical relations program, SSA will ensure that
providers of consultative examinations are provided adequate training on disability
requirements, both initially and as program changes occur.
Administrative Appeals Process
The Administrative Appeals Process Will Be Simple and Accessible and Maintain
Public Confidence in the Integrity of the Process. The administrative appeals
process will be simplified to increase the accessibility of the process. The public
perceives multiple, mandatory appeal steps as obstacles to receiving timely, fair,
and accurate decisions. SSA will reduce the number of mandatory appeals steps in
the administrative process. Streamlining the appeals process in this manner will
not only promote more timely decisions but also ensure that claimants do not
inappropriately withdraw from the claims process based on a perception that it is
too difficult or time-consuming to pursue their appeal rights.
Claimants will be able to fully participate in the administrative appeals process
with or without a representative. SSA will ensure that claimants are fully advised
of their right to representation and SSA will routinely provide the appropriate
referral sources for representation. SSA will also encourage the early participation
of a representative when the claimant has appointed one and will give the
representative responsibility for developing evidence necessary to decide a claim.
However, the decision whether to appoint a representative must remain with the
claimant and SSA will neither encourage nor discourage claimants in seeking
representation.
The administrative appeals process will function so that it maintains the public's
confidence in the integrity of the system. To instill such confidence, SSA will
provide an initial decisionmaking process that is thorough and results in fully
developed records with fair and accurate decisions. Additionally, SSA will explain
the basis of a decision in clear and understandable language. Finally, SSA will
ensure that disability claims are decided on the merits of the evidence and that
SSA regulations and policies have been consistently applied at all levels of
administrative review.
As noted previously, the initial disability determination will use a "statement of the
claim." approach which will set forth the issues in the claim, the relevant facts,
the evidence considered, including any evidence or information obtained during the
predenial interview, and the rationale in support of the determination. The
statement of the claim will be part of the on-line claim record and will stand as
the basis and rationale for the Agency action, if the claimant seeks further
administrative review. SSA will standardize claim file preparation and assembly,
including the use of appropriate electronic records, at all levels of administrative
process until such time as the claims record is fully electronic.
The Next Level of Administrative Appeal Will Be An Administrative Law Judge
Hearing
Because the initial determination will be the result of a process that ensures fully
developed evidentiary records and ample opportunity for the claimant to personally
present additional evidence prior to an adverse determination, there will be no
need for any intermediate appeal
(e.g.,reconsideration) prior to the administrative law judge (ALJ) hearing. If the
claimant disagrees with the initial determination, the claimant may, within 60 days
of receiving notice, request an ALJ hearing.
An Adjudication Officer Will Conduct All Prehearing Proceedings. If a claimant
decides to request an ALJ hearing, an adjudication officer will conduct an
interview in person, by telephone, or by videoconference, and become the primary
point of contact for the claimant. The adjudication officer will have the same
knowledge, skills and abilities as the adjudicators who decide claims initially. The
adjudication officer will also have specialized knowledge regarding hearings and
appeals procedures. The adjudication officer will be the focal point for all
prehearing activities but will be expected to work closely with the ALJ, medical
consultants and the disability claim manager, when appropriate.
The adjudication officer will explain the hearing process; advise the claimant
regarding the right to representation; provide the appropriate referral sources for
representation; give the claimant, where appropriate, copies of necessary claim file
documents to facilitate the appointment of a representative; and encourage the
claimant to decide about the need for and choice of a representative as soon as is
practical.
The adjudication officer will also identify the issues in dispute and whether there
is a need for additional evidence. If the claimant has a representative, the
representative will have the responsibility to develop evidence. The adjudication
officer will also conduct informal conferences with the representative, in person or
by telephone, to identify the issues in dispute and prepare written stipulations as
to those issues not in dispute. If the claimant submits additional evidence, the
adjudication officer may refer the claim for further medical consultation, as
appropriate. The adjudication officer will have full authority to issue a revised
favorable decision if the evidence so warrants. If the adjudication officer issues a
favorable decision, the adjudication officer will refer the claim back to the
disability claim manager to effectuate payment.
The adjudication officer will consult with the ALJ during the course of prehearing
activities, as necessary and appropriate to the circumstances in the claim. As a
preliminary matter, the adjudication officer will also set a date for the hearing
that is 45 days after the hearing request. The adjudication officer may exercise
discretion in establishing an earlier or later hearing date depending on the
individual circumstances. Electronic access to ALJs' calendars will facilitate timely
scheduling of hearings. The adjudication officer will refer the prepared record to
an ALJ only after all evidentiary development is complete and the claimant or a
representative agrees that the claim is ready to be heard.
The ALJ will retain the authority and ability to develop the record. However, use
of an adjudication officer realigns most, if not all, prehearing activities so that the
burden of ensuring their completion rests with other members of the adjudicative
team. ALJs' primary function will be hearing and deciding claims.
The Administrative Law Judge Hearing Will Be a De Novo, Nonadversarial Proceeding
The ALJ hearing will be a de novo proceeding in which the ALJ considers and
weighs the evidence and reaches a new decision.
A de novo hearing is consistent with the role of an ALJ envisioned under the
Administrative Procedure Act. Under that scheme, the ALJ is an independent
decision maker who must apply an agency's governing statute, regulations and
policies, but who is not subject to direction and control by the agency with
respect to the decisional outcome in any individual claim. ALJs are independent
triers of fact who perform their evidentiary factfinding function free from agency
influence. At the same time, the Administrative Procedure Act ensures that an
ALJ's decision is subject to review by the agency, thus giving the agency full
power over policy. Policy responsibility remains exclusively with the agency while
the public has assurance that the facts are found by an official who is not subject
to agency influence.
A hearing before an ALJ will remain an informal adjudicatory proceeding as it is
under the current process. The claimant will have the right to be represented by
an attorney or a non-attorney with the decision regarding representation made by
the claimant alone. An informal, nonadversarial proceeding is consistent with the
public's strong preference for a simple, accessible hearing process that permits,
but does not require, an attorney. An informal process facilitates the earlier and
faster resolution of the issues in dispute, thus promoting more timely decisions.
As an independent factfinder in a nonadversarial proceeding, the ALJ will still
have a role in protecting both SSA interests and the claimant's interests,
particularly when the claimant is unrepresented. However, an improved initial
determination process with its focus on early and comprehensive evidentiary
development, predenial personal conferences, fully rationalized initial decisions, and
prehearing analysis of contested issues should ensure that the Agency position is
fully explored and presented to the ALJ. Moreover, the primary burden of
compiling an evidentiary record will be shifted to the representative˛if one is
appointed˛or to the claimant (when able to do so), with assistance (when
appropriate), from SSA personnel.
Adjudication officers and other decision writers will assist ALJs in preparing
hearing decisions, using the same decision support system that supports the
preparation of initial disability determinations. A simplified disability decisional
methodology, in conjunction with the use of prehearing stipulations that frame the
issues in dispute, will result in shorter, more focused hearing decisions. If the ALJ
issues a favorable decision, he or she will refer the claim back to the disability
claim manager to effectuate payment.
The Administrative Law Judge Decision Will be the Final Decision of the Secretary
Subject to Judicial Review Unless the Appeals Council Reviews the Administrative
Law Judge Decision On Its Own Motion
Under the new process, if a claimant is dissatisfied with the ALJ's decision, the
claimant's next level of appeal will be to Federal district court. A claimant's
request for Appeals Council review will no longer be a prerequisite to seeking
judicial review.
As under the current process, the Appeals Council will continue to have a role in
ensuring that claims subject to judicial review have properly prepared records
and that the Federal courts only consider claims where appellate review is
warranted. Accordingly, the Appeals Council, working with Agency counsel, will
evaluate all claims in which a civil action has been filed and decide, within a fixed
time limit whether it wishes to defend the ALJ's decision as the final decision of
the Secretary. If the Appeals Council decides to review a claim on its own motion,
it will seek voluntary remand from the court for the purpose of affirming,
reversing or remanding the ALJ's decision. Favorable Appeals Council decisions will
be returned to the disability claim manager to effectuate payment.
Additionally, the Appeals Council will have a role in a comprehensive quality
assurance system. As part of this system which is described in greater detail
below, the Appeals Council will also conduct own motion reviews of ALJ decisions
(both allowances and denials) prior to effectuation. If the Appeals Council decides
to review a claim on its own motion, the Appeals Council may affirm, reverse or
remand the ALJ's decision. The Appeals Council's review will be limited to the
record that was before the ALJ.
Quality Assurance
Quality Assurance Will be a System of Agency Accountability
SSA will be accountable to the public, the ultimate judge of the quality of SSA
service, and SSA will strive to consistently meet or exceed the public's
expectations. SSA will have a comprehensive quality assurance program that
defines its quality standards, continually communicates them to employees in a
clear and consistent manner, and provides employees with the means to achieve
them. SSA will devote resources to building quality into the system of adjudication
to ensure that the right decision is made the first time. SSA will also
systematically review the quality of the overall system of adjudication to ensure
the integrity of the administrative process and promote uniform application of
agencies policies nationally. Finally, SSA will measure customer satisfaction against
the SSA standards for service.
Ensuring That The Right Decision Is Made The First Time Requires An Investment
in Employees
SSA's ability to ensure that the right decision is made the first time depends on a
well-trained, competent, and highly motivated workforce that has the program tools
and technological support to issue quality decisions.
SSA will make an investment in comprehensive employee training to ensure that
employees have the necessary knowledge and skills to perform the duties of their
positions. SSA will develop national training programs for initial job training and
orientation as well as continuing education to maintain job knowledge and skills.
Such training will include general communication skills and how to deal effectively
with the public generally, and disability claimants in particular. National training
programs will also address changes to program policy.
In addition to initial program training, continuing education opportunities will be
made available to employees to enhance current performance or career development.
These opportunities may be in the form of self-help instruction packages,
videotapes, satellite broadcasts, or non-SSA training or educational opportunities.
SSA will ensure that employees are given sufficient time and opportunity to
complete the required continuing education. Employees will be encouraged to
provide feedback on the value of these continuing education opportunities,
including the quality of training materials, methods, and instructors.
Employees, other than ALJs (because of Administrative Procedure Act limitations),
who complete initial training and pass a set of performance evaluations based on
national quality standards will receive a certificate of competence. This certificate
will attest that the employee has successfully completed both initial training and a
probationary period on the job. Certification will be renewed yearly upon
successfully completing required training and having no less than a fully
satisfactory performance rating. Those employees not certified initially or renewed
will be provided an improvement plan with goals and time targets for improved
performance.
In addition to formal program training, SSA will rely on a streamlined and targeted
system of in-line quality reviews and monitoring of adjudicative practices. The
elements include a mentoring process for new employees and peer review for
experienced employees. SSA will encourage peers to discuss difficult claims or
issues and resolve them informally whenever possible. Peer reviews and mentoring
will not only promote timely and accurate development of disability claims, but will
also foster a spirit of teamwork. They will also promote earlier identification and
resolution of problems with policy or procedures. As part of this process,
managers will be expected to oversee the adjudication process. They will conduct
spot checks at key points in the adjudication process or perform special reviews
based on profiles of error-prone claims. The goal of these reviews is to provide
immediate, constructive feedback on identified errors to reduce or eliminate their
possible recurrence.
To ensure that adjudicators have the necessary program tools to issue accurate
decisions, SSA will use a single mechanism for the presentation of all substantive
policies used in determining eligibility for benefits. Additionally, an integrated
claims processing system will provide the necessary technological support for
adjudicators at all levels of the administrative process. Among other things, the
claim processing system will facilitate the preparation of accurate decisions by
providing on-line editing capacity to identify errors in advance and decision
support software to assist in analysis and decisionmaking.
Although comprehensive employee education and an in-line review system will build
quality into the system of adjudication with the goal of error prevention, SSA must
still monitor quality on a systematic, national basis. Accordingly, all employees will
be subject to and receive continuous feedback from comprehensive end-of-line
reviews as described in the following section.
Quality Measurement Will Focus On Comprehensive End-of-Line Reviews
Another component of quality assurance is an integrated system of national
postadjudicative monitoring to ensure the integrity of the administrative process
and to promote national uniformity in the adjudication of disability claims. This
system will include comprehensive review of the whole adjudicatory process
including both disability and nondisability issues, allowances and denials, and at
all levels of decisionmaking. The review will focus on whether accurate decisions
were made at the first possible step in the process. This type of review will not
be aimed at correcting errors in individual claims but, rather, will be the means to
oversee, monitor and provide feedback on the application of agency policies at all
levels of decisionmaking. Reliance on an integrated claim processing system will
facilitate the selection of a statistically valid sample of claims for this review.
SSA will use the results from these end-of-line reviews to identify areas for
improvement in policies, processes or employee education and training. SSA will
also use the results to profile error-prone claims with the goal of preventing
errors at the front end.
SSA Will Conduct Surveys to Measure Customer Satisfaction
To measure whether SSA has met or exceeded the public's service expectations,
SSA must measure their level of satisfaction with the level of service SSA
provides. Customer surveys and periodic focus groups will be the most frequently
used methods of determining the public's views on the quality of SSA service. SSA
will also survey representatives and third parties who provide assistance or act on
claimants' behalf in dealing with SSA. Survey results will be communicated to staff
on a timely basis, both as Agency feedback and individual feedback, along with
any plans to address identified problems.
SSA will also seek employee feedback on how well SSA has met their expectations.
Employee feedback will be sought on a wide array of issues including Agency goals
and performance indicators, training and mentoring needs, and the quality of
operating instructions. Although formal mechanisms will be used to obtain feedback
periodically, each employee will be encouraged to provide continuous feedback on
how to make improvements in the process.
Measurements
SSA Will Measure Disability Service From the Perspective of the Claimant
SSA's management information will be revised to assess the performance of the
Agency as a whole in providing service to claimants for disability benefits.
Management information regarding the contributions at each step in the process to
the final product, as well as to the work product passed on to other steps will be
available. For example, current component processing time measures will be
replaced by a measure of time from the first point of contact with SSA until final
claimant notification. Meaningful, timely management information will be facilitated
by a seamless claim processing system with a common database that is used by all
individuals who contribute to each step in the process.
Other measures, such as cost, productivity, pending workload, and accuracy will be
developed or revised to assess the performance of the Agency as a whole and the
participants in the process who contribute to this performance. Measurements for
public awareness, as well as claimant and employee satisfaction will add to this
assessment.
New Process Enablers
Reengineering is dependent upon a number of key factors that provide the
framework for the new process design. Each of these "enablers" is an essential
element in the new disability determination process.
Process Unification
Under the Social Security Act, the Secretary has been granted broad authority to
promulgate regulations to govern the disability determination process. In addition
to the regulations, SSA publishes Social Security Rulings and Acquiescence Rulings.
Social Security Rulings are precedential court decisions, policy statements, and
policy interpretations that SSA has adopted as binding policy. Acquiescence
Rulings explain how a decision by a U.S. Court of Appeals will be applied when the
court's holding is at variance with the Agency's interpretation of a provision of
the statute or regulations.
These source documents provide the basic framework for the policies that regulate
eligibility for benefits. Administrative law judges (ALJ) and the Appeals Council
use these source documents in making disability decisions. However, they are not
directly used by decisionmakers at the first two levels of the process, i.e., initial
and reconsideration determinations. Guidance for these decisionmakers is provided
in a series of administrative publications specifically designed for and aimed at the
audiences responsible for adjudicating these claims.
The Program Operations Manual System instructions provide the substance of law,
regulations, and rulings for adjudication issues in a structure format that does not
necessarily repeat the wording of the source documents for field offices, State
disability determination services (DDS), the processing centers, and quality
assurance reviewers. The Program Operations Manual System is supplemented by
other administrative issuances to clarify or elaborate specific policy issues. The
Program Operations Manual System also provides basic operating instructions to
the initial, reconsideration and quality components responsible for processing
claims. The Hearings, Appeals, and Litigation Law Manual provides operating
instructions and summaries of court decisions to hearing offices and the Appeals
Council.
Neither the Program Operations Manual System or the Hearings, Appeals, and
Litigation Law Manual is binding on ALJ decisionmaking because this material is
not considered Agency policy under the Administrative Procedures Act. Only those
regulations and interpretative rulings published in the Federal Register, in
accordance with the Administrative Procedures Act guidelines, can be binding on
ALJs. Other decisionmakers are bound by interpretative guidance in the Program
Operations Manual System and supplemental issuances. This situation fosters the
perception that different policy standards are used at different levels of
decisionmaking in the claims process.
SSA will develop a single presentation of all substantive policies used in the
determination of eligibility for benefits. All decisionmakers will be bound by these
same policies. These policies will be published in accordance with the
Administrative Procedures Act. In addition, to facilitate the flow of work in the
new process, a single operating manual will be developed.
Public and Professional Education
Public and professional education is essential for the proper understanding of and
participation in the disability claims process. The goal is to ensure that those
individuals and groups involved in the disability process have a better
understanding of SSA disability programs, their medical and nonmedical
requirements, and the nature of the decisionmaking process.
SSA will make information widely available for the general population. Pamphlets,
factsheets, posters, videos, information on diskettes and on computer bulletin
board systems will be developed. This information will be written in a simple,
straight forward and understandable manner. It will be available in many
languages and dialects and will accommodate vision and hearing impaired
individuals. Videotapes will be available to show in SSA offices, welfare offices and
in places where medical care is provided. It will explain the definition of disability,
stressing the durational and level-of-severity requirements while giving real life
examples. Insured status requirements for SSA disability insurance (DI) and income
and resource limitations for supplemental security income (SSI) will be explained in
general terms.
This same information will be distributed to third parties who may be referral
sources for disability claims. It will serve to provide them with basic information
about medical and nonmedical eligibility criteria and the options available for filing
claims.
SSA will work with nationally and locally interested and involved groups to
develop direct lines of communications about the disability process and program.
These efforts will not be limited to providing information, but will include opening
and maintaining a dialogue about the disability process as part of an ongoing
organizational relationship.
Professionals who work with the disabled population will require more detail. The
current "Understanding SSI" booklet will be enhanced to include more information
on the disability aspects of the SSI program˛including the requirements and
process, as well as the options available to claimants or interested third parties to
speed up the process. A similar booklet for the DI program will be developed.
These booklets will serve as training manuals and reference tools, and will include
information and examples about providing functional assessments. Special efforts
will be made to have coverage of these booklets included in courses which are
part of a social service delivery curriculum at the post-secondary and graduate
levels.
SSA will conduct outreach efforts with the legal community, to ensure that
information about the disability programs is widely available to the organized bar
and the Federal judiciary. Policy documents, regularly updated electronically, and
rules of representation will be available at forums sponsored by the organized bar
and in initial orientation and continuing legal education programs designed for
Federal judges.
Treating physicians, medical providers and other treating professionals need
up-to-date information on medical evidence requirements. SSA will conduct
educational outreach with the medical community to provide them with a better
understanding of the SSA disability programs, the medical and functional
requirements for eligibility, and the best ways to provide medical information
needed for decisionmaking. In addition to the use of printed materials, SSA will
arrange briefings and training sessions in association with medical organizations
and societies at the local, State and national levels, as well as through hospital
staff meetings.
Those medical providers who conduct consultative examinations for SSA will need
ongoing training regarding changes in the disability program. SSA will prepare
training programs for this audience which will utilize written, audiotape, videotape,
and computerized training methods.
Claimant Partnership
As part of their partnership with SSA, claimants will be encouraged to actively
participate at all levels of the adjudication process and will be fully informed of
their rights and responsibilities. SSA's interaction with claimants will facilitate
claimant responsibility and active participation in the processing of their claims.
The resources of interested and capable third parties will be garnered to assist
claimants and SSA in fulfilling their partnership responsibilities.
The majority of claimants are able to complete simple forms, attend appointments,
and obtain medical and nonmedical documentation, either on their own or with the
assistance of third parties. Other claimants are unable to accomplish some of these
tasks, even with the assistance of third parties. Still others have substantial
difficulty fulfilling any of these tasks, and may have no third party to assist
them. Given the range of claimant capabilities, SSA will retain ultimate
responsibility for development of claims when claimants are not formally
represented.
What SSA Will Do
SSA's interaction with claimants will focus on enabling their participation in the
process. Understandable public information materials and application packets will
be widely available. Explanations of the program, the process, and claimant
responsibilities will be furnished at the point individuals first make contact with
SSA. SSA will also work with third parties, such as family members and
community-based organizations, to provide additional claimant support.
In addition, SSA will provide ongoing assistance and appropriate status information
throughout the process. The opportunity for personal contact with the disability
claim manager will be afforded to each claimant prior to the issuance of an initially
unfavorable decision. A claimant will be advised of evidence that has been
considered in making the disability determination and provided an opportunity to
present additional evidence for consideration.
Claimants will be provided the opportunity to fully participate in the appeals
process. Decision rationales, appeal rights, and representation rights will be
explained in clear, understandable language.
What Claimants Will Do
Early, ongoing dialogue between claimants and SSA will ensure that claimants have
access to information and resources they need to actively pursue their claims and
make informed choices.
Claimants will be asked to do more to facilitate development of supporting
information when they are able, particularly with respect to medical evidence. When
they file for disability benefits, claimants having had medical treatment will be
asked to request that their treating sources complete standardized forms.
Information about this requirement will be publicized in the general community and
given to claimants and third parties when they first contact SSA. Third parties
will be encouraged to assist claimants who are unable to fulfill this obligation on
their own. However, when necessary, a disability claim manager will assist claimants
in obtaining evidence.
To encourage the release of evidence by treating medical sources, SSA will network
with the treating source community to overcome the lack of understanding and
possible resistance to providing patient information. SSA will develop fax, E-mail,
and other electronic means for physicians to provide direct certification
information.
There will be situations where claimants have no treating sources, or where
treating sources provide insufficient medical evidence to make a disability
determination. SSA will work with willing treating sources and other medical
providers to assist in developing medical evidence (including testing and
examination) in these circumstances
.
In order to expedite the referral of potentially eligible individuals, SSA will
develop productive working relationships, with Federal, State and local programs
that serve individuals with disabilities. While eligibility requirements vary
significantly for programs such as Food Stamps, Aid to Families with Dependent
Children, General Assistance, foster care and adoption assistance, and Veterans
Benefits, effective working relationships can be built around agreements that
expand sharing of authorized information and awareness of program requirements.
Claimants will be able to fully participate in the appeals process with or without a
representative. During the appeal process, claimants and/or their representatives
will have primary responsibility for compiling an evidentiary record. SSA will
provide appropriate assistance for unrepresented claimants.
Assistance to Claimants
Many claimants today rely on other individuals; private and public organizations;
and for-profit and nonprofit organizations to pursue their claims. Although they
assist claimants, these individuals and organizations do not serve as official
representatives. In most instances, those who assist in the process have the best
interests of the claimant in mind. However, some individuals and organizations have
been instrumental in attempts to defraud programs or take unfair advantage of
claimants. In the future, SSA will develop ongoing relationships with community
organizations to ensure that competent third-party resources are available to
assist the claimants..
Examples of resources that SSA will help develop include:
Transportation and escort services for indigent claimants and those who experience
difficulty in getting to consultative examinations. This would include a combination
of volunteer services and reimbursement for transportation on a contract basis.
These services will be immediately available as the need dictates.
Enhancement of medical provider capacity to identify potentially eligible patients,
secure claims and provide medical evidence. This type of activity has been
successfully demonstrated through the use of seed monies from SSA in the SSI
outreach program. An additional financial benefit to the providers will be realized
through concurrent Medicaid eligibility for patients.
Software with compatible format design which will allow direct input of
claims-related information to SSA. This will be available to claimant advocates and
medical providers ensuring the rapid and accurate transmission of information.
After a certification process, eligible users will be kept apprised of software,
procedural, and policy changes. SSA will perform ongoing document verification to
ensure the integrity of claims submitted by such users.
SSA will have an ongoing demonstration program that provides funds for truly
innovative projects that test models for national implementation.
In order to expedite the referral of potentially eligible individuals, SSA will
develop productive working relationships with Federal, State and local programs
that serve individuals with disabilities. While eligibility requirements vary
significantly for programs such as Food Stamps, Aid to Families with Dependent
Children, General Assistance, foster care and adoption assistance, and Veterans
Benefits, effective working relationships can be built around agreements that
expand sharing of authorized information and awareness of program requirements.
Other programs will be able to use SSA-developed decisional support systems to
evaluate potentially eligible persons prior to referral. This information will be
transferred to SSA through compatible databases. To further enhance these
relationships, disability claim managers will be available in remote locations, such
as Department of Veterans Affairs homeless program sites, where the workload
warrants their presence. With appropriate information available at these sites, the
on-site disability claim manager will be able to complete the entire initial
application process, with access to other program experts through information
systems. Local managers will be encouraged to develop and maintain appropriate
working relationships with local Federal, State and third-party resources.
The Payoff will be Greater Customer Satisfaction
Active participation by claimants, supported by SSA's efforts and the contributions
of third parties will result in a fundamental shift in claimant expectations and
satisfaction with the SSA disability process. From the SSA perspective, the results
will be better service to customers through timely, fully supported decisions
rendered at all decisional levels; better use of SSA resources focused on helping
those who need assistance; and greater public confidence in the disability
adjudication process.
Workforce Maximization
Teamwork
The teamwork concept is a fundamental ingredient in the new process. The
disability claim manager will be the focal point at the initial claim level, assisted
by technical and medical support staff. The adjudication officer will be the focal
point at the prehearing level, relying on technical and medical support staff, as
well as interacting with the disability claim manager and the administrative law
judge (ALJ), as necessary. The ALJ will be the focal point at the hearing level,
receiving support from technical and medical support staff, and also interacting
with the adjudication officer and disability claim manager, as necessary.
Each team member will have at least a basic familiarity with all the steps in the
process and an understanding of how he/she complements another's efforts.
Everyone will achieve a greater sense of participation, closure, and accomplishment
because of shared responsibility for performing the whole process. Team members
will maintain ownership of the process and the outcomes. The teams will function
effectively and efficiently because:
All members will have electronic access to the claim throughout the process and
thus be better able to engage in meaningful discussions with the claimant.
Handoffs, rework, and non-value steps will be significantly reduced and fewer
employees will be involved in shepherding each claim through the process. This
will enhance SSA's capacity to provide world-class service by allowing employees
to devote more time to each claimant, providing more personalized service.
Team members will be knowledgeable but will also be able to draw upon each
other's expertise on complex issues.
Improved automated systems will enable members of the team to work together
using a shared data base even when they are not co-located.
Communication between team members and other disability claim managers will
encourage consistent application of disability policy.
Customer service is the primary focus at all steps of the process and an integral
part of the teams' goals. This focus and commitment will increase claimant satisfaction.
Team members will work closely with social service and medical/professional
agencies and advocacy groups in the service area to improve their ability to
obtain the necessary medical and functional information to appropriately evaluate
disabling conditions.
Varying levels of job complexity will provide the opportunity for personal
development, growth, and learning.
Disability Claim Managers
Disability claim managers will be responsible for intake of DI and SSI
disability/blindness benefit claims, development of all evidence (medical and
nonmedical) required to adjudicate those claims, final adjudication of claims,
ongoing communication with claimants, and issuance of notices and/or payment
actions. In carrying out these responsibilities, disability claim managers will work
in a team environment with medical and nonmedical experts who provide advice and
assistance with complex case adjudication, as well as support personnel who handle
more routine aspects of case development and payment effectuation. Tasks will be
facilitated by a fully automated intake process, developmental and decisional expert
system applications, personalized automated notices, and automated payment
computations.
Disability claim managers will be able to:
Provide claimants with current and accurate information about their claims;
Anticipate documentation needs and eliminate development that is not necessary in
favorable determinations;
Eliminate time lost and rework caused by frequent handoffs and queues;
Access expert advice through shared databases, thus eliminating the need to
transfer files;
Provide claimants with complete information if their claims are proposed for denial
and enhance claimants' ability to rebut such outcomes easily and early in the
process; and
Effectuate payment quickly, thus avoiding the need for recontacts and verification
of nondisability factors of eligibility.
Adjudication Officers
Adjudication officers will be responsible for claims from the point of receiving
hearing requests until they are ready to be heard by ALJs. In carrying out their
responsibilities, adjudication officers will work in a team environment with medical
and nonmedical experts, requesting advice and counsel from ALJs as necessary.
Adjudication officers will be able to:
Address the claimants' questions and concerns regarding their claims;
Identify and discuss issues in dispute with claimants and determine the need for
additional evidence. If the claimant is represented, conduct personal conferences
with the representative and prepare written stipulations as to those issues not in
dispute;
Review claim records prior to hearings and issue revised decisions if additional
information or evidence so warrants or refer claims for medical consultation; and
Take responsibility for all evidentiary development and refer prepared records to
the ALJs.
Administrative Law Judges
Administrative law judges (ALJ) will be responsible for hearing and deciding
appeals. ALJs will receive support from technical and medical personnel, including
decision writers. ALJs will also work with adjudication officers and disability claim
managers as necessary.
ALJs will be able to:
Review and focus on fully developed claims records prior to hearings;
Deal with claimants who have already made informed decisions regarding
representation before they appear at hearings; and
In most circumstances, close the record at the conclusion of hearings, deliberate
on issues and render prompt decisions.
Workforce Enrichment/Empowerment
The work in the new process will raise job satisfaction and increase employee
skills in the following way:
Employees involved with the initial level of claims will perform multiple tasks
instead of singular activities, thus their roles will expand to encompass more of
the "whole" job. This increases the sense of accomplishment as employees
experience the direct relationship between their actions and the final product.
Those at the prehearing step will also be able to do more of the "whole" job,
including taking action to allow claims much earlier in the process. For medical
consultants and ALJs, tasks will be eliminated that are not commensurate with
professional skill levels. Employees will feel more of a sense of ownership for the
services they perform as a member of a team focused on serving claimants.
Entry level positions will be developed in which employees work as part of the
team while gaining experience and qualifying for greater responsibility. Adequate
resources and sufficient training and mentoring will allow them to acquire the
skills they need to process the claim from intake through adjudication rather than
guessing what someone else needs or using the current all-encompassing approach
to information gathering.
The new process will rely heavily on increased employee empowerment applying
information technology and professional judgment to complete tasks more
effectively and efficiently without constant checking, direction and
micro-management. Recognition and reward processes will be revised to emphasize
contributions to team outcomes and acquisition of knowledge bases. Continuous
quality improvement activities will foster ongoing incremental process change.
Representatives: Fees, New Rules and Standards of Conduct
The Social Security Act and implementing regulations have long recognized the
representational rights of claimants and have provided an administrative framework
designed to ensure that claimants will have access to the legal community in the
pursuit of their claims. Since the inception of the disability program,
representatives have played a significant role in the disability process. The rate of
representation in SSA disability claims has risen from approximately 55% in fiscal
year (FY) 1982 to 75% in FY 1993. Focus groups of claimants and the general
public have indicated that the disability program is too complex to understand and
the process too fragmented and difficult for them to navigate alone. While many
claimants resent having to pay a representative to establish entitlement to
government-sponsored benefits, they feel that they have no choice if they want to
be successful in this pursuit. While the rate of representation has risen, so too
has the average fee for representation. The average fee received by
representatives has jumped from approximately $1,500 in FY 1987 to $2,500 in FY
1993, further adding to the dismay of claimants. As more claimants seek
representation and fees continue to climb, SSA has a heightened responsibility to
monitor representational activity and to safeguard the interests of claimants. The
proposed process will utilize new rules of representation and standards of conduct
to ensure that representatives, as key players in the disability process, fulfill
their responsibilities and adequately serve the needs of the claimants they
represent.
Under the present statutory and regulatory scheme, representatives are not
permitted to charge and collect a fee in any case without first obtaining the
approval of the Secretary. There are two distinct procedures available to
representatives for obtaining fee approval. The "fee petition" method requires the
representative to itemize the services rendered and the time expended. The
Secretary must evaluate each individual petition and determine the reasonable fee,
considering such factors as case complexity, time expended, skills needed, and the
results obtained. There is no maximum fee set y law for this procedure.
The second method, commonly referred to as the "fee agreement procedure",
involves an agreement between the claimant and the representative whereby the
fee is agreed to be no more than 25% of the retroactive benefits due, or $4,000,
whichever is less. The agreement must be executed and submitted to the Secretary
prior to the determination of the claim. While there is a maximum fee under this
procedure, the Secretary does not have to conduct an individual evaluation of the
reasonableness of the fee unless either the claimant, the representative, or the
administrative law judge (ALJ)files a protest of the fee. The fee may be reduced
by the Secretary only on the basis of evidence of the failure of the representative
to adequately represent the interests of the claimant or on the basis of evidence
that the fee is clearly excessive for the services rendered. Under limited
circumstances, the representative may ask the Secretary to increase the fee.
In addition to approving all fees under both DI and SSI of the Social Security Act,
there are withholding and direct payment of fee provisions that apply only to DI
claims where an attorney is involved. Specifically, the Secretary must withhold and
pay to the attorney the lesser of (1) 25% of the retroactive benefits due the
claimant, or (2) the fee approved by the Secretary under either the fee petition or
fee agreement procedures. The intent of this procedure is to provide an incentive
for attorneys to accept Social Security claims work in order to increase claimant
access to attorneys. In FY 1993, SSA paid nearly $300 million in fees to attorneys
out of claimants' retroactive DI benefits. This withholding and payment provision
does not apply to SSI claims because Congress did not find it appropriate to
reduce a claimant's benefits in order to pay an attorney in a means-test program.
However, even though SSA does not withhold and pay attorneys fees in these
cases, it is estimated that SSI claimants paid over $133 million in fees to their
representatives in FY 1992. Thus, the total cost to claimants for representation in
1993 approached the $500 million mark.
Since the inception of the fee agreement procedure in 1991, fee agreements have
been rapidly replacing fee petitions as the vehicle for procuring agency approval
of fees. SSA received 52,297 fee agreements in FY 1992, representing 39% of all fee
approval requests. In FY 1993, fee agreements jumped to 87,395, accounting for 63%
of all fee approval requests. Fees are generally higher under the fee agreement
procedure, averaging $2,800 in FY 1993 as compared to an average fee of $2,200
for fee petitions. One of the factors causing higher fees under the fee agreement
procedure is the lengthy processing time for disability claims; the longer it takes
to issue a decision, the greater the retroactive benefits due the claimant. Under
the fee agreement procedure, the fee is based on the amount of retroactive
benefits due, and there may be little or no correlation to the time expended by the
representative or the skills involved in rendering representational services. By
eliminating fragmentation and handoffs, the proposed process will significantly
reduce processing time. SSA will issue decisions faster, the amount of resulting
retroactive benefits will be reduced, and resulting fees will likewise be reduced.
However, as the fee agreement procedure continues to claim an ever-increasing
share of the total number of fee requests filed each year, more and more fees will
be based upon a predetermined, mathematical formula rather than by an
independent evaluation of the quality of services rendered. In order to maintain
the emphasis on quality in representational matters, the proposed process will
adopt new representation rules and standards of conduct to effectively safeguard
the rights and interests of claimants. These new regulations will:
establish qualifications for representatives, attorneys and non-attorneys, to ensure
that claimants receive competent representation;
define the duties and responsibilities of representatives, including the duty to
fully develop the record in a timely manner and to respond to requests to submit
evidence;
establish a code of professional conduct for representatives in all matters before
SSA, including conduct at prehearing conferences, hearings, and interaction with
SSA employees and claimants generally;
provide a forum for claimants to air their grievances and file charges against
representatives for failure to provide adequate representation or otherwise
violating the rules of representation and standards of conduct;
provide meaningful sanctions against representatives, including suspension and
disqualification from appearing before the agency in a representative capacity, for
violating any of the provisions contained in the rules of representation and
standards of conduct.
Without disturbing the statutory intent of facilitating claimant access to
representatives, the simplified and user-friendly new process may well result in
more claimants pursuing their claims without representation. However, the issue of
representation will remain a matter of personal choice. In addition, the proposed
process will reduce the trend of inflationary fees by eliminating the artificially
high retroactive benefits that result from excessively long processing times.
Finally, while current statutes and regulations attempt to protect claimants from
fee abuses, they fall short of extending to claimants the assurances which they
need most: that the representatives they retain will be qualified, will have the
obligation to fully develop the record on their behalf, will adequately represent
their interests, and will be accountable for misconduct or dereliction of duty. The
new rules and standards of conduct provide the framework for these assurances.
Information Technology
Information technology will be a vital element in the redesign of the disability
claim process. To the fullest extent possible, SSA will take advantage of the "
Information Highway" and those technological advances that can improve the
disability process and help provide world-class service. Existing Agency design
plans for Intelligent Workstation/Local Area Network (IWS/LAN) and a Modernized
Disability System are critical enablers for successful implementation of the
proposed process redesign. Reengineering of the disability process is on the
critical path of the design and development of the Modernized Disability System
and implementation of IWS/LAN.
The Modernized Disability System and IWS/LAN will provide an integrated system to
support the entire reengineered disability process. This system will provide
electronic connectivity throughout the process. Current SSA systems that support
disability processing operate independently of each other. Field offices, DDSs and
hearing offices all have their own systems. The DDSs have their own baseline
automation systems, but for the most part can only use the systems within the
particular State on that State's machines. Likewise, hearing offices have a
disability processing system that applies only to claim processing inside the
hearings and appeals organization. Each organization independently inputs claim
information into their systems and no automated information can be passed outside
the organization for subsequent, much less parallel, claim processing.
The reengineered process relies on the ability to build a single electronic claim
record as it goes from point to point in the disability process. This includes the
ability for any facility to process the medical and nonmedical segments of claims
for another facility. This is the primary benefit of the IWS/LAN and Modernized
Disability System architectures. Both architectures are a prerequisite for enabling
reengineering of the entire disability process.
The Enabling Platform
The IWS/LAN architecture and Modernized Disability System design will support a
major objective of the redesigned disability process˛ seamless, reengineered
electronic processing of disability claims from the first contact with the claimant to
the final decision, including all levels of administrative appeal. All employees will
use the same hardware, the same claim assignment and scheduling software, the
same claim processing software, the same case control system, the same fiscal and
accounting software, the same integrated quality assurance functionality, and the
same management information system throughout all stages of the process.
Therefore, data will need to be input and validated one time only, leading to more
consistent decisions in establishing both the medical and nonmedical aspects of DI
and SSI claims. All employees will also have access to decision support systems for
those complex entitlement decisions. Since all facilities will be able to access the
same record, all SSA representatives will be able to respond to inquiries from the
same base of information. This will produce more consistent and accurate Agency
responses to inquiries.
SSA will continue to move aggressively towards the goal for complete electronic,
paperless processing with all aspects of the claims process. Key tenants of
reengineered electronic, paperless processing will be encouraging electronic
information exchanges with medical evidence providers˛and then keeping
information received electronically in that same (or a similar) digitized format for
claim processing, use of cost effective scanning/imaging of decision supporting
paper records, abstraction and/or summarization of key, paper-based information
by employees via direct keying, and finally, direct keying of information into the
claim processing system by employees, third parties, and/or claimants. Direct
keying of information into the electronic file will be minimized whenever possible
by reliance on data propagation from other SSA files and comprehensive database
support throughout the claims processing systems.
Although full realization of a completely automated system will be a long-term
initiative, a number of aspects of the redesigned process will be quickly realized
and made possible by IWS/LAN and Modernized Disability System support in the
very near future.
Redesign of Access to Services
Information technology will be applied in several ways to enhance the claimants'
and representatives' access to services and information under the new process.
Through reengineering, claimants will be able to conduct business with SSA via
telephone, self-help workstations, kiosks, videoconferencing, and electronic data
transfer at SSA facilities and other satellite locations. SSA will provide TV/VCRs
and/or kiosks in SSA facilities and public places where there is a high
concentration of potential customers to dispense information about SSA programs,
the requirements for eligibility, and the information requirements for filing an
application. The better informed the customers, the better prepared they are at
the time of the interview. This reduces recontacts and allows the customer to more
fully participate in the timely pursuit of their claim.
Waiting rooms will be equipped with self-help workstations housed in private
cubicles. They will help to pre-screen program eligibility and furnish application
requirement information for walk-in claimants. These workstations can also be used
as front-end interviewing devices that collect preliminary application information
from claimants. The preliminary information will be used to access SSA databases to
gather all known information on the claimant, including earnings history and any
prior filings.
Application information will include the telephone numbers from which claimants or
representatives will make telephone inquiries. SSA office telephone systems will be
equipped with automatic number identification technology (also known as "caller
ID"). Using this technology, SSA will be able to provide improved service by
responding to telephone inquiries with increased assurance that the caller is the
claimant or representative.
Customer Self-Help Redesign
An efficient paper application form designed to be easily read and indexed by
scanning equipment will be widely available as part of a comprehensive consumer
information publication about the disability program that will be stocked in SSA
facilities and other appropriate community-based locales. Self-help instructional
material will also be mailed to some applicants who inquire about disability benefits
by calling SSA. Up-front completion of the form will not be a requirement of filing,
but will enhance the intake process for applicants. The Modernized Disability
System will have the capability to accept scanned information from the application
form and integrate all relevant information into the electronic file.
In addition, an electronic application form will be made available to claimants with
access to a personal computer and modem using an SSA bulletin board service or
through other publicly available bulletin board services. The information will be
completed and returned electronically to SSA via an agreed upon electronic filing
method.
Finally, as previously mentioned, some claimants will begin the application process
by completing a brief electronic application form using SSA self-help workstations
in SSA offices and other community-based locations.
Enhanced Third Party Support
SSA will conduct forums and produce video and computer-based training materials
for third parties who wish to participate in assisting customers to file applications
and gather medical evidence. Wherever possible, physicians and health care
organizations, advocates, community counseling services, and other professionals
who regularly provide assistance to SSA claimants will be supplied with SSA
software to electronically complete Agency forms. The data will be transferred to
SSA using agreed upon methods. As long as these parties comply with certain
stipulations, SSA will supply updates to software and procedures, and/or establish
an SSA bulletin board from which these third parties can download current
software.
SSA will allow representatives access to electronic claim folders. This access will be
limited to the authorized representative (attorney or non-attorney) of the claimant
and will be allowed from self-help workstations at an SSA facility, or via an agreed
upon electronic data transfer method.
Evidence Collection Redesign
Medical Evidence of Record is to the disability process what the earnings record is
to the Retirement and Survivors' Insurance program. SSA will marshall its
resources for an "Evidence Modernization Project" as was successfully done for
the Earnings Modernization Project. The success of Earnings Modernization was
due, in no small part, to the partnership SSA established with the employer
community to streamline and focus the wage reporting requirements. The
redesigned disability process approach provides for similar partnership with
medical providers and the necessary streamlining of evidence collection
requirements.
SSA will expand its acceptance of interpretive data from the medical community.
Instead of relying solely on actual medical records, SSA will focus on obtaining
certifications of the diagnostic and functional information needed to make disability
determinations. These standardized certifications will be designed to solicit from
the treating source the specific information needed and enable SSA to process the
information in a timely and accurate manner.
Electronic standardized treating source information will be transmitted from
physicians to SSA and associated with the appropriate electronic record. If
additional medical evidence is needed and it is not already electronic, it will be
scanned and stored digitally, or it may be abstracted and stored electronically.
"Fax ID" and "caller ID" will be established with all parties submitting evidence or
who have rights to legitimately request evidence. As was done during Earnings
Modernization with the employer community, SSA will take advantage of the
expanding use of computer applications by medical providers by working with
software vendors that currently service the medical community to include an
application for treating source reporting in office automation software.
The paper version of the standardized treating source form will be designed so
that the data can be read by scanning equipment into SSA claims processing
systems. The form will be designed to support the structure of the Modernized
Disability System.
A single vendor payment system utilized by all appropriate employees will be used
to pay certain evidence providers for information which they provide SSA to aid in
making a disability determination. To further paperless processing, SSA will adopt
a. "signature on file" policy for the claimant's evidence release authorization to
eliminate routing of paper medical release forms.
SSA will also set up information exchanges with other Federal and State agencies
and major medical providers using pin/password access to data stores as well as
caller/fax ID to conduct information exchange over the telephone.
Reengineered Tools For Decisionmakers
The ability of decisionmakers to conduct thorough interviews and evidence
evaluation, and timely and accurate claims adjudication is predicated on the
implementation of the functionality provided by the IWS/LAN hardware and
software components, and the decision support features of the Modernized
Disability System. The IWS/LAN environment provides access from the
decisionmakers' desktop to electronic policy and procedures, multiple/simultaneous
information processing and retrieval sessions with SSA claims processing systems,
simultaneous access to both intelligent workstation-based office automation software
and SSA claims processing systems, and access to modern information-handling and
transfer technologies such as fax. With all of the tools at the decisionmakers
fingertips, time is not wasted in logging on and off claim processing systems to
get to other claim processing systems or office automation applications, nor is time
lost by having to log off the system in order to leave the workstation to research
manual reference materials.
Expert system software will be included in SSA claims processing systems to assist
disability decisionmakers in the analysis and evaluation of complex eligibility
factors, and to ensure that the correct procedures for disability evaluation are
followed. While conducting interviews, disability decisionmakers will use the
decision support features of the Modernized Disability System which ask specific
questions based on claimants' alleged impairments. This will provide more
personalized service for claimants since the decision support questions will be
tailored to their
particular impairments. The decision support system will use the accumulated data
of the electronic record to automatically produce "statement of the claim"
summaries and decision rationales used throughout the determination process.
Where disability decision team members cannot be physically co-located, they can
remain in communication by using two-way TV and other videoconferencing
technologies. Handoffs, and the queues associated with each handoff, can also be
minimized by the use of expert systems because much of the specialized knowledge
that a task requires will be electronically stored in the knowledgebase of the
expert system and immediately available. Therefore, the number of situations where
employees will have to handoff claims to other employees having more technical
expertise will be reduced.
Expert systems will also be developed to improve the delivery of disability policy.
Disability policy will be developed and stored in a format that can be integrated
into computer systems as the source of context-sensitive help screens and
decision-support messages. SSA components responsible for disability policy will be
responsible for updating the system with policy language revisions that do not
require programming changes.
Quality Assurance and Management Information Redesign
Quality assurance features fully supported by the Modernized Disability System will
be integrated throughout the new process. For example, the national end-of-line
quality review sample will be electronically selected and automatically routed to
appropriate staff. In-line programmatic quality assurance, enhanced by the use of
decision support systems, will be programmed into the computer applications and
will help to identify errors of both oversight and substance, and also support
routine analysis to aid in avoiding future similar errors. An on-line technical
review will occur each time information is added to the electronic record.
Quality assurance and productivity measures will be incorporated in a new,
total-process management information system. Meaningful, timely management
information for the disability process is dependent on a seamless data processing
system used by all components which affords a common case control system and a
common data base. SSA's claim processing systems integrated on an Agency-wide
IWS/LAN platform will provide this seamless environment.
The Modernized Disability System management information design supports the new
process goal of providing access from a desktop computer to total process
management information data no more than 24 hours old. In addition to the routine,
published national reports generated from the management information system,
other reports needed by national or local entities, or individual employees will be
preformatted and system-generated on demand. Managers and empowered employees
will have the flexibility to change parameters and to access the full data base,
permitting comparison of peer performance and trend analysis. The system would
also permit custom, ad hoc reports for special studies or immediate special purpose
activities with access to the full data base. Tools including user-friendly report
generator software and statistical forecasting and modeling applications will be
available on the intelligent workstation to assist users in the data analysis.
Appendix I
Reengineering Design Partners
Director, SSA Process Reengineering Program
Rhoda Davis
Office of the Commissioner, Baltimore, MD
Disability Process Reengineering Team
William Anderson
Office of Disability, Baltimore, MD
Mary Ann Bennett
Office of Budget, Baltimore, MD
Bryant Chase
Office of the Deputy Commissioner for Systems, Baltimore, MD
Kayla Clark
Office of Hearings and Appeals, Seattle, WA
Judith Cohen
Office of Supplemental Security Income, Baltimore, MD
Judge Alfred Costanzo, Jr.
Office of Hearings and Appeals, Pittsburgh, PA
Kelly Croft
Office of Workforce Analysis, Baltimore, MD
Mary Fischer Doyle
Office of Hearings and Appeals, Falls Church, VA
Virginia Lighthizer
Chicago Region, Detroit Conner Branch Office, Detroit, MI
Rebecca Manship
Disability Determination Service, Sacramento, CA
Mary Meiss
Office of Hearings and Appeals, Philadelphia, PA
Michael Moynihan
Office of Disability and International Operations, Baltimore, MD
Donna Mukogawa
Office of the Regional Commissioner, Chicago, IL
William Newton, Jr.
Office of Disability and International Operations, Baltimore, MD
Ralph Perez
Atlanta Region, Miami South District Office, Miami, FL
Dr. Nancie Schweikert
Disability Determination Section, Nashville, TN
Ronald Sribnik
Office of Regulations, Baltimore, MD
Sharon Withers
Philadelphia Region, Welch District Office, Welch, WV
Special Thanks To:
Linda Kaboolian
Kennedy School of Government, Harvard University, Cambridge,MA
Miriam Kahn
Process Reengineering Staff, Baltimore, MD
Kenneth Nibali
Process Reengineering Staff, Baltimore, MD
Leonard Ross
Office of Workforce Analysis, Baltimore, MD
John Shaddix
Office of Telecommunications, Baltimore, MD
Sandi Sweeney
Process Reengineering Staff, Baltimore, MD
Latesha Taylor
Process Reengineering Staff, Baltimore, MD
Process Reengineering Program Executive Steering Committee
Shirley Chater
Commissioner, SSA
Lawrence Thompson
Principal Deputy Commissioner, SSA
Rhoda Davis
Director, Process Reengineering Program, SSA
Dennis Brown
Moderator, Association of OHA Analysts
Bruce Bucklinger
President, OHA Managers' Association
Robert Burgess
President, National Association of Disability Examiners
Mary Chatel
President, National Council of Social Security Management Associations, Inc.
Herbert Collender
President, SSA/AFGE National Council of Payment Center Locals (Council 109)
Renato DiPentima
Deputy Commissioner for Systems, SSA
John Dyer
Deputy Commissioner for Finance, Assessment and Management, SSA
Richard Eisinger
Senior Executive Officer, SSA
George Failla
Director, Office of Information Resources Management, SSA
Gilbert Fisher
Assistant Deputy Commissioner for Programs, SSA
Howard Foard
Assistant Deputy Commissioner for Policy and External Affairs, SSA
Hilton Friend
Acting Associate Commissioner for Disability, SSA
John Gage
President, SSA/AFGE SSA Headquarters (Local 1923)
Randolph Gaines
Acting Associate General Counsel, SSA
Robert Green
SSA Regional Commissioner, Boston
Joseph Gribbin
Associate Commissioner for Program and Integrity Reviews, SSA
James Hill
President, National Treasury Employees Union (Chapter 224)
