Part 3: Medical Evidence


>>WELL, LISA,
WHAT HAPPENED NEXT?>>WELL, THE CLAIMS
REPRESENTATIVE IN THE FIELD OFFICE, MRS. JONES,
WAS SATISFIED THE NON-MEDICAL CRITERIA WERE MET. ELECTRONICALLY SENT MR. KAY’S
APPLICATION TO THE STATE DISABILITY DETERMINATION
SERVICE, WHICH IS ALSO CALLED THE STATE AGENCY, FOR
ITS MEDICAL DETERMINATION. I HAD A CHANCE TO VISIT
WITH THEM, AND THIS IS WHAT I LEARNED.>>I’M STANDING HERE OUTSIDE
THE STATE AGENCY THAT REVIEWED MR. KAY’S CLAIM FOR
DISABILITY BENEFITS. THERE ARE 54 OF THESE STATE
AGENCIES ACROSS THE NATION. ALL STATE AGENCY OFFICES ARE
FULLY FUNDED BY THE FEDERAL GOVERNMENT AND ARE RESPONSIBLE
FOR MAKING THE MEDICAL DETERMINATION ON INITIAL
CLAIMS FOR DISABILITY BENEFITS. IT’S HERE WHERE A DISABILITY
EXAMINER AND A MEDICAL CONSULTANT REVIEWED MR. KAY’S
CLAIM FOR DISABILITY BENEFITS. AS WE SAID EARLIER, AN
INDIVIDUAL MUST HAVE A MEDICALLY DETERMINABLE IMPAIRMENT THAT IS
SEVERE ENOUGH TO PREVENT THEM FROM WORKING FOR AT LEAST A
ONE-YEAR TIME PERIOD OR WHICH IS EXPECTED TO RESULT IN DEATH. THE STATE AGENCY LOOKS TO AN
INDIVIDUAL’S MEDICAL TREATING SOURCES, INCLUDING PHYSICIANS,
HOSPITALS AND CLINICS IN ORDER TO ESTABLISH THE EXISTENCE
OF THAT IMPAIRMENT. IN THESE REPORTS, THEY LOOK
FOR THE SIGNS, SYMPTOMS AND LABORATORY FINDINGS THAT
SUPPORT THE SEVERITY AND EXISTENCE OF A MEDICALLY
DETERMINABLE IMPAIRMENT. IN ORDER TO FIND OUT HOW THE
AGENCY GATHERS THIS INFORMATION, I HAD THE OPPORTUNITY TO
TALK WITH ELIZABETH WATSON, THE DISABILITY EXAMINER
WHO HANDLED MR. KAY’S DISABILITY CLAIM.>>MRS. WATSON, HOW DO YOU GO
ABOUT GATHERING THE INFORMATION TO SHOW WHETHER A
PERSON IS DISABLED?>>WE START WITH THE INFORMATION
THAT THE PERSON PROVIDED IN HIS OR HER ONLINE APPLICATION OR
THAT THE CLAIMS REPRESENTATIVE GATHERED ON THE DISABILITY
FORMS DURING THE FIELD OFFICE INTERVIEW. WE LOOK THROUGH THE EVIDENCE
FOR ANY DOCTOR’S NOTES OR RECORDS THE CLAIMANT MAY
HAVE SUBMITTED DURING THE FIELD OFFICE INTERVIEW. WE CONTACT THE DOCTORS,
HOSPITALS AND CLINICS THAT THE PERSON TOLD US
TREATED HIM OR HER. GENERALLY, WE REQUIRE AT LEAST
12 MONTHS OF MEDICAL EVIDENCE, ALTHOUGH THAT MAY BE LONGER
DEPENDING UPON THE NATURE OF THE IMPAIRMENT OR WHEN THE
CLAIMANT INDICATED THEIR DISABILITY BEGAN.>>IT SOUNDS LIKE THE INFORMATION COMPLETED IN THE FIELD OFFICE IS
IMPORTANT TO THE PROCESS.>>YOU ARE RIGHT. THE FIELD OFFICE
ROLE IS CRITICAL. ALL OF THE INFORMATION WE NEED
TO DO OUR JOB HERE IN THE STATE AGENCY SHOULD BE ON THE
FORMS COMPLETED ONLINE OR AT THE FIELD OFFICE. THE FORMS SHOULD PROVIDE US
WITH AS COMPLETE A PICTURE AS POSSIBLE ABOUT MEDICAL SOURCES. THEN WE CAN REQUEST ADDITIONAL
MEDICAL EVIDENCE FROM THEM WHEN APPROPRIATE.>>SO WHAT HAPPENS IF THE
INFORMATION THAT YOU’RE GIVEN IS NOT COMPLETE?>>WHEN WE’RE MISSING
ADDRESSES, PHONE NUMBERS, DATES OF TREATMENT, NAMES
OF MEDICATION OR CLINIC IDENTIFICATION NUMBERS,
WE HAVE TO CALL OR TRY TO RESEARCH THAT INFORMATION. THIS OFTEN INVOLVES CONTACTING
THE CLAIMANT TO HELP US GET THAT INFORMATION. AS YOU CAN IMAGINE, THIS SLOWS
DOWN THE ENTIRE PROCESS.>>IS ALL OF THE MEDICAL
INFORMATION RECEIVED IN PAPER FORM?>>ACTUALLY, VERY FEW RECORDS
COME TO US ANYMORE AS PAPER. A FEW YEARS AGO, SOCIAL SECURITY
TRANSITIONED TO AN ELECTRONIC CLAIM FILE WHICH WE CALL
THE ELECTRONIC FOLDER. WHEN THAT HAPPENED, WE WERE ABLE
TO OFFER MEDICAL PROVIDERS A NUMBER OF OPTIONS FOR HOW THEY
COULD SUBMIT MEDICAL RECORDS TO US SO THE RECORDS
WOULD GO DIRECTLY TO THE ELECTRONIC FOLDER. THESE INCLUDE THINGS LIKE A
SECURE WEBSITE AND THE USE OF FAX TO SUBMIT RECORDS. IN ADDITION TO REDUCING THE
PAPER BURDEN, THESE OPTIONS ALSO HAVE THE ADDED BENEFIT
OF ELIMINATING THE MAIL TIME SO WE RECEIVE THE
RECORDS MORE QUICKLY.>>IT SOUNDS LIKE
A GREAT TIME SAVER.>>YES, IT IS. AND IN ADDITION, SOCIAL SECURITY
HAS BEEN INCREASING THE USE OF HEALTH INFORMATION TECHNOLOGY
FOR OBTAINING MEDICAL RECORDS. THIS FULLY AUTOMATED PROCESS
ALLOWS US TO RECEIVE ELECTRONIC MEDICAL RECORDS WITHIN MINUTES
OR HOURS OF OUR ELECTRONIC REQUEST BEING SENT TO THE
PARTICIPATING MEDICAL PROVIDER. SINCE WE RECEIVE THE RECORDS
SO QUICKLY THROUGH HEALTH INFORMATION TECHNOLOGY AND THEY
GO DIRECTLY TO THE ELECTRONIC FOLDER, WE ARE OFTEN
ABLE TO MAKE OUR MEDICAL DETERMINATION MORE QUICKLY.>>DID YOU HAVE TO
CONTACT MR. KAY FOR ANY ADDITIONAL INFORMATION?>>WELL, MR. KAY HAD ONE
DOCTOR THAT HE SAW IMMEDIATELY FOLLOWING HIS INJURY AND
THEN REGULARLY FOR FOLLOW-UP. WE CALL THIS KIND OF DOCTOR
A TREATING PHYSICIAN. WE HAVE THE NAME, DATES OF
TREATMENT, ADDRESS AND PHONE NUMBER OF THIS DOCTOR AND
REQUESTED HIS REPORTS. FORTUNATELY, MR. KAY’S DOCTOR
MAINTAINS ELECTRONIC RECORDS AND WE RECEIVED THE
MEDICAL RECORDS QUICKLY.>>SO IF THE DOCTOR’S RECORDS
REFLECT THAT THERE IS A MEDICAL PROBLEM, IS THAT ENOUGH TO
SHOW THAT MR. KAY IS DISABLED?>>NOT NECESSARILY. REMEMBER THAT THE SOCIAL
SECURITY ACT SAYS THAT THE IMPAIRMENT HAS TO BE SEVERE
ENOUGH TO PREVENT HIM FROM WORKING FOR AT LEAST 12
MONTHS OR BE EXPECTED TO RESULT IN DEATH.>>HOW DOES THE STATE AGENCY
DETERMINE IF AN IMPAIRMENT IS SEVERE ENOUGH? THE DISABILITY EXAMINER REVIEWS
THE MEDICAL REPORTS OBTAINED FROM A PERSON’S TREATING SOURCES
AND OTHER MEDICAL SOURCES. THE REPORTS MAY INCLUDE THE
DIAGNOSIS, TREATMENT AND INFORMATION ABOUT THE PERSON’S
ABILITY TO PERFORM WORK-RELATED ACTIVITY, SUCH AS STANDING,
SITTING, LIFTING, CARRYING AND WALKING. AND WHILE THOSE ACTIVITIES SEEM
TO DESCRIBE SOMEONE WHO CAN’T WORK BECAUSE OF
PHYSICAL LIMITATIONS, WHAT ABOUT INDIVIDUALS WITH
MENTAL HEALTH PROBLEMS? I ASKED MS. WATSON WHAT SHE
WOULD HAVE DONE IF MR. KAY ALLEGED A MENTAL DISORDER
OR IF SHE DIDN’T GET HIS MEDICAL RECORDS.>>IF MR. KAY WAS BEING TREATED
FOR A MENTAL IMPAIRMENT, WE WOULD LOOK AT HIS MEDICAL
RECORDS TO SEE IF THEY SHOW ANY LIMITATIONS, SUCH AS
A DIMINISHED CAPACITY FOR ACTIVITIES OF DAILY LIVING,
UNDERSTANDING AND MEMORY PROBLEMS, AN INABILITY TO
CONCENTRATE OR INTERACT SOCIALLY OR AN INABILITY TO ADAPT TO
CHANGING WORK SITUATIONS. WE WOULD ALSO LOOK TO
SEE WHETHER HE HAD HAD ANY HOSPITALIZATIONS.>>AND WHAT IF MR. KAY DIDN’T
HAVE A DOCTOR OR HIS DOCTOR DIDN’T SUBMIT ANY
MEDICAL EVIDENCE?>>IF WE DO NOT HAVE ENOUGH
MEDICAL EVIDENCE TO MAKE A DECISION, WE WOULD HAVE ASKED
MR. KAY TO GO TO A MEDICAL EXAMINATION WITH AN INDEPENDENT
PHYSICIAN AT GOVERNMENT EXPENSE. WE CALL THIS A
CONSULTATIVE EXAMINATION.>>SO CAN ANY DOCTOR DO THESE?>>TO PERFORM A CONSULTATIVE
EXAMINATION, A PHYSICIAN MUST BE CURRENTLY LICENSED IN THEIR
STATE AND BE THOROUGHLY FAMILIAR WITH THE SOCIAL SECURITY
DISABILITY PROGRAM, INCLUDING SOCIAL SECURITY’S
EVIDENTIARY REQUIREMENTS. WE TRY TO SCHEDULE THE
EXAMINATION WITH THE CLAIMANT’S OWN PHYSICIAN WHEN APPROPRIATE. WE CAN ALSO USE OTHER
PROFESSIONALS LIKE SPEECH AND LANGUAGE THERAPISTS OR
AUDIOLOGISTS TO PERFORM THESE EXAMS DEPENDING ON THE
CLAIMANT’S ALLEGATIONS AND THE TYPE OF ADDITIONAL
DOCUMENTATION WE NEED. WE WANT THE PERSON PERFORMING
THE CONSULTATIVE EXAMINATION TO REPORT HIS OR HER OBJECTIVE
FINDINGS AND PROVIDE A MEDICAL SOURCE STATEMENT TO US.>>WHAT EXACTLY IS A
MEDICAL SOURCE STATEMENT?>>IT’S A STATEMENT OR OPINION
ABOUT WHAT THE CLAIMANT CAN STILL DO DESPITE THE IMPAIRMENT
CONSIDERING HIS OR HER MEDICAL HISTORY, DIAGNOSIS AND
CLINICAL AND LAB FINDINGS.>>WHAT DO YOU DO
WITH THIS STATEMENT?>>THE STATE AGENCY USES THE
MEDICAL SOURCE STATEMENT TO HELP DETERMINE THE CLAIMANT’S
RESIDUAL FUNCTIONAL CAPACITY. THIS IS THE MOST THE CLAIMANT
CAN DO DESPITE HIS OR HER PHYSICAL AND MENTAL LIMITATIONS.>>IT SOUNDS LIKE ALL OF
THIS CAN BE COMPLICATED. SO HOW DOES A STATE AGENCY
DISABILITY EXAMINER REACH A DECISION ON A CLAIM
LIKE MR. KAY’S? HERE’S WHAT I LEARNED. LIKE ADJUDICATORS AT ALL
ADMINISTRATIVE LEVELS, THE DISABILITY EXAMINER FOLLOWS A
DECISION-MAKING PROCESS THAT TAKES THE CLAIM IN LOGICAL
ORDER THROUGH FIVE STEPS. THESE FIVE STEPS ENSURE THAT
THE DEFINITION OF DISABILITY IS APPLIED CONSISTENTLY NATIONWIDE
AND PERMITS A CLAIM TO BE DECIDED AS EARLY IN THE
PROCESS AS POSSIBLE. STEP ONE IS HANDLED
BY THE FIELD OFFICE. AT THIS STEP, THE CLAIMS
REPRESENTATIVE LOOKS AT THE CLAIMANT’S INFORMATION TO
SEE IF HE OR SHE IS CURRENTLY PERFORMING WORK WITH EARNINGS
ABOVE A SPECIFIC AMOUNT, WHICH THE SOCIAL SECURITY
ADMINISTRATION CALLS SUBSTANTIAL GAINFUL ACTIVITY. IF THE CLAIMANT IS PERFORMING
SUCH WORK, THEN HE OR SHE IS EARNING TOO MUCH INCOME FOR
SOCIAL SECURITY TO CONSIDER HIM OR HER DISABLED AND
THE CLAIM IS DENIED. STEPS TWO THROUGH FIVE ARE
HANDLED BY THE STATE AGENCY. AT STEP TWO, THE QUESTION IS
WHETHER OR NOT THE CLAIMANT HAS A SEVERE PHYSICAL
OR MENTAL IMPAIRMENT OR COMBINATION OF IMPAIRMENTS. SEVERE IN THIS CASE MEANS
THE IMPAIRMENT HAS MORE THAN A MINIMAL EFFECT ON THE
CLAIMANT’S ABILITY TO DO BASIC WORK ACTIVITIES. IF THE CLAIMANT DOES NOT HAVE A
SEVERE IMPAIRMENT, THE CLAIM IS DENIED AT THIS STEP. IF THE CLAIMANT DOES HAVE
A SEVERE IMPAIRMENT, THE DISABILITY EXAMINER
MOVES TO STEP THREE. AT STEP THREE, THE DISABILITY
EXAMINER DETERMINES IF ANY OF THE CLAIMANT’S SEVERE
IMPAIRMENTS, ALONE OR IN COMBINATION, MEET OR EQUAL
THE LISTING OF IMPAIRMENTS. WHAT IS THE LISTING
OF IMPAIRMENTS? THE LISTINGS ARE A SERIES OF
CAREFULLY DEVELOPED REGULATIONS ABOUT EACH MAJOR BODY SYSTEM. THE LISTINGS DESCRIBE THE
MEDICAL IMPAIRMENTS CONSIDERED SEVERE ENOUGH TO PREVENT
A PERSON FROM PERFORMING GAINFUL ACTIVITY. MOST OF THE LISTED IMPAIRMENTS
ARE PERMANENT HEALTH PROBLEMS THAT CAN RESULT IN DEATH OR,
AT A MINIMUM, ARE EXPECTED TO LAST A CONTINUOUS 12 MONTHS. IF A CLAIMANT HAS AN IMPAIRMENT
THAT MEETS OR EQUALS A LISTING, THE DISABILITY EXAMINER
FINDS THE CLAIMANT DISABLED. HOWEVER, IF NONE OF A CLAIMANT’S
IMPAIRMENTS MEET OR EQUAL A LISTING, THEN THE DISABILITY
EXAMINER DETERMINES WHAT THE CLAIMANT’S RESIDUAL
FUNCTIONAL CAPACITY IS. THIS IS THE MOST A CLAIMANT
CAN DO DESPITE HIS OR HER PHYSICAL AND MENTAL LIMITATIONS. THEN AT STEP FOUR, THE
DISABILITY EXAMINER EVALUATES WHETHER OR NOT THE CLAIMANT CAN
PERFORM HIS OR HER PAST WORK CONSIDERING THE RESIDUAL
FUNCTIONAL CAPACITY. THE EXAMINER LOOKS BACK AT A
CLAIMANT’S JOBS FOR THE PRIOR 15 YEARS AND AT THE CLAIMANT’S
DESCRIPTION OF HIS OR HER JOB DUTIES AND THEIR PHYSICAL
AND MENTAL DEMANDS, THE DISABILITY EXAMINER THEN
COMPARES THAT DESCRIPTION WITH NATIONAL OCCUPATIONAL DATA. IF THE CLAIMANT CAN STILL
PERFORM ONE OF HIS OR HER PRIOR JOBS, THEN SOCIAL SECURITY WILL
DENY THE CLAIM AT STEP FOUR. HOWEVER, IF THE CLAIMANT CANNOT
PERFORM ANY PAST WORK, THE DISABILITY EXAMINER MOVES ON
TO THE FIFTH AND FINAL STEP. AT STEP FIVE, THE DISABILITY
EXAMINER DETERMINES WHETHER THE CLAIMANT’S RESIDUAL FUNCTIONAL
CAPACITY PRECLUDES HIM OR HER FROM BEING ABLE TO PERFORM
OTHER TYPES OF WORK IN THE NATIONAL ECONOMY. THE DISABILITY EXAMINER ALSO
CONSIDERS THE CLAIMANT’S AGE, EDUCATION, AND WORK EXPERIENCE. AND HOW FAR INTO THIS EVALUATION
PROCESS DID MR. KAY GO?>>AFTER REVIEWING ALL THE
MEDICAL EVIDENCE AND CONSULTING WITH MY MEDICAL TEAM MEMBER,
I MADE THE DECISION TO DENY HIS CLAIM AT STEP FIVE. ALTHOUGH MR. KAY CANNOT RETURN
TO HIS PAST JOB BECAUSE OF HIS BACK INJURY, HIS AGE, EDUCATION
AND RESIDUAL FUNCTIONAL CAPACITY INDICATED AN ABILITY
TO DO OTHER WORK. I USED A TERRIFIC SOFTWARE
PROGRAM CALLED eCAT TO HELP ME CRAFT MY MEDICAL DETERMINATION. IT ENSURES THAT DISABILITY
EXAMINERS LIKE MYSELF CONSIDER ALL OF THE FACTORS AND ADHERE TO
ALL OF THE DISABILITY RULES WHEN MAKING A MEDICAL DETERMINATION. I CAN ACCESS NATIONAL
OCCUPATIONAL DATABASES AND COMPARE THAT INFORMATION
TO A CLAIMANT’S RESIDUAL FUNCTIONAL CAPACITY. I KNOW THAT ECAT HAS
INCREASED QUALITY IN CLAIMS PROCESSING NATIONWIDE. IN MR. KAY’S CASE, HE RECEIVED A
NOTICE EXPLAINING HOW WE CAME TO THE DECISION TO DENY HIS CLAIM. THE NOTICE TOLD HIM WHAT
TO DO IF HE DISAGREED WITH OUR FINDINGS.>>WHAT WOULD HAVE HAPPENED IF
MR. KAY HAD ALLEGED A MEDICAL PROBLEM THAT WAS OBVIOUSLY
FATAL OR SERIOUSLY DISABLING?>>THAT’S A GREAT QUESTION. I LEARNED THAT THE SOCIAL
SECURITY ADMINISTRATION HAS BEEN ACTIVELY FINDING DIFFERENT
WAYS TO IMPROVE THE WAY IT MAKES DISABILITY DECISIONS. LET ME HIGHLIGHT
TWO OF THEM FOR YOU. THE FIRST IS CALLED
COMPASSIONATE ALLOWANCES. IT’S A LIST OF SPECIFIC
HIGHLY DISABLING OR TERMINAL CONDITIONS. IF OBJECTIVE MEDICAL INFORMATION
SHOWS THAT A CLAIMANT HAS AN IMPAIRMENT THAT’S ON THE LIST
OF COMPASSIONATE ALLOWANCES, SOCIAL SECURITY WILL ALLOW THE
CLAIM QUICKLY WITHOUT NEEDING TO COMPLETE ALL FIVE
STEPS OF THE PROCESS. A SECOND METHOD IS CALLED QUICK
DISABILITY DETERMINATION. A SOPHISTICATED SOFTWARE PROGRAM
SCREENS A CLAIMANT’S INITIAL APPLICATION AND NOTIFIES A
DISABILITY EXAMINER IF THERE’S A HIGH LIKELIHOOD THAT THE
CLAIMANT IS DISABLED AND MEDICAL EVIDENCE IS READILY AVAILABLE. DISABILITY EXAMINERS WILL
REVIEW THESE CLAIMS SOONER. OFTEN THESE CLAIMS
ARE ALLOWANCES.>>THAT’S QUITE A THOROUGH
PROCESS, THEY REALLY LOOK AT ALL POSSIBILITIES BEFORE DENIAL.>>WELL, MRS. WATSON SAID THAT
DISABILITY EXAMINERS REALIZE THAT THEIR DETERMINATIONS AFFECT
HUMAN LIVES EACH AND EVERY DAY, AND THEY WANT TO BE SURE THEIR
DETERMINATIONS TO APPROVE OR DENY SOMEONE ARE CORRECT.>>ON MR. KAY’S CASE, THE
DISABILITY EXAMINER DETERMINED THAT ALTHOUGH HE COULD NOT
PERFORM HIS USUAL WORK, HE COULD STILL
PERFORM OTHER WORK. WAS MR. KAY DISAPPOINTED
WITH HIS DENIAL?>>WELL, ACTUALLY, MR.
KAY WAS NOT YET NOTIFIED.

Leave a Reply

Your email address will not be published. Required fields are marked *