IN-LINE QUALITY REVIEW PROCESS AT THE DISABILITY DETERMINATION SERVICES: THE NADE VIEW
Over the course of the almost 50 year history of the Social Security Administration’s (SSA) Disability Insurance Program, the SSA Quality Assurance (QA) process has focused almost exclusively on the quality of the product produced by the Disability Determination Services (DDS). In recent years, a minimal number of cases produced by the Administrative Law Judges (ALJ) at the Office of Hearings and Appeals (OHA) have been reviewed. The intent of the Quality Assurance process for all components should be the same; however, historically, this has not been the case. Historically, reviews of the DDS product have been focused on a greater percentage of allowance decisions while it is primarily OHA denials which have been reviewed. The percentage of cases reviewed from each component has also differed drastically. NADE believes that this different foci and inequity in the review process has helped to create the public perception that in order to be allowed disability benefits, the claimant must appeal to OHA (when in fact nearly 80% of claimants who receive disability benefits are allowed by the DDSs). Further complicating the quality review process is that the SSA Field Offices (FO) have never been the focus of the same type of accountability and quality reviews as have the DDS offices.
Historically, and currently, there is a perception of wide inconsistencies in the final decisions made at the OHA level and the final decisions made at the DDS level. Process Unification Training was provided for OHA staff and DDS staff early in the mid-1990s as a way to reduce the inconsistencies between DDS and ALJ decisions. The intent of Process Unification was to provide a more consistent approach to decision making at all levels of the process. Unfortunately, after the initial Process Unification training efforts, no additional initiatives have been undertaken to follow up on or confirm on-going consistency and quality in this area.
To quote Social Security Administration Commissioner Jo Anne B. Barnhart: “Quality is providing service that meets the needs of the people we serve, balancing the five elements of accuracy, timeliness, productivity, cost and service.”
The National Association of Disability Examiners (NADE) fully supports Commissioner Barnhart’s goal to create a culture of quality. By focusing on quality from the time of the first contact through the internet, at the SSA Teleservice Center (TSC) or local Social Security Field Office for initiation of the disability application, through the final decision at the ALJ level (including review of the proposed Reviewing Official), NADE believes that we will truly be able to achieve the goals of greater customer satisfaction and improved efficiency. We are encouraged by the Commissioner’s commitment to quality and her recognition that quality is more than accuracy rates based on end-of-line reviews conducted by Quality Assurance Units in the DDS offices and by the review of DDS decisions at the Disability Quality Branches in each of the ten SSA Regional Offices.
NADE strongly believes that for the entire disability process to improve in terms of accuracy, timeliness, productivity, cost and service, similar reviews in similar quantities at EACH step of the determination process MUST be made part of the overall quality review process. We further suggest that with implementation of a fully electronic system, it will be feasible, and advisable, for these reviews to be conducted during the process (in-line) rather than just at the end of the process (end-of-line) as is the current process of the SSA Regional Quality Branches.
NADE favors a comprehensive approach to quality review and we reaffirm our position that all components involved with the Social Security Disability Insurance Program (Teleservice Centers, Field Offices, DDS offices, OHA) are accountable for quality. NADE recognizes that each component is the best authority on what that quality should be on a national level. For example, DDS staff would not have the necessary expertise to determine issues related to providing a quality product in the area of income and resources; Field Office staff would not have the expertise to determine issues related to providing a quality product in the area of sufficiency of medical evidence; and neither the Field Office staff nor the DDS staff would have the necessary expertise to determine issues related to providing a quality product in the area of legal precedents. The development of a comprehensive quality review process for all components should involve the experts from each component as well as collaboration with the other components to determine the areas of most significant impact. Any quality review process that is developed should be implemented nationally and should provide for consistency from region to region and state to state. The success of the process will be directly related to consistency in information technology programs, training, sufficiency of resources and, most importantly, the commitment to quality of all involved entities.
NADE would like to address the DDS component. As such, our objective for the remainder of this document is to outline current procedures and to make recommendations for an improved quality process in the DDS environment.
The current quality review process is a regional quality control one, based on the Programs Operations Manual. This process consists of random system selection of cases at the point of DDS disposition of the case. Currently, cases selected for regional quality review are selected randomly, based on changing SSA requirements; however, the 50 percent pre-effectuation review of Title II allowances is a constant. When states fall below a 90% accuracy level based on random reviews of a specific sample type, the state is placed on enhanced review of that particular type of claim. Additional cases from that DDS are reviewed for a minimum of one month or until the individual DDS accuracy rate has improved to an acceptable level. Quality reviews at the SSA Regional Offices are done by regional Disability Quality Branches (DQB) and can sometimes take six to eight weeks to complete before a case is returned to the DDS for corrective action. Upon receipt and review of a case returned for corrective action, the DDS has sixty days to rebut the cited deficiency and/or to take the corrective action suggested by DQB. A second level rebuttal process involving the SSA Office of Quality Assurance (OQA) is also in place.
Cases returned to DDSs by DQBs are usually to reverse the decision or to procure additional documentation to support the decision. For cases involving an onset date that is perceived to be incorrect by DQB, DQB will assume jurisdiction and change the onset without returning the case to the DDS. In those situations, DQB provides feedback through other methods to the DDS on the case in question. At times, DQB returns cases to the Field Offices for additional development and asks the Field Office, upon completion of their action, to return the case to the DDS for additional work. DDSs are charged errors for not recognizing and resolving FO problems in cases, such as use of incorrect procedures, lack of work activity development, failure to clarify last date of substantial gainful activity, etc.
The accuracy of OHA claims is not reviewed by the Regional Disability Quality Branches, but rather by other components associated with the Office of Hearings and Appeals. It is clear, then, that accountability for an accurate product at the present time focuses mostly on the DDS and is an end-of-line quality control process. NADE believes that an end-of-line quality control process is still required but supports centralization of this process as proposed by Commissioner Barnhart so that all DDS, as well as all OHA, decisions are reviewed by one component. NADE believes this component should be situated in the office that is responsible for policy (currently the Office of Disability Programs) as this will assure consistent national application of SSA policy.
NADE recently conducted an informal survey of their local chapters as to the current operational processes related to quality in their DDS offices. Twenty-seven NADE chapters responded; of those that responded, most stated that in the majority of DDS offices, there is some manner of formal end-of-line QA review process. However, some chapters stated that several states have adopted a formal in-line quality review process in recent years to replace the end-of-line QA review process. It should be noted that respondents that indicated their state has a formal end-of-line review also stated that their state utilizes an informal in-line quality review in specific situations. The in-line quality review processes include but are not limited to: new trainee cases, case development procedures, consultative exam ordering, aged cases, areas of error trends, appropriateness of medical referrals, etc. Some of the NADE informal survey results indicated that as staffing resources have dwindled over the past few years, efforts formerly directed at quality reviews were redirected to disability case adjudication.
NADE found that most DDSs that utilize an end-of-line quality review process base their process on the model in the POMS and followed by the SSA Regional Disability Quality Branches. In some states, supervisors alone are responsible for the informal in-line quality review based on the information found on the Electronic Worksheet (EWS) case management screen. Other states, especially those states currently using a formal end-of-line review, use a formal QA unit for DDS in-line reviews. The majority of local NADE chapters that responded to NADE’s survey stated that their state utilizes case consultants who are often QA reviewers to assist with in-line quality reviews. Medical consultants are used in some states to approve consultative examination orders for appropriateness, and some states use QA reviewers to assess the appropriateness of the decisions/actions of the Medical Consultants. One overwhelming fact is clearly evident from the NADE survey. . . there is widespread inconsistency in the current quality processes among the DDS offices across the nation.
There is a need to change the current structure and nature of quality review to a uniform process across all service components. The current end-of-line quality control review process utilized by the SSA Regional Disability Quality Branches is concentrated narrowly on DDS case adjudication accuracy while providing little meaningful information or timely guidance on cases. Traditional end-of-line quality control reviews are perceived as more evaluational in nature; problems are not identified early in development and correcting deficiencies negatively impacts processing time.
From our experience, NADE believes that in-line quality reviews are a more constructive training and monitoring tool than end-of-line quality control reviews because immediate feedback and timely guidance is provided to disability examiners as they proceed through case development. This improves both processing time and quality of decisions. Formalizing in-line quality reviews for data collection will benefit the DDSs by allowing each DDS to analyze its effectiveness and by providing assessment tools so that training efforts can be directed to specific areas of need to improve the quality of the overall disability case product. Training needs in terms of case development, caseload management and the ordering of unnecessary consultative exams can be addressed at the time of the action rather than at the end of the process.
In-line quality reviews at the DDS should be conducted in such a way that they reinforce positive work behaviors, enhance the skills of the disability examiner, identify best practices and identify training needs. NADE recommends that cases be reviewed soon after development, at some mid-point (such as 30 or 45 days), when consultative examinations are requested, and when cases reach 60 or 70 days of age. We recommend an enhanced sample review for trainees or those individuals who have demonstrated difficulty in specific target areas. In-line quality case reviews should provide positive feedback, expedite case processing and enhance customer service. Utilizing in-line quality reviews should result in a more knowledgeable DDS staff, increased accuracy of the decisions as a result of more appropriate case actions, decreased case costs as a result of decreasing the number of unnecessary consultative examinations and decreased processing time as a result of highlighting timely and appropriate case actions. NADE believes another added benefit of in-line quality reviews will be making the correct decision as early in the process as possible and this in turn should result in increased customer satisfaction.
While in this paper, we will not address specific details of a DDS in-line quality review process, we are attaching some reference documents that will give examples of the types of elements in the adjudication process that could be utilized as part of a DDS in-line quality review process.
NADE believes that a revised SSA quality review process should be based on:
- A universally agreed upon definition of quality,
- Uniformly understood and applied measurements of quality, and
- Elements of quality that are specific, measurable, attainable, relevant and time based.
In addition, NADE believes that the purpose of SSA quality reviews should be to:
- Provide feedback that enables the Teleservice Centers (TSC), the Field Offices (FO), the DDSs, and OHA to take appropriate and timely corrective action in identified problem areas;
- Provide feedback that allows management in each of these components to monitor the efficiency and effectiveness of all internal organizational components; and
- Result in feedback that allows management in each of these components to assess the training needs of all staff in their individual components.
NADE believes that a revised quality standard should include and measure:
- Adherence to SSA rules and regulations;
- Appropriateness of case development/caseload management procedures and practices;
- Timeliness and appropriateness of case actions;
- Service to the claimant/beneficiary population;
- Service to intra-organizational and inter-organizational components;
- Case processing costs for each TSC, FO, DDS and OHA component; and
- TSC, FO, DDS and OHA staff productivity.
Some DDS offices currently have in-line processes in place, and a few of the tools currently being used in such processes are attached. NADE recommends development of a nationwide in-line quality review process that uses a consistent approach to quality assessment and the development of tools that can be used nationwide by the various components in the disability process. Implementation of any new in-line quality review process must include adequate resources and be preceded by implementation of consistent systems software. Intense training must also be provided prior to implementation. (Current quality review software in use in some states is inconsistent in utilization of consistent applications based on inconsistencies in programming.)
To assure that the entire disability claims process is considered in revising the quality review process, NADE recommends some basic elements be included in the plan. In addition to in-line quality reviews in all components, NADE recommends SSA DQB review the FO/TSC product as part of the front-end review. DQB could electronically transfer a copy of each review sheet weekly to the FO/TSC manager. A monthly assessment and statistical analysis of the FO/TSC review will be provided to DDS management, SSA Regional Office and OHA on an ongoing basis for their information and review.
Another critical element in improving the overall quality of the disability claims process is assuring a thorough understanding of the DDS decision by the ALJ’s. DDS in-line quality review cases that are appealed to OHA should be tracked as to reversals, mean processing time, case costs, etc. to determine the possible effect that in-line reviews have on cases coming before an ALJ.
NADE concurs with the intent of Commissioner Barnhart to measure quality in terms of of accuracy, timeliness, productivity, cost and claimant service. We believe that the only way to truly achieve a quality product is to hold each component in the disability process accountable for achieving a stated standard of excellence in each of these five areas of measurement. We believe it is necessary to assure consistency of systems, resources and training in order to achieve the desired standard of excellence. And finally, we support the Commissioner’s proposal to assure that quality by monitoring our efforts during the process, rather than at the end of the process. We look forward to the development of a new, consistent in-line quality review process, and we stand ready to assist in the development of such an approach.
Prepared by the National Association of Disability Examiners
Approved by the NADE Board April 7, 2004
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