Aug 14, 2014

OIG Report On Obtaining Medical Records -- And How Much Does It Cost To Review Disability Claims

     Social Security's Office of Inspector General (OIG) has issued an audit report with the title Completeness of the Social Security Administration's Disability Claims Files. The report found that Social Security is not obtaining all medical records on claimants at the initial and reconsideration levels, mostly because medical providers don't always respond to requests for records or because the claimants failed to inform Social Security of all their medical sources. If you think that claimants are failing to tell Social Security of some of their medical sources for some devious reason, you lack experience with Social Security disability claimants. Virtually always the problem is forgetfulness and confusion. Medical treatment histories can get complicated when you're sick. You get referred to multiple specialists and you forget about some of them. Your brain isn't operating at 100% because of depression. There's rarely a reason for a claimant to even think of concealing any part of their treatment history. 
      The report assumes that medical development is done by at hearing offices after an Administrative Law Judge hearing is requested. In the very old days, more than 30 years ago, that was the case but now, are you kidding me? Hearing offices don't have anything like the staff to do this.
     The report does have this nugget of information on a subject that I don't think I've seen updated in a long time: "For Fiscal Year 2012, SSA reported that it cost the Agency $607 to process an initial DI claim and $463 to process an initial SSI claim, while it cost $2,328 to process a DI case and $1,431 to process an SSI case at the hearing level." I can attribute the lower cost of SSI cases at the initial level to the fact that SSI claimants typically have less access to medical care, which means fewer requests for medical records and less time spent reviewing medical records. The divergence at the hearing level makes no sense to me. On average, SSI files are shorter and take less time to review but the difference isn't that dramatic. I don't know what it is but there has to be some problem with these numbers.

11 comments:

Anonymous said...

maybe it's the disproportionate percentage of dismissals at the ALJ level of SSI claims. Losing that 30-60 minutes of ALJ hearing time and 4-8 hours of writing time would add up.

Anonymous said...

If there is a rep at hearing level, the office assumes the rep will update the record. However, if the claimant is unrepresented, we routinely ask claimant about medical treatment and order updated records.

Anonymous said...

SSDI cases are probably longer. People can allege onset dates that go back years or decades to get to a point when they were insured. Also, SSDI applicants are going to tend to have longer/more skilled work histories so there's more analysis needed at Step 4 (maybe at Step 1 too). I would guess that means some ODARs are more likely to hire VEs for Title II cases than for Title XVI.

Anonymous said...

In our area the reps sign these folks up with tv ads, and then demand (despite their contractual, regulatory, ethical and moral obligation to zealously represent them) that the hearing office develop all of the evidence for the sole reason that they don't want to pay for copying fees/do the work to qualify their clients for free records. It is disgusting. We don't have the staff to do their work nor should we do it. If we are obtaining all of the medical evidence to support the claim why should they be entitled to a fee?

Anonymous said...

_6:56 - They are entitled to a fee because the statute says they are. But it does not say how much they are entitled to receive. If it is a fee petition case, the ALJ sets the fee based on the services performed by the rep and the value to the favorable decision. If it is a fee agreement case, then the ALJ has the right to request administrative review. On review the RCALJ will determine the amount of the fee based on whether the fee set under the fee agreement is unreasonable based on the services performed. A rep that refuses to adequately develop the record faces a very real chance of a lowered fee. However, it is up to the hearing office to actually look at the services performed - or not performed.

Anonymous said...

And I can count on one hand with multiple fingers left over the number of times an rcalj will actually set an amount that accurately represents the garbage work most reps do.

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Anonymous said...

Wonder if the $$ amounts listed include salaries? That could account for the higher cost at the hearing level.

Anonymous said...

I am all for due process and very pro claimant, however, the regs should be changed that if the claimant is repped, then the rep is responsible for obtaining the records and if the records are not in the file, then there should be a presumption that they do not exist. Now, I realize that often a rep comes in at the last minute. Therefore, I would also argue that if a rep enters a case less than 30 days before hearing, then claimant should get an automatic 30 days post hearing to get evidence, which can be extended. This nonsense of only giving reps 2 weeks to get evidence is not right either. Clearly the Agency is missing the forest for the trees.

Anonymous said...

The problem with only giving any reps 2 weeks to get records is that government regs conflict--HIPPA allows treatment providers 30 days to produce requested records. More and more providers' records custodians are aware that they can stall and not produce for 30 days, then the records must be reviewed for duplications and submitted.

Anonymous said...

all this talk about exigent situations where records are being held by medical providers for 30 days, rep was just hired, the Tx/evidence in the records to be requested is brand new (just happened) and just isn't available yet...

The reality is a majority of post-hearing evidence from reps is not new, nobody bothered to ask about it or track it down until after it was obvious the hearing didn't go well for the claimant. The reps weren't just hired days before the hearing--maybe the last rep in a string of reps signed on shortly before the hearing, but the firm has been retained before or shortly after the request for hearing (giving said firm months, if not more than a year, to gather up the evidence).

This is a crock. If these things were only happening (or mostly happening) in truly exigent situations such as a newly hired rep, very recent Tx, etc., it wouldn't happen often, wouldn't overburden ODAR, and wouldn't be an issue we are discussing right now.