Social Security Disability:

Collection of Medical Evidence Could Be Improved with Evaluations to Identify Promising Collection Practices

GAO-09-149: Published: Dec 17, 2008. Publicly Released: Dec 17, 2008.

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The timely collection of relevant medical evidence from providers, such as physicians and psychologists, is key to the Social Security Administration (SSA) process for deciding whether an estimated 2.5 million new claimants each year have impairments that qualify them to receive disability benefits. The initial determinations are generally made by state agencies called Disability Determination Services (DDSs). We evaluated: (1) the challenges, if any, in collecting medical records from the claimants' own providers and ways SSA and the DDSs are responding to these challenges; (2) the challenges, if any, in obtaining high-quality consultative exams and ways SSA and the DDSs are responding to these challenges; and (3) the progress SSA has made in moving from paper to electronic collection of medical evidence. We surveyed 51 DDS directors, visited 5 state DDSs, reviewed sample case files, and interviewed officials with SSA, DDSs, and associations for claimants and providers.

Obtaining timely and complete medical records is a challenge to DDSs in promptly deciding disability claims, and DDSs have responded with additional provider contacts and adjustments to their payment procedures. Although DDSs pay most medical providers for medical records and SSA pays the DDSs to cover these expenses, 14 of 51 DDSs reported the percentage of requests for which they did not receive records was 20 percent or more in fiscal year 2007. In response to this challenge, all DDSs conduct follow-up with providers and claimants to urge them to provide records. Over half of the DDSs (34 of 51) have also implemented more timely payments for records and six increased the amount they pay. Although SSA evaluates DDS collection of medical records, it does not compile key data necessary to identify and share promising collection practices. Recruiting and retaining qualified providers is a challenge to obtaining consultative exams needed to supplement insufficient medical records. For example, 41 of 51 DDSs reported routinely asking claimants' own providers to perform these exams; yet 34 reported providers never or almost never agree to do so. DDSs directors in our survey believe that current payment rates account for some of the difficulty recruiting and retaining consultative exam providers. In response to these challenges, 32 DDSs rely on medical providers who specialize in performing disability evaluations, and 20 pay providers for time spent preparing for appointments claimants fail to attend. SSA evaluates evidence from consultative exams, but these evaluations and the data they yield are too limited to identify and share promising DDS practices. SSA has made progress moving to electronic collection of medical records, but faces challenges in fully implementing electronic retrieval and analysis of medical evidence. SSA now uses electronic images instead of paper copies of new claimants' records. Though SSA seeks to obtain all records electronically and provides options for online submission of records, only one large provider accounts for most of the records submitted online, and about half of all records received are on paper. To date, SSA has taken only limited action to identify and analyze the barriers providers face in using current electronic record submission options, and has not developed a strategy to address them. In the long run, SSA is participating in an advanced prototype to collect medical records in formats that can be searched and analyzed by electronically querying a hospital's records database and directly retrieving the claimants' records.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To foster timely and effective collection of medical evidence for disability determinations, the Commissioner of SSA should identify DDS medical evidence collection practices that may be promising, evaluate their effectiveness, and encourage other DDSs to adopt effective practices where appropriate. As a part of these evaluations, the Commissioner should work with the DDSs to find cost-effective ways to gather consistent data on the effectiveness of DDS medical evidence collection activities. Such data should include key indicators, such as the proportion of requests that yield medical records, the timeliness of medical record receipts, and how frequently claimants fail to attend consultative exams.

    Agency Affected: Social Security Administration

    Status: Closed - Implemented

    Comments: In 2009, SSA concurred with this recommendation, described some efforts to identify promising practices, and agreed to find ways to gather consistent data on the effectiveness of Disability Determination Services (DDS) medical evidence collection activities. However, it noted challenges with gathering consistent national data because there were five separate DDS case processing systems at that time. In FY 2010, SSA continued to develop a common disability case processing system that would provide consistent management information on medical evidence collection practices. SSA reported in FY 2011 that it held an annual national meeting with DDS Medical Professional Relations Officers to discuss issues and share best practices, and conducted conference calls with the regional offices and DDSs as needed depending on the specific subject and audience of the call, to discuss issues and best practices. They encouraged the DDSs to notify their regional office contacts with issues and best practices that include medical evidence collection. They conducted pilots of new business processes to evaluate their effectiveness, and if successful, encouraged other DDSs or regions to implement these business practices. One example of this collaboration is the adoption of software programs developed by the Florida and Ohio DDSs to locate medical evidence that a medical provider submitted, but for various reasons, were not placed in the claimant's electronic folder. After determining the effectiveness of these software applications in locating medical evidence, the agency is now using them in all of the DDSs. In addition, they added functionality to the Electronic Records Express (ERE) website to accompany the functionality of these software applications (these enhancements, known as Track Status of Submissions and Customer Status Inquiries, were implemented in July 2008). The Office of Disability Determinations (ODD) continues to host monthly ERE Support Calls to provide an informal forum for the ERE Customer Support team to share information with DDSs and SSA components. In January 2010, SSA began legacy system rollout functionality, which allows for requesting payment for CE and MER via the ERE website.

    Recommendation: To achieve a more timely and efficient collection of medical records by encouraging medical evidence providers to submit records electronically, until the nationwide health information network is in operation, the Commissioner of SSA should conduct an evaluation of the limited utilization of its online submission options. This evaluation should include an analysis of the needs of small, medium, and large providers; identify any barriers to expanded use; and develop strategies to address these barriers.

    Agency Affected: Social Security Administration

    Status: Closed - Implemented

    Comments: SSA agreed with this recommendation and described its efforts to identify barriers to use of electronic medical evidence submission options and prioritize them. It has continued to seek input from users about electronic submission options, requested systems enhancements, and continued to inform medical evidence providers of electronic submission options.

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