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Consultative Exams And Social Security Disability Claims

By Pitt Dickey

This column will take a look at how the Social Security Administration (SSA) will use outside medical professionals to help it evaluate disability claims. The SSA will typically review all of the medical records from the claimant’s treating physicians. In many cases the SSA will require the claimant to submit to further evaluation by another medical professional to obtain additional information about the claimant. This column will examine when such evaluations are ordered, what the medical professional is looking for, the scope of the evaluation, the types of tests performed and how the SSA will use these reports.

The medical professional chosen by the SSA will perform what is called a consultative exam on the claimant. Depending upon the type of claim involved, the SSA can refer the claimant to a medical doctor, a psychiatrist or a psychologist. The medical professional performing the consultative exam will not treat the claimant. His job is to examine the patient and then prepare a report on his findings and submit it to the SSA. This report is called a Disability Determination Evaluation will be considered by the SSA in determining whether to award disability benefits. This report may be examined by the claimant prior to his hearing.

Not every case will have a consultative evaluation performed in it. Some cases will have several such evaluations based upon the individual facts of the case. If a claimant has more than one type of health problem in different specialty areas such as neurology or orthopaedics the SSA may order reports from different specialists. The decision to order a consultative exam is up to the SSA. The SSA will base its decision on whether to order a consultative exam upon such factors as whether additional information is needed beyond the existing medical evidence such as clinical findings, lab tests or reports with diagnosis and prognosis.

The consultative evaluation is paid for by the SSA. If one is requested the claimant is required to participate in the evaluation. If the claimant does not show up for the evaluation without a good reason the SSA may deny his disability claim. It is very important to cooperate and attend such an evaluation. Some of reasons the SSA may have for requiring the evaluation include a need for additional evidence that is not in the claimant’s medical records or the medical evidence needed from the treating physician or source is not available due to reasons beyond the claimant’s control such as death or non-cooperation of a medical source. The SSA may also need highly technical information that is not available from the treating physician. The SSA may have determined that there is an ambiguity in the existing medical evidence that needs to be resolved by a consultative evaluation. Such an evaluation can also be requested if it appears to the SSA that there has been a change in the person’s medical condition that is likely to effect his ability to work.

If the claimant is not covered for Disability Insurance benefits at the time he alleged his disability began and there is no chance that the onset date could be established earlier than his onset date, the SSA will not order an evaluation. The SSA will pay for certain specific exams but will not authorize a comprehensive exam if the only evidence the SSA needs is for a specific test such as an Xray, cardiogram or blood studies.

The SSA can purchase consultative evaluations from a person’s treating physician. However in 20 years of handling these claims I have never seen a treating physician be hired to do a consultative evaluation. The SSA typically hires a physician who has not treated the claimant to do the evaluation. The claimant can object to the SSA’s choice of physician if there is good reason to do so. The grounds for such objection could be that the physician had previously examined the patient for an adverse party such as his employer in a workers’ compensation case or insurance claim case. If the doctor or psychologist had previously examined the patient in a prior disability claim that was denied, this is also grounds to request another doctor perform the evaluation.

The SSA will request copies of any diagnostic tests performed by the claimant’s treating physician in the past. The SSA will not order any diagnostic tests that could involve significant risk to the claimant such as myelograms, arteriograms or cardiac catheterizations. The SSA has guidelines for the amount of time that the doctor should actually spend with the patient in performing the evaluation. A comprehensive general medical examination should take at least 30 minutes. A comprehensive musculoskeletal or neurological evaluation should take at least 20 minutes. A comprehensive psychiatric evaluation should take at least 40 minutes. A comprehensive psychological examination should take at least 60 minutes and longer depending upon the type of psychological testing administered by the psychologist. There will be some variance in these times but this is what the SSA anticipates the medical provider will generally spend with the claimant.

After the evaluation is completed the doctor will provide the SSA with a report. Typically these reports are dictated over the telephone. The reports are typed, reviewed and signed by the physician and become part of the permanent claim file. The reports will include the following information: 1. The claimant’s chief complaints; 2. A detailed description within the physician’s area of specialty of the history of the major complaints; 3. A description of the positive and negative clinical findings based upon history, lab tests and examination; 4. The results of lab tests; 5. The diagnosis and prognosis for the claimant’s condition; 6. A statement of what the claimant can do despite his health problems. The physician has to express his opinion about the claimant’s ability to perform work related tasks such as sitting, standing, walking, lifting, carrying objects, and traveling; 7. The physician is also to evaluate and comment upon the claimant’s major complaints and any abnormalities found on examination or in the lab tests.

The SSA will then consider this consultative evaluation in making its decision regarding the claimant’s disability claim. The claimant’s treating physician’s evaluation is entitled to greater weight with the SSA than a consultative evaluation.

Pitt Dickey has practiced law handling Social Security disability cases in Fayetteville since 1978. . He practices with the firm of Smith, Dickey, Dempster & Harris, P.A. at 315 Person Street and can be reached at 910 – 484-8195 or [email protected] Copies of prior Disability Update articles are available on line at www.smithdickeydempster.com