The Social Security Administration recently released a 2008 study of consultative medical examinations (CEs) performed by Comprehensive Occupational Medical Services (COMS), a contractor. Not all, but many, disability claimants are sent to these exams conducted at Social Security's expense. I have no idea why Social Security took so long to release this. Here are a few findings from the study:
- The mean Quality Rating (QR) of the CE’s reviewed was 2.97 within a range of 1-5: “1” represents an unsatisfactory and unredeemable CE Report and “5” a superbly documented, consistent, and logical report. This finding implies that the majority of CE Reports reviewed were sufficient to provide the DDS with enough clinical information to make an informed claim decision, but were deficient in the amount of clinical detail provided. The common deficiencies noted included: an inadequate history of present illness(es), failure to note medications or medication dosages, an absent or incomplete review of systems, omissions of important details of the physical findings, most commonly involving the musculoskeletal or neurological body systems, and an absent or qualitative medical source statement (MSS).
- Medical evidence of record (MER) was often not forwarded to CE providers. On the other hand, when MER was forwarded, it was unusual to find in CE Reports an adequate description of what items of MER were reviewed by the CE provider. COMS did not find any current policy or regulatory guidance requiring the inclusion of such information in CE Reports.
- The mean QR for CE’s associated with allowance decisions was statistically higher than for denials.
- COMS found that about 25% of X-Rays purchased by DDS’s as part of the CE process were probably unnecessary. Also, most purchased X-Rays, even when apparently indicated based on other CE findings or MER, do not demonstrate important pathological findings for SSA purposes.
- A consistent theme expressed by the DDS’s is that it is difficult at current fee levels to recruit and (retain) CE providers, especially specialists.
Is it DDS or Social Security procedure to send claimants for a Consultative Exam during reconsideration for the same issues if those issues were addressed in the initial decision six months earlier during a Consultative Exam?
ReplyDeleteI would appreciate any DDS or SSA DE/MC/PC answer to my question.
Anyone who reads enough CE reports knows that about 80-90% of them are completely bogus and are no better than WC or NF IMEs. I can probably count on one hand the number of legimate, accurate, detailed, and comprehensive CE reports I have seen that are actually consistent with the treating evidence and diagnostic testing. Let's face it, SSA loves these bogus CEs because they have a solid reason to deny cases based on supposed examinations of claimants.
ReplyDeleteIn my area, there is a group that has been created specifically to provide medical evaluations for worker comp claims, DDS evals, and the like. This group is called Southern Medical Group (www.southernmedgroup.com). Their reports definitely give the impression of an assembly line approach. There is never a specific medical source statement included, and most often the conclusion is that the claimant can "walk, talk, sit, stand, lift and/or carry, hold a conversation and follow instructions for a full workday". That's it.
ReplyDeleteI agree with Anonymous #2; this "evidence" does nothing but provide a basis for denials. The DDS and SSA must love this approach, because this "medical group" has taken the recruitment difficulties away from the agency. The doctors join this group on their own, to supplement their income, apparently with performing little real work. It's a joke.
Well, I should start by saying I work at a DDS.
ReplyDeleteI find that the quality of consultative exams tends to vary between providers. There are some of these doctors that I actually like, because they actually do a thorough evaluation and produce meaningful conclusions. However, most of them I see as somewhat lacking. Some, especially in certain large urban areas, are just absolutely atrocious. Unfortunately, it's the claimants with low incomes (who live in said large urban areas) that end up being sent to these exams the most.
Regarding the first anonymous comment, there's no absolute requirements for scheduling these exams. But the general office culture in all DDS's is to be overly cautious for the sake of *possible* QA reviews, which actually takes things to unreasonable extremes sometimes.
Actually, most of the time.
The perception that there's no recent evidence or certain specific findings is often used to justify a CE request. Sometimes the fact that a doctor's notes are only in bad handwriting is the reason for a CE.
I know medical consultants and examiners who ask for CE's because they want numeric joint range of motion for people with joint complaints, ask for back x-rays because an MRI clearly demonstrating the problem is over a year old, and obtain psychiatric evaluations because a claimant's family doctor put them on Effexor. All of which are generally unnecessary.
To answer your question, though, it's not a procedure and there's probably no sound logical reason for it. The most likely cause is that it serves to resolve a perceived deficiency, not an actual one.
Of course, I'm anonymous and that's just my opinion, so you'll have to take it with a grain of salt.
CE exams are there to give SSA something to deny.
ReplyDeleteMost good ALJs do not give them much credit. Bad ALJs (and bad MEs) latch on to these like they are from God. It is amazing how some ALJs will completely ignore a treating physician report in favor of a CE. They are bogus.
I actually had a good ALJ conduct a hearing to expose on the record how horrible a CE exam was. My client had severe MS and was definitely disabled. But the CE said she could perform medium work. This good ALJ basically wanted to expose this fraud on the record. But that is very rare.
It is nice to see the SSA have some oversight on these exams.
You've just given me the info I was searching for. Cool to read such a well-considered article! So here is my saving grace: PDFfiller helped me to fill out the SSA HA-1151-BK and and esign them. Just try it "http://pdf.ac/9DwQyc", you'll love it.
ReplyDeleteI was in car accident that left me paralyzed with progressive nerve disorders and chronic severe pain controlled with massive amounts of medications. My neck surgery included placing metal plates with fusion in my neck, paralysis of my right side, disminishing eye sight due to trigeminal nerve damage and brachial neuropathy to name a few of many injuries. I filed for ssdi in 2013 and have been denied to the point of awaiting a hearing date. Now I just received a request to attend a CE appointment because ssdi does not have enough medical information to make a decision. however the CE is for a medical evaluation on a bone and back injury nothing to do with my neck! This to me spells denial of claim since I have been waiting for a hearing date for 2 years. Well, I have submitted 3" of medical info and can provide again versus attending this bone and back eval they want. Should I call rep and explain my injuries do not involve my bones and back? I am broke have lost everything and am at the end of my rope as everyone else waiting for ssdi benefits and cannot afford another denial. Please someone help with advice suggestions something other than wasting my time attending this CE. Which I know will be a waste of time. Your suggestions are very much appreciated!
ReplyDelete