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Congress Requests Study of Social Security Medical Reviews

Empire Justice Center July 31, 2019

A recent series by the Tennessean, a local Tennessee newspaper, has brought to light the downfalls of using contracted doctors to perform medical reviews for determinations of disability.  The investigation in Tennessee has prompted Congressman John B. Larson, Chairman of the Ways and Means Social Security Subcommittee, to request that the U.S. Government Accountability Office (GAO) conduct a study of the quality of the medical reviews performed by doctors used by the Disability Determination Service (DDS). DDS is a state agency that performs eligibility determinations on behalf of the Social Security Administration (SSA).

 

In requesting the study, Chairman Larson states that “[b]eyond Tennessee, little is known about the extent to which DDS offices . . . use contracted medical consultants, how these consultants are compensated and overseen, how quality is measured, and in what ways, if any, the use of contracted medical consultants affects determination accuracy.”

 

The series revealed that the Tennessee DDS mostly contracts independent doctors who are paid a flat rate for each application they review.  These doctors work fast, being incentivized by the flat rate pay.  The state also employs a few staff doctors who are paid a salary not based on how many applications they review. These doctors, without the flat rate incentive, work slower and more accurately.  The Tennessee DDS, however, plans to terminate all doctors on salary and rely solely on contract physicians.

 

The federal standard for reviewing claims is 1.5 cases per hour. One Tennessee review physician featured in the series pumped out an average of five case reviews per hour, spending an average of 12 minutes per case. He earned $420,000 for reviewing 9,088 applications in the year ending on June 30, and has made $2.2 million since 2013. Around 80% of the applications he reviewed were denied under his recommendation. The Tennessean reported that one in five contract doctors doubled the federal standard pace.  Experts and both former and current state employees have stated that it is impossible to review cases at these rates without making mistakes.

 

Tennessee has one of the highest denial rates for disability applicants in the country, rejecting 72% of applications, 6% higher than the national average. The state has reported an average of 95.8% accuracy since 2016 and received a “Phoenix Award” for its performance in 2017. But those numbers are based on SSA’s review, as required by law, of at least half of all the eligibility approval determinations.  There are no specific requirements for review of denials.  As a result SSA has reviewed fewer than 2% of all rejections, according to an analysis by the National Organization of Social Security Claimants’ Representatives. Thus, Tennessee’s accuracy rate is based almost entirely on its approval determinations.

 

According to Jeffrey Price, the former legislative director for the National Association of Disability Examiners, approximately half of the state disability offices in the country use a model similar to that of Tennessee. Of note, New York’s DDS, the Division of Disability Determinations (DDD), apparently employs its Medical and Psychological Consultants.  Advocates are currently questioning, however, if they comply with federal standards.

 

According to Chairman Larson and others, a GAO study of the quality and quantity of case reviews by DDS doctors is sorely needed. Summer law intern Lyssabeth Pedersen provided this summary of Chairman Larsen’s request and the Tennessean series.