DDS MEDICAL CONSULTANT POSITION PAPER
Throughout the nearly 50 year history of the Social Security Administration’s disability programs, the medical consultants in the state Disability Determination Service (DDS) agencies have played a crucial role in the development and adjudication of claims. The 1954 amendments to the Social Security Act specified that disability determinations would be made by state agencies under individual contractual agreements with the Social Security Administration. That federal-state partnership continues today, with the state DDSs making the initial disability determination for both the Social Security (SSDI) and Supplemental Security Income (SSI) disability programs. An adjudicative team, generally composed of a Disability Examiner and a DDS Medical Consultant, makes the initial disability determination in accordance with an ever-changing complex set of federal rules and regulations. This team also evaluates reconsideration and continuing disability review cases using other complex and ever-changing rules and regulations.
Because of the medical/ legal/ regulatory nature of the Social Security Administration’s disability programs, this team approach is crucial if the DDSs are to process claims efficiently and accurately.
The Social Security Administration’s disability programs are unique among disability programs. The decision regarding an applicant’s eligibility to receive Social Security or SSI disability benefits is not solely a medical decision, nor is it solely a legal decision. It is an administrative decision. An impairment is disabling only if it prevents an adult from working or a child from functioning in normal age-appropriate activities. While other disability programs may accept a treating source or a consultant’s opinion that an individual is disabled, this is not true in the SSDI or SSI disability programs. Based on all information in the file the DDS Medical Consultant must independently determine if a medical impairment is present, assess the severity of that impairment (or impairments) and, if the applicant is an adult, assess his or her remaining ability to perform work related activities (standing, walking, reaching, bending, talking, listening, following directions, relating to supervisors and co-workers, etc.).
Because the Social Security and SSI disability programs themselves are unique, the individuals who evaluate these claims, including the DDS Medical Consultant, whether he or she is a physician, a psychologist or a speech/language pathologist, must also possess a unique combination of knowledge and skills and must be specially trained to assess functional capacity based on exam, laboratory and diagnostic test findings. The program knowledge required to adjudicate Social Security and Supplemental Security Income disability claims is not acquired in medical school or as part of an individual’s professional training. Rather, it is learned through formal SSA training, case reviews and on-going interaction with other members of the adjudicative team.
There is a very real difference between clinical and regulatory medicine and it takes at least a year to become proficient in Social Security disability rules and regulations.
The DDS Medical Consultant must be able to translate the medical concept of clinical severity into the legal concepts of the Social Security program. He or she must evaluate the impact of the impairment and treatment on the applicant’s ability to function and place that assessment within the framework of SSA rules and regulations. The DDS Medical Consultant must recognize the disabling aspects of the alleged disorders and their treatments, the typical clinical course and prognosis, and the resultant impact upon function both psychiatrically and physically. In addition, he or she must be able to recognize the impact of multiple impairments, and be aware of related additional impairments that the applicant may not have alleged that could factor in the individual’s residual functional capacity for work activities.
Regional SSA court cases and acquiescence rulings impact individual DDSs differently. The DDS Medical Consultant is aware of the impact of those decisions on local case development and adjudication. Based on knowledge of the SSA disability program’s evidentiary requirements, local medical practices, and court decisions and acquiescence rulings affecting that specific DDS, the DDS Medical Consultant helps to assess whether additional development is needed to accurately adjudicate the case, and determine whether the additional development would change the decision of disability or simply satisfy the clinical desire to make a diagnosis. The DDS Medical Consultant is pivotal in cost containment of DDS expenditures for consultative examinations (CE’s) by reviewing the medical evidence in file and contacting treating sources when appropriate.
Only through experience with the Social Security disability program is the DDS Medical Consultant able to ascertain what evidence is needed or, conversely, what evidence is not needed, to make a correct decision while preventing costs and processing time from becoming prohibitive.
The role of the DDS Medical Consultant is described in SSA’s Program Operations Manual System (POMS) DI 39518.010 B and in Regulations 20 CFR 404.1520a; 404.1523; 404.1546; 416.920a; and 416.946. This role includes:
- Performing a full professional evaluation of the case, including the assessment of residual functional capacity.
- Assisting examiners, as necessary, in determining whether proposed development seems likely to provide sufficient detail about the applicant’s impairment to complete the case to the extent necessary for a disability determination.
- Judging collectively with the examiner whether:
- Re-contact with the applicant’s physician is indicated;
- Contact should be made with other agencies, hospitals, institutions, etc.;
- A consultative examination should be purchased, including specialty examinations or specific tests deemed necessary
- Making physician to physician contacts to obtain or clarify medical evidence, as needed.
The DDS Medical Consultant is equally responsible with the disability examiner for insuring that:
- The case is fully documented;
- All significant facts are reflected in the determination;
- Conflicting evidence is reconciled;
- The conclusion reached is sound and rational;
- The weight given to the evidence is explained;
- The reasoning and thought process followed in evaluating the evidence are reflected; and
- The effect of the impairment(s) on the applicant’s work capacity is clearly indicated.
In addition, the DDS Medical Consultant is expected to provide ongoing on-the job medical training for adjudicative personnel to:
- Assure uniform understanding of instructions containing medical content.
- Eliminate deficiencies in the application of disability evaluation standards, guides, and procedures suggested by subsequent case reviews and first-hand observations.
- In addition to the training of individual examiners, periodic formal training of the entire examiner staff will be performed.
Finally, the DDS medical consultant is expected to participate in the DDS’s professional relations program.
Performing these functions within the framework of the complex and frequently changing rules and regulations of the SSDI and SSI disability programs requires a unique blend of both clinical expertise and adjudicative knowledge.
In order for the DDS Medical Consultant to “…assure uniform understanding of instructions containing medical content…”, he or she must stay current with SSA’s rules and regulations, as well as any relevant court decisions or acquiescence rulings. This unique training enables DDS adjudicators to effectively “…eliminate deficiencies in the application of disability evaluation standards, guides, and procedures suggested by cases returned following subsequent reviews…”
Just as physicians, psychologists and speech/language pathologists must participate in ongoing medical education in order to keep their clinical skills and knowledge current, it is through ongoing SSA case reviews and SSA-sponsored training that DDS Medical Consultants maintain their program knowledge and skills. While SSA’s Program Operations Manual and other regulations provide some structure for addressing various allegations, the accuracy of the decision is a function of the knowledge of the requirements of the SSA and SSI disability program. Assisting Disability Examiners in sorting out and weighing of evidence of varying quality and credibility provided by treating physician opinions or evaluations by nurses and other medical sources requires a SSA programmatically trained physician.
The DDS Medical Consultant interacts with Disability Examiners on a daily basis in difficult claims and offers advice on complex case development or decision-making issues. He/she maintains liaison with the local medical community and has knowledge of local care patterns and the availability of diagnostic studies and state regulations to facilitate the adjudication process within the complex Social Security system. There are many critical consultative examination issues that require combined medical knowledge and program experience to ensure that risks to applicants are minimized in any diagnostic tests needed for adjudication. In fact, many local state laws require a medical doctor licensed within that state to authorize these tests before the applicant can participate.
Under the Single Decision Maker (SDM) pilot, the requirement for medical sign off on every case was eliminated. However, this has not diminished the need for the unique knowledge and skills of the DDS Medical Consultant but rather has allowed these Medical Consultants to invest more of their time in the more medically complex cases. It has allowed for increased assistance to less experienced adjudicators and medical consultants, for additional mentoring and training, and more time to provide medical expertise and sign-off on specialized exams and tests. There has also been more time for public relations activities, such as outreach, to improve the quality of records received from community medical providers, to make personal contacts to obtain information for adjudication and to assist in recruitment of consultative examination physicians.
DDS Medical Consultants are not only medical specialists — physicians, psychologists or speech/language pathologists; they are also SSA program specialists. Most disability applicants have multiple impairments involving more than one body system and require a comprehensive view of the combined limitations and resultant impact on function. Specialty consultants with limited scope and experience cannot fully assess the combined effects of multiple impairments on an applicant’s functioning. The SSA programmatically trained DDS Medical Consultant has the education, clinical experience and decision-making skills, along with expertise in evaluating medical records and disease conditions and making prognosis predictions regarding a claimant’s function and future condition, to more accurately assess the case as a whole.
In 2003 the DDSs made 2.5 million initial disability determinations, over 484,000 reconsideration determinations and approximately one million continuing disability review determinations. The DDS Medical Consultant is an integral part of the team which enables the DDSs to maintain quality and productivity. The onsite DDS Medical Consultant strengthens the efficiency and accuracy of the DDS adjudicative team. Their unique knowledge of SSA’s complex rules and regulations and regional variants of those regulations, their medical expertise in many fields and knowledge of local medical sources, and their familiarity with DDS examiner staff, quality specialists and supervisors, make the DDS Medical Consultant an invaluable asset to the DDS’s and the SSA Disability Program as a whole. The importance of maintaining this proven effective adjudicative team structure within the DDS is critical to efficient and effective processing of the ever increasing number of disability applications the DDS is expected to handle.
Approved by the NADE Board, April 15, 2004