[Federal Register Volume 59, Number 73 (Friday, April 15, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-8265]
[[Page Unknown]]
[Federal Register: April 15, 1994]
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Part II
Department of Health and Human Services
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Social Security Administration
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Disability Reengineering Project Proposal; Notice
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Social Security Administration
Process Reengineering Program; Disability Reengineering Project
Proposal
AGENCY: Social Security Administration, HHS.
ACTION: Announcement of proposal and request for comments.
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SUMMARY: The Disability Process Reengineering Team of the Social
Security Administration (SSA) announces a proposal to redesign the
disability claims process for Social Security Disability Insurance and
Supplemental Security Income (SSI) Disability and Blindness benefits.
This notice contains the Proposal (as well as background information)
of the Disability Process Reengineering Team (composed of SSA and State
Disability Determination Service (DDS) employees). The aim of the
proposal is to achieve dramatic improvements in customer service to the
public. Accordingly, we seek comments on the proposal to ensure that it
meets the needs of the public. The comments will be weighed in the
Agency's subsequent decisions on implementation.
DATES: To be sure that your comments are considered we must receive
them no later than May 27, 1994.
ADDRESSES: Submit your comments as follows: (1) Mail them to the Social
Security Administration, PO Box 17052, Baltimore, MD 21235, or (2)
telefax them to (410) 966-9884, or (3) deliver them to 4-N-3 Operations
Building, 6401 Security Boulevard, Baltimore, MD 21235, between 8 a.m.
and 4:30 p.m. on regular business days. If you telefax your comments,
please do not also mail a hard copy document.
FOR ADDITIONAL COPIES CONTACT: Social Security Administration, PO Box
17052, Baltimore, MD 21235, (410) 966-8255. The Proposal is available
in alternative formats for visually impaired individuals. Please use
this same telephone number to request the document in an alternative
format.
SUPPLEMENTARY INFORMATION:
Background--What is the Reengineering Program?
SSA began an Agency-wide program of Process Reengineering in the
summer of 1993. The Process Reengineering Program is one way SSA is
seeking to improve its overall service delivery process.
The Process Reengineering Program essentially asks the question,
``If SSA had the opportunity today to design the processes, what would
they look like?'' In other words ``how would we design a process if we
were starting over?'' The Program's objective is to fundamentally
rethink and radically redesign SSA's work processes to achieve dramatic
improvements in critical measures of performance. In this rethinking
and redesign process, the ultimate aim is to achieve dramatically
improved levels of service from the customer's perspective while
enriching and improving the work lives of employees.
The Process Reengineering Program is the culmination of an
investigation by SSA of the reengineering efforts conducted by
companies, public organizations, academic institutions, and consulting
firms with ``hands on'' experience. The very positive findings from
that investigation, combined with our concerns about our ability to
provide the very best service to the public, led to the conclusion that
a process reengineering effort was absolutely critical to SSA's
objective of providing ``world class'' service to the American public.
Based on analysis of what has worked best in other organizations,
SSA developed a customized reengineering methodology. This methodology
uses a reengineering team approach and combines a strong customer focus
with classic management analysis techniques and computer modeling and
simulation to intensely review a single business process. While the
reengineering team is comprised of employees and experts who are very
knowledgeable about the SSA process being redesigned, the methodology
focuses heavily on obtaining the views of a broad segment of the
public.
What Does the Disability Project Address?
Despite the outstanding efforts of SSA and State DDS employees
throughout the country, we continue to have difficulty providing a
level of service to claimants for disability benefits that approaches
what would be considered ``good'' service. The steps in the current
disability process have not changed in any important way since the
beginning of the Disability Insurance program in the 1950s. Yet case
loads, types of disabilities, and the demographic characteristics of
individuals with disabilities who are potentially eligible for benefits
have changed radically.
The State DDSs make the initial decisions about whether an
applicant for Disability Insurance or SSI benefits is disabled. In
1989, SSA forwarded to the State DDSs 1.6 million claims for disability
benefits in the Disability Insurance and SSI programs. Claims have
increased significantly in every year since that time. In 1994, the
number of disability claims we will forward to the State DDSs is
expected to reach about 2.7 million. The number of requests for
hearings on denied claims is expected to reach 522,000--an increase of
about 60 percent in the last 3 years. The result is that many claimants
have to wait much too long at each stage in the process. SSA and State
DDS employees are working longer and harder, while becoming
increasingly frustrated about their inability to provide the type of
service the public deserves.
For these reasons, the first SSA reengineering project focuses on
the process for claiming benefits--beginning with the initial claim and
continuing through the payment of benefits or the final administrative
appeal--under both the Disability Insurance program and the disability
component of the SSI program.
The scope of the assignment to the disability reengineering project
team did not include making any changes to the statutory definition of
disability or the amount of benefits for which individuals are
eligible. Other issues relating to the disability programs are being
addressed by SSA in other ways, including the continuing disability
review process and the referral of individuals for vocational
rehabilitation services.
What the Proposal Contains
The proposal contained in this announcement is the product of the
disability reengineering team. It begins by providing background on the
current disability determination process. It discusses input received
in person, by telephone and by mail, from almost 3,000 Social Security
and State DDS employees, 750 members of the external community of
individuals and organizations interested in SSA's disability programs,
and from focus groups conducted with members of the public.
We next provide a conceptual proposal for a new disability claims
process; it gives a view of how the new process will work from the
applicant's perspective. Many readers will want to know how these
concepts will actually work in detail. However, the development of that
level of information will not be done until SSA is confident that the
basic concepts presented here have the potential to achieve the level
of service we seek to provide. We are committed to extensive future
dialogue on the next level of detail once we make the final decision on
these concepts.
The proposal contains many charts, some of which may be difficult
to read in the Federal Register format. We considered deleting some of
them but decided that the greater public interest was served by
publishing the entire proposal as it was presented on March 31, 1994,
to the Executive Steering Committee.
How Should Comments Be Presented to the Project Team?
The Project Team seeks public reaction to the concepts in the
proposal. We are particularly interested in your response to the
following questions concerning the proposal's goals:
Does the proposal have the potential to provide a process
that is easy for claimants and those who assist claimants to access and
understand?
Will it enable SSA and the State DDS to make the right
decision the first time a case is adjudicated?
Will it result in dramatically improved process times?
Will it result in a more efficient use of SSA and State
DDS personnel?
Will it create jobs for employees in the process that are
satisfying?
In considering these questions, you are encouraged to identify
factors that would assure that the concepts presented will achieve
these goals. To the extent that the proposal is not seen as achieving
these goals, alternative suggestions about how to do so will be
welcome.
What Happens Next?
The Project Team will receive all comments from the public and
employees. The comments will be analyzed and used to revise and/or
refine the proposal. The final proposal of the team will be presented
to the Executive Steering Committee for the project for its review and
recommendations. Members of this committee include SSA and HHS General
Counsel executives, the presidents of the 8 union locals/councils that
represent SSA employees, a State DDS Administrator, and the presidents
of 6 associations of SSA and State DDS employees that work in the
disability process.
The Commissioner of Social Security will seek the advice and
recommendations of the Executive Steering Committee in making her
decisions on how SSA will proceed.
Dated: March 29, 1994.
Rhoda M. G. Davis,
Director, Process Reengineering Program.
Introduction
A claimant for disability benefits from the Social Security
Administration faces a lengthy, bewildering process. An initial
decision from SSA will likely take more than three months. Anywhere
from 16 to 26 employees will handle the claim before the initial
decision is reached. If that decision is a denial, and the request for
reconsideration is also denied, chances are the claimant will hire an
attorney. It will likely be an additional eight months or more before a
response on the hearing is received, and even longer before a check is
issued or eligible dependents' benefits are paid. As many as 45
employees could handle the claim.
If the claim for benefits is approved after a hearing, the claimant
will view the SSA disability application process as one which requires
jumping through lengthy bureaucratic hoops. Dealing in person or on the
telephone with SSA field office staff and, possibly, the State
disability determination service (DDS) staff at the initial and
reconsideration levels, the claimant must appear at a hearing and
finally talk to a person in a position to make a decision on the claim.
The claimant will rate SSA employees as courteous and knowledgeable,
but the disability determination process as bureaucratic and
unresponsive.
Congress agrees with this assessment; in May 1991, the House Ways
and Means Committee cited SSA for an excellent job of delivering
retirement benefits, but gave SSA a failing grade for the way it
processes applications for disability benefits, with Chairman Dan
Rostenkowski stating, ``* * * those who are unfortunate enough to
become disabled find their problems compounded by inefficiencies at
SSA.''
SSA employees reiterate this belief, as illustrated in the
following statement by a claims representative, ``I wish we could stop
shuffling all this stuff back and forth. I don't really know what the
DDS is looking for, so I try to do the best generic job I can on these
forms.''
The report of the National Performance Review reflected
Administration concern by directing SSA to ``Improve Social Security
disability claims processing to better serve people with disabilities *
* *''.
SSA has reached a critical juncture; disability claims receipts at
the initial claims and appeals levels have reached all time highs--
Fiscal Year (FY) 1995 claims requiring a disability determination will
increase 69 percent over FY 1990 levels; appeals workloads will
increase 75 percent over FY 1990 receipt levels; employees in field
offices, DDSs and hearing offices are overburdened despite recent
significant increases in productivity. As an agency, SSA must vie for
scarce administrative resources in an era of spending limitations and
competing social spending priorities. The ability of SSA to cope with
further workload increases is questionable; it is clear that only
radical change can address the disability service delivery problems
facing the Agency today.
SSA is meeting this challenge with an unprecedented effort to
reengineer the entire disability process--from the point a potential
claimant first contacts the Agency to file for disability benefits,
through the disability allowance or final administrative appeal.
Reengineering the disability process involves asking the question,
``Given what we know about technology and resources available to us
today, how can we best design a disability process for the 1990s and
beyond?'' This report will answer that question by proposing a radical
redesign of disability program policies and procedures, to ensure
dramatic improvements in the way the entire process works and is
managed to serve the American public.
The report represents the collective efforts and recommendations of
the 18-member Disability Reengineering Team, composed of Federal and
State DDS employees, operating under the auspices of the Director of
the SSA Process Reengineering Program, and the SSA Executive Steering
Committee formed to provide advice to the Commissioner on the
disability reengineering process change proposal development.
The Executive Steering Committee provided the following parameters
for the disability reengineering proposal: ``Every aspect of the
process except the statutory definition of disability, individual
benefit amounts, the use of an administrative law judge as the
presiding officer for administrative hearings and vocational
rehabilitation for beneficiaries is within the scope of this
reengineering effort.''
The recommendations in this report represent the Team proposal to
SSA for reengineering the disability process; this is not a final SSA
proposal. The Commissioner of SSA asks interested parties to comment on
the proposal within the next 60 days. The Team looks forward to
receiving comments from the community concerned with the delivery of
disability benefits.
Current Process
The procedures in the current process have not changed in any
significant way since the Social Security Disability Insurance (DI)
program began in the 1950s, a time when caseloads, demographic
characteristics of claimants, types of disabilities, and available
technology were radically different.
In the 1970s, Congress federalized State programs of cash
assistance to the aged, blind and disabled into the Supplemental
Security Income (SSI) program and added this to the responsibilities of
SSA. SSA then adopted the DI disability determination procedures for
SSI blind and disabled claims.
Overview
A claim must now pass through from 1 to 4 decisional paths within
SSA to receive a favorable disability decision. The initial claim,
reconsideration, administrative law judge (ALJ) hearing and Appeals
Council review levels all involve multi-step uniform procedures for
evidence collection, review, and decisionmaking.
The process starts at the initial level when an individual first
applies for DI or SSI disability benefits on the basis of a disabling
physical or mental condition. An individual calls the national toll-
free telephone number and is referred to a local SSA field office or
visits or calls one of 1,300 local field offices to apply for benefits.
Field office personnel assist with application completion, obtain
detailed medical and vocational history and screen nonmedical
eligibility factors. Field office personnel forward the claim to 1 of
54 State disability determination services where medical evidence is
developed and a final determination is made regarding the existence of
a medically determinable impairment which meets the definition of
disability.
After possible quality assurance review in the DDS or in the SSA
regional Disability Quality Branch, the claim is returned to the field
office. Thirty-nine percent of these claims were paid in FY 1993;
denials are retained pending possible appeal. Allowed DI claims are
sent to one of 7 processing centers (which include the Office of
Disability and International Operations and the 6 Program Service
Centers) for final processing and storage, as well as adjudication of
claims for dependents. Allowed SSI claims remain in the field office
for payment and retention.
An initial claim currently takes an average of 100 days to process
from the time it is filed until a final decision is made according to
SSA's computer-based processing time measurements. However, a better
understanding of how long the process takes from the claimant's
perspective comes from a 1993 study conducted by SSA's Office of
Workforce Analysis, which showed that an average claimant waits up to
155 days from the initial contact with SSA until receiving an initial
claim decision notice. Sixteen to 26 employees will handle the claim
during this period.
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An appeal of the initial decision can be made within 60 days of the
denial notice (see Fig. 2). Reconsiderations were requested on 48
percent of denied claims in FY 1993. The local field office receives
the request, updates the information, and forwards the claim file to
the DDS for review, possible medical development, and final medical
decision. The determination is made by a different adjudicative team
than the one that made the initial determination.
After possible quality assurance review in the DDS or in the
regional Disability Quality Branch, about 14 percent of these claims
are returned to the field office for payment, and forwarding to the
processing centers, while the remaining denials are forwarded to the
field office for retention, pending a request for a hearing before an
ALJ. The average reconsideration itself takes about 50 days according
to SSA's computer-based processing time reports--however, according to
the Office of Workforce Analysis study, a claimant has now been
involved with the SSA process for roughly 8 months from the point of
initially contacting the Agency, and up to 36 different employees could
have handled the claim.
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Within 60 days of receiving an unfavorable reconsideration
decision, a claimant can request a hearing before an ALJ (Fig. 3). In
FY 1993, about 75 percent of all reconsideration denials were appealed
to ALJs. At this point, a claimant has usually retained an attorney or
other representative to assist in pursuing the claim for benefits.
About 75 percent of all claimants retain a representative at the
hearing. The local field office receives the request for hearing and
forwards it with the claim file to one of 132 local SSA hearings
offices. Hearing office personnel review the file for possible
additional development, conduct a hearing, and render a final decision.
Allowed DI claims are sent to a processing center for final action
and storage, as well as adjudication of claims for dependents. Allowed
SSI claims are returned to the local field office for income and
resource development, and payment. Denied claims are forwarded to the
Appeals Council for retention in case a request for review is filed.
The hearing process itself takes about 265 days according to computer-
based reports. However, according to the Office of Workforce Analysis
study, a claimant has been dealing with SSA for over a year and a half
at this point in the process.
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If still dissatisfied with an unfavorable decision, a claimant or
representative has 60 days to request a review of the ALJ decision by
the Appeals Council (Fig. 4). About 23 percent of hearing decisions are
unfavorable and forwarded to the Appeals Council pending possible
appeal. The Appeals Council considers about 18 percent of all ALJ
dispositions, including cases it reviews on its own motion.
Requests for Appeals Council review are typically received directly
from the claimant's representative. The Appeals Council may either deny
review, issue a decision, or remand the claim to an ALJ. The Appeals
Council remands claims to the ALJ level about 27 percent of the time
for subsequent development and decision. Denied claims, representing
about 70 percent of the Appeals Council dispositions, are held in the
Appeals Council for possible appeal to Federal District court.
Allowed DI claims are sent to a processing center for final action
and storage, as well as adjudication of claims for dependents. Allowed
SSI claims are returned to the local field office for income and
resource development, and payment. According to processing time
reports, this part of the process takes on average about 100 days;
however, according to the Office of Workforce Analysis study, a
claimant has spent almost 2 years dealing with SSA since initially
contacting the Agency.
Trends
The current disability process served SSA and the public well for a
number of years. However, over the last several years, as workloads
have increased dramatically, the current process has been placed under
increasing stress. The upward trend in the number of claims for
benefits SSA has received is reflected as follows:
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The growth in claims and benefits awarded is reflected in increases
in the number of beneficiaries SSA pays and the growth in Federal
program outlays over recent years.
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The increase in workload has occurred concurrently with significant
downsizing activity in SSA and staffing fluctuations in the State DDSs.
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Even with the downsizing, the total costs for processing initial
disability and appeals determinations (excluding the costs for
processing the Sullivan v. Zebley court case) remain enormous--more
than half of the total administrative costs (including DDS costs) for
SSA in FY 1993 were devoted to this task.
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Despite these funds, and despite directing a larger percentage of
the SSA resources toward disability initial claims and appeals
processing in recent years, average processing times for initial
claims, as well as appeals, have escalated dramatically since 1988.
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At least part of the increase in processing time results from the
time added as the claim moves from one employee or facility to another
(handoffs), and waits at each employee's workstation to be handled
(queues). As workloads increase, the amount of time a claim waits at
each processing point grows.
``Task time'' is the time employees actually devote to working
directly on a claim, rather than the total amount of time it takes for
a claimant to receive a final decision. Based on the Office of
Workforce Analysis study, a claimant can wait as long as 155 days from
the first contact with SSA until receiving an initial claim decision
notice--of which only 13 hours of this is actual task time. The same
study reveals a claimant can wait as long as 550 days from that initial
contact through receipt of the hearing decision notice--of which only
32 hours is actual task time.
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The Team's research revealed that the problems of queues, handoffs,
and task time are compounded by problems with the way SSA takes claims,
collects evidence, and determines disability. These problems are
discussed in the following section.
Research Summary and Analysis
Overview of Methodology and Findings
The Team's methodology called for extensive site visits and
interviews with members of the disability community. Team members
visited 421 locations in 33 States and conducted over 3,600 interviews.
Almost 2,900 of these involved front-line employees, managers and
executives. The interviews provided insights into the problems
confronting the disability program and recommendations for solving
these problems. The Team conducted an additional 111 interviews by
telephone.
The Team also interviewed over 750 parties external to SSA--members
of the medical, legal, advocate and interest group community--for their
views. Finally, the Team has analyzed the results of focus groups
involving disability claimants and the general public in order to
determine what SSA customers experience and expect from the disability
process.
The information collected from these activities resulted in the
framework for the analysis and recommendations that follow. At a
minimum, the Team was determined to address the most pressing problems
identified by SSA employees, claimants, and other interested parties.
Not surprisingly, all three groups were in general agreement regarding
many of the problems with the SSA disability process. All agreed that
the current fragmented process takes too long to provide applicants a
decision, and leaves them confused about who has responsibility for
their claim, and puzzled about the status of their claim during various
points in the process. Additionally, nearly all believe that many
claimants can and should assume more responsibility for submitting
evidence and pursuing their claim.
Most view the reconsideration step as little more than a rubber
stamp of the initial determination, creating additional work for
employees and yet another bureaucratic obstacle for claimants and their
representatives. Some believe a face-to-face interview with the
decisionmaker is vital to reaching a fair, accurate determination;
others believe just as strongly that the decision should be reached on
the basis of a paper review, and that a face-to-face interview can lead
to subjective decisions that are not based on objective criteria.
Higher allowance rates at the ALJ level lead to the perception that
different adjudicative standards apply at the initial and appeals
levels. The public, in particular, believes that it is necessary to
hire an attorney to maneuver through this process, and voices
resentment at having to do so. Quality reviews and Appeals Council
reviews are often mentioned as areas where opportunities exist for
improving current processes.
The Case for Change
The Public and Third Parties Find the Current Process Confusing
Many applicants enter the SSA disability process uninformed about
the process itself and the definition of disability. They are unaware
of the criteria for establishing disability and the evidence they will
be required to submit. Even third parties and advocate organizations,
often more knowledgeable than the general public about SSA procedures,
experience difficulty obtaining meaningful information about the status
of their clients' claims, finding that they often are transferred from
one employee to another.
Disability claimants face a ``one size fits all'' approach to the
intake and processing of their claim, finding themselves answering
questions they believe are intrusive and irrelevant to their claim.
Front-line employees currently devote hours to completing forms and
obtaining information which may not be necessary for a finding of
disability. If the claim is approved, whether at the initial or
appellate level, claimants and their representatives, as well as front-
line employees, are concerned about the complicated procedures and
length of time it takes to effectuate payment and entitle eligible
dependents.
Evidence Collection and Decision Methodology Pose Problems
The collection of medical evidence presents problems as the case is
developed in the DDS. Medical providers who have treated the claimant
often do not understand the requirements for establishing disability,
and find the forms for the collection of medical evidence confusing. In
order to compensate for poor or missing medical evidence, DDSs purchase
consultative examinations, devoting substantial resources to
scheduling, purchasing, and processing these examinations.
Once the medical evidence has been collected, the methodology used
to reach a decision on the case is complex and controversial. Criteria
originally developed to identify and evaluate cases simply and rapidly
have grown increasingly complex as a result of court decisions and
changes in medical technology. Today's 330 different vocational rules,
which have been added to SSA's regulations since 1980, can lead to
varying interpretations resulting in inconsistent decisions.
Claimants and their representatives have learned their chances for
a favorable decision improve if they appeal their claim to an ALJ. A
variety of factors may be contributing to this. The facts of many cases
change over time as a claimant's condition changes. ALJs often have
access to information not considered at lower levels in the process
because earlier decisionmakers are not as likely to have face-to-face
interaction with the claimant. Finally, the fragmented nature of SSA's
policy making, policy issuance, training and review apparatus all
reinforce the differences.
The Fragmented Process Contributes to Difficulties
The fragmented nature of the disability process is driven by and
exacerbated by the fragmentation in SSA's policy making and policy
issuance mechanisms. Policy making authority rests in several
organizations with few effective tools for ensuring consistent guidance
to all disability decisionmakers. Different vehicles exist for
conveying policy and procedural guidance to decisionmakers at different
levels in the process. While the standards for disability
decisionmaking are uniform, they are expressed in different wording in
the various policy vehicles.
Training on disability is not delivered in a consistent manner, nor
is it provided simultaneously to disability decisionmakers across or
among levels in the process. Mechanisms for reviewing application of
policy among levels of the process are fragmented and inconsistent.
Review of DDS decisions is heavily weighted toward allowances; no
systematic quality assurance program is in place for hearing decisions
although the opportunity for feedback from the appeals council or court
cases is heavily weighted toward denials.
The organizational fragmentation of the disability process creates
the perception that no one is in charge of it. SSA measures the process
from the perspective of the component organizations involved, rather
than the perspective of the claimant. Multiple organizations (field
offices, DDSs, hearings offices, Appeals Council operations, and
processing centers) have jurisdiction over the claim at various points
in time, with each line of authority managing toward its own goals
without responsibility to the overall outcome of the process.
Additionally, the impact of one component's work product on other
components is not measured, further contributing to the fragmentation
of the process. Each component's narrow responsibilities reinforce a
lack of understanding among component employees of the roles and
responsibilities of other employees in different components.
Customer Research and Demographics
Customer Research
The National Performance Review report, released in the fall of
1993, calls upon agencies to establish customer service standards equal
to the best in the business to guide their operations. Federal agencies
are encouraged to identify ``the customers who are, or should be served
by the agency,'' and survey these customers ``to determine the kind and
quality of services they want and their level of satisfaction with
existing services.''
SSA customers include the individuals who file for social security
or supplemental security income disability benefits, or who are
potential filers for these benefits. They were surveyed through a
series of 12 focus groups conducted throughout the country last fall.
Participants represented a demographically diverse cross-section of
current claimants, including those who had been initially denied, and
who filed for a reconsideration or hearing; new beneficiaries; and the
general public. Two focus groups were conducted with non-English
speaking participants.
Focus group participants were quick to offer their frank opinions;
the general view was that they:
--Wait too long for a decision--this is the most common complaint; the
claim process is a struggle characterized by stress, fear, and the
anger associated with running out of funds;
--Do not understand the program or process--what happens to the claim
after initial contact with SSA is unclear, they view SSA multiple
requests for medical information with skepticism, do not understand
their decision and believe it was reached arbitrarily;
--Want more information and personal contact--while they would prefer
to deal with one person for all claim business, their major preference
is to receive accurate, consistent information from all SSA sources and
to be provided substantive status reports on their claim;
--View the initial and reconsideration denials as bureaucratic
precursors to final approval at the ALJ level--they believe the process
is designed ``to make you go away'';
--Resent the need for attorney assistance to obtain benefits--the
process should not be so complicated that an attorney is needed; and
--Want more active involvement in pursuit of their claim--they want to
make their case directly to the decisionmaker, and would personally
obtain needed additional evidence to speed the decision on their claim.
Demographics
Changes in demographics of the general population and in SSA's
claimant population present challenges as well as opportunities for SSA
as it focuses on claimant needs and reengineers its disability
determination process.
American society has changed dramatically since the DI program
began in the 1950s. This is reflected in an increased demand for SSA's
services, changes in the characteristics of claimants seeking benefits,
and complexities in claim related workloads and processes.
The demographic character of the SSA disability claimant population
has changed as well. The enactment of the SSI program in the 1970's
added individuals who have sketchy work histories, increased the number
of individuals filing based on disabilities such as mental impairments,
and provided for eligibility of disabled children. Additionally, the
requirements of the SSI program added complex and time consuming
development of non-disability eligibility factors such as income,
resources and living arrangements. The 1990 U.S. Supreme Court
decision, Sullivan v. Zebley, resulted in increased claims for
children; children comprised 21 percent of all SSI claims in 1992, up
from 11 percent in 1988. Claims for homeless individuals and others
with special needs have increased in recent years. These claimants
require significant intervention and assistance to navigate the
disability claims process.
A trend in the general population which is reflected in SSA's
disability claimant population is the increased number of people in the
United States for whom English is not the native language. Recent
national Census data indicate that 1 in 7 people speak a language other
than English in the home; this is an increase of almost 38 percent in
the last 10 years. SSA will need to accommodate the special
communication needs of these claimants in its ongoing claimant contacts
and in public information vehicles.
Forty percent of claimants filing for disability benefits and
polled in a recent SSA survey had filed for or received benefits from
Aid to Families with Dependent Children, welfare or social services
within the past year. Approximately three-fourths of them were awarded
this assistance and three-fourths of those awardees were still
receiving benefits when they applied for disability benefits. SSA has
the opportunity to develop productive relationships with these entities
to improve the processing of disability claims for mutual customers.
Technological advances such as personal computers, facsimile
machines, electronic mail, and videoconferencing are increasingly
available to our claimants, their representatives, medical providers
and other third parties involved in the disability process. SSA can
take advantage of these capabilities to offer expanded service options
and to modernize evidence collection.
New Process
Overview
A claimant for disability benefits under the proposed process will
be provided a full explanation of SSA's programs and processes at the
initial contact with SSA. The claimant and third parties will be able
to assist in the development of the claim, deal with a single contact
point in the Agency, and request a personal interview with the
decisionmaker at each level of the process. Additionally, if the
claimant requests a hearing, the issues and evidence to be addressed at
the hearing will be focused, the responsibilities of representatives
clarified and, if the claim is approved, the effectuation of payment to
the claimant, eligible dependents and the representative streamlined.
The new process will result in a correct decision at the initial
level by simplifying the decision methodology, providing consistent
direction and training to all decisionmakers, enhancing the collection
and development of medical evidence, and employing a single quality
review process across all levels.
A single claim manager will handle most aspects of the initial
level claim, thus eliminating many steps caused by numerous employees
handling discrete parts of the claim (handoffs) and the time lost as
the claim waits at each employee's workstation to be handled (queues).
This will reduce the time needed to rework files and redevelop
information from the same medical sources. Levels of appeal will be
combined and improved, reducing the need to redevelop nonmedical
eligibility factors after a favorable decision because less time will
have elapsed since initial filing.
The proposed process will enable the current work force to handle
an increased number of claims, freeing the most highly skilled staff
(physicians and ALJs) to work on those cases and tasks that make the
best use of their talents, and targeting expenditures for medical
evidence to those areas most useful in determining disability.
Employees will perform a wider range of functions, using their
skills to their full potential, enabling them to meet the needs of
claimants and minimize unnecessary rework. The proposed process will
facilitate employees' ability to do the total job by providing
technology and the support to use that technology.
The New Process--A Brief Description
Under the proposed process, the number of appeal steps will be
reduced and opportunities for personal interaction with decisionmakers
will be increased. At the initial claim level, the claimant will be
offered a range of options for filing a claim, pursuing evidence
collection, and conferring with a decisionmaker, using various modes of
technology to interact with SSA. At the hearing level, the claimant
will have an additional opportunity to participate in a personal
conference and meet with a decisionmaker.
BILLING CODE 4190-29-P
TN15AP94.016
A Disability Claim Manager Will Handle Initial Disability Claims
Processing
Claimants initially will deal almost exclusively with a disability
claim manager--a front-line employee knowledgeable about the medical
and nonmedical factors of entitlement--responsible for making the
initial determination, with technical support if necessary, to allow or
deny the claim.
The disability claim manager will determine the level of
development needed to make a disability decision using a simplified
determination methodology; relying on evidence submitted by or through
the efforts of the claimant (whenever the claimant is able to do this);
requesting medical evidence or a functional assessment; or referring
complex medical questions to a medical consultant for expert advice and
opinion, if necessary. The disability claim manager will contact the
claimant if the decision on a claim appears to be a denial. The claim
manager will explain the situation including the evidence that was
considered, and offer the claimant an opportunity to submit additional
information as well as an option for an interview in-person or via
telephone, before the claim is formally denied.
All initial claims will be subject to a randomly selected
postadjudicative national sample review designed to determine whether
disability policies are being properly applied. Extensive ongoing
training will enable adjudicators to consistently issue correct
decisions. By the time the initial decision is issued, the claim will
have been handled by seven or eight employees.
An Adjudication Officer Will Prepare the Claim for a Hearing
A claimant wishing to appeal an unfavorable initial decision to an
ALJ will continue to have 60 days to file a request for a hearing. The
disability claim manager will assist the claimant with the request, and
forward the claim to an adjudication officer. The adjudication officer
will be responsible for explaining the hearing process to the claimant,
as well as conducting personal conferences, preparing claims, and
scheduling hearings. The adjudication officer will have the authority
to allow the claim at any point prior to the hearing that sufficient
evidence becomes available to support a favorable decision.
An ALJ Will Conduct the Hearing
The ALJ will conduct the hearing and issue the decision. At any
point in the process where the claim is approved, it will be returned
to the claim manager for payment effectuation, whether the claim is DI,
concurrent, or SSI. Denied claims will be forwarded to the Appeals
Council, for retention in the event of civil action. At this point, an
average claimant will have been dealing with SSA for approximately five
months from the first contact with the Agency. A total of up to 14
employees will have been involved with the process during this entire
period.
An ALJ decision will be the final decision of the Secretary,
subject to judicial review, unless the Appeals Council reviews the ALJ
decision on its own motion. The Appeals Council will conduct reviews of
ALJ allowances and denials prior to effectuation, at its discretion,
and on its own motion. The Appeals Council will also review all claims
in which a civil action has been filed, and decide whether the ALJ
decision should be defended as the final decision of the Secretary. If
a claim is selected for own motion review, a total of 17 employees will
have been involved in the process from first claimant contact with SSA
through Appeals Council review.
Claimants Will Receive World-Class Service
The time from a claimant's first contact with SSA until issuance of
a final initial decision, will be reduced from an average of 155 days
(as cited in SSA's Office of Workforce Analysis study) to less than 40
days, enhancing SSA's capacity to provide world-class service.
Available employees will be able to process a greater number of claims,
and devote more time to each claimant, providing more personalized
service.
The time from a claimant's first contact with SSA until issuance of
a hearing decision, will be reduced from an average of a year and a
half (as cited in SSA's Office of Workforce Analysis study) to
approximately 5 months.
BILLING CODE 4190-29-P
TN15AP94.017
TN15AP94.018
TN15AP94.019
TN15AP94.020
TN15AP94.021
BILLING CODE 4190-29-C
Detailed Description of New Process
Process Entry and Intake
SSA Will Customize Its Disability Claims Entry and Intake Processes to
Maximize Access, Efficiency, Accuracy, and Personal Service
The disability claims entry and intake processes will reflect the
SSA commitment to providing world-class service to the public. The
hallmarks of the process will be accessible, personal service that
ensures timely and accurate decisions. SSA will work to make potential
claimants better informed about the disability process and fully
prepare them to participate in it. SSA will also be flexible in
providing modes of access to the claims process that best meet the
needs of claimants and the third parties who act on their behalf. SSA
will provide claimants with a single point of contact for all claims-
related business. Finally, SSA will ensure that the disability
decisionmaking process promotes timely and accurate decisions.
SSA Will Make Information About Its Disability Programs Available to
Potential Claimants Prior to Entry Into the Process
SSA will make available to the general public comprehensive
information packets about the Disability Insurance (DI) and
Supplemental Security Income (SSI) disability programs. The packets
will include information about the purpose of the disability programs;
the definition of disability; the basic requirements of the programs; a
description of the adjudication process; the types of evidence needed
to establish disability; and the claimant's role in pursuing a claim.
SSA will make disability information packets commonly available in
the community, both at facilities frequented by the general public
(libraries, neighborhood resource centers, post offices, the Department
of Veterans Affairs offices, and other Federal government
installations) and at facilities frequented by potential claimants
(hospitals, clinics, other health care providers, schools, employer
personnel offices, State public assistance offices, insurance
companies, and advocacy groups or third party organizations that assist
individuals in pursuing disability claims). SSA studies have shown that
claimants frequently rely on advice from their physicians and from
State public assistance personnel in deciding whether to file a claim
for disability benefits. Therefore, SSA will make a special effort to
target its public information activities at these and other known
sources of referrals for claims. SSA will also make the disability
information packets available electronically.
In addition to comprehensive program information, the packets will
describe the types of information that a claimant will need to have
readily available when the individual files a claim. It will also
contain two basic forms: the first, designed for completion by the
claimant, will include general identifying information and will serve
as the claimant's starter application for benefits; the second,
designed for completion by the treating source(s), will request
specific medical information about a claimant's alleged impairments.
SSA will encourage claimants to review the information in the packet
and have the basic forms completed prior to telephoning or visiting an
SSA office to apply for disability benefits. Claimants filing will be
encouraged to immediately submit starter applications to protect the
filing dates for benefits. The starter application will serve as a
claim for both programs, but it will include a disclaimer should the
claimant want to preclude filing for benefits based on need (i.e.,
SSI).
SSA Will Permit Claimants to Choose the Mode of Entry Into the Process
That Best Meets Their Individual Needs
The disability claims entry process will be multi-faceted, allowing
claimants the maximum flexibility in deciding how they will participate
in the process. Claimants may choose to enter the disability claims
process by telephoning the SSA toll-free number, electronically, by
mail, or by telephoning or visiting a local office. Claimants may also
rely on third parties to provide them assistance in dealing with SSA.
Finally, claimants may formally appoint representatives to act on their
behalf in dealing with SSA. SSA field managers will also have the
flexibility to tailor the various service options to their local
conditions, considering the needs of client populations, individual
claimants, and the availability of third parties who are capable of
contributing to the application process.
If an individual submits a starter application by mail or
electronically, SSA will contact the claimant to schedule an
appointment for a claims intake interview or, at the claimant's option,
conduct an immediate intake interview by telephone.
If an individual telephones SSA to inquire about disability
benefits, the SSA contact will explain the requirements of the
disability program, including the SSA definition of disability, and
provide a general explanation of evidence requirements. The SSA contact
will determine whether the individual has the disability information
packet, and mail it or advise the claimant regarding possible means of
electronic access. If an individual indicates a desire to file a claim
at that time, the SSA contact will complete the starter application
available on-line as part of the automated claims processing system to
protect the claimant's filing date and schedule an appointment for a
claims intake interview. The interview may be in person or by telephone
at the claimant's option. If the individual has no medical treating
sources, the SSA contact will annotate this information within the on-
line claim record.
If a claimant visits an SSA office, the SSA contact will refer the
claimant for an immediate claims intake interview or, at the claimant's
option, complete the starter application and schedule a future
appointment for an intake interview.
In all cases, appointments for claims intake interviews will be
made available within a reasonable time period, generally 3 to 5
working days, but no later than two weeks.
Local management will determine how to best accommodate claimants'
needs in learning about the disability process and completing a claims
intake interview. Depending on an individual's circumstances, such
accommodation may involve: referral to the nearest location for
obtaining an information packet which can then be mailed in; an
immediate telephone or in-person interview; arranging for an on-site
visit from an SSA representative; or referral to appropriate third
parties who can provide assistance. Additionally, depending on the
nature of the individual's disability, SSA may encourage the individual
to file in person when it appears that a face-to-face interview will
assist in the proper claims intake and development. Face-to-face
interviews, when considered necessary by either the claimant or SSA,
can also be accomplished via videoconferencing. In any case, SSA will
make every reasonable effort to meet the needs of the claimant in
completing the application process.
Similarly, local managers will modify the claims entry and intake
process to provide maximum flexibility for representatives who act on
behalf of claimants or third parties who can assist claimants in
completing the application process. Such accommodations may include,
but are not limited to: (1) Using automated means to interact with SSA
to protect a claimant's date of filing (e.g., telephone, fax, or E-
mail); (2) providing appointment slots for third parties to accompany
claimants to interviews or to provide assistance during telephone
claims on a claimant's behalf; (3) out-stationing SSA personnel at a
third-party location to obtain applications and/or medical evidence,
when appropriate; and (4) providing open appointment'' scheduling to
permit claimants to contact SSA within a flexible band of time.
Interested third parties will be encouraged to participate in the
development of claims by becoming certified by SSA to do so.
Local managers will also conduct outreach efforts that are designed
to meet the needs of hard-to-reach populations or assist those
individuals unable to access the SSA claims process without
considerable intervention. As appropriate, outreach efforts may be
facilitated through videoconferencing, teleconferencing or other
electronic methods of obtaining and processing claims information to
provide timely service despite claimants' geographic or social
isolation.
A Disability Claim Manager Will Be Responsible for a Disability Claim
From Intake Through Payment
A disability claim manager will have responsibility for the
complete processing of an initial disability claim. The disability
claim manager will be a highly-trained individual who is well-versed in
both the disability and nondisability aspects of the program and has
the necessary knowledge, skills, and abilities to conduct personal
interviews, develop evidentiary records, and adjudicate disability
claims to payment. However, the disability claim manager will also be
able to call on other SSA resources such as medical and technical
support personnel to provide advice and assistance in the claims
process.
The disability claim manager will rely on an automated claims
processing system that will permit the disability claim manager to:
gather and store claims information; develop both disability and
nondisability evidence; share necessary facts in a claim with SSA
medical consultants and specialists in nondisability technical issues;
analyze evidence and prepare well-rationalized decisions on both
disability and nondisability issues; and produce clear and
understandable notices that accurately convey all necessary information
to claimants.
The disability claim manager will be the focal point for claimant
contacts throughout the claim intake and adjudication process. The
disability claim manager will explain the disability program to the
claimant, including the definition of disability and how SSA determines
if a claimant meets the disability requirements. The disability claim
manager will also convey what the claimant will be asked to do
throughout the process; what the claimant may expect from SSA during
this process, including anticipated timeframes for decision; and how
the claimant can interact with the disability claim manager to obtain
more information or assistance. The disability claim manager will
advise the claimant regarding the right to representation and provide
the appropriate referral sources for representation. The disability
claim manager will also advise the claimant regarding community
resources, including the names of organizations that could help the
claimant pursue the claim. The goal will be to give claimants access to
the decisionmaker and allow for ongoing, meaningful dialogue between
the claimant and the disability claim manager.
Claims Intake and Development Will Be Directed at Reaching a Decision
in the Most Timely and Accurate Manner
The disability claim manager will conduct a thorough screening of
the claimant's disability and nondisability eligibility factors. If the
claimant appears ineligible for either disability program based on the
claimant's allegations and evidence presented during the claim intake
interview, the disability claim manager will explain this to the
claimant. If the claimant decides not to file a claim, the disability
claim manager will give the claimant an informal denial notice.
If the claimant decides to file, the disability claim manager will
complete appropriate application screens from the automated claims
processing and decision support system. Impairment-specific questions
will assist the claim manager in obtaining information that is relevant
and necessary to a disability decision. Based on the claimant's
statements and the evidence that is available at that interview, the
disability claim manager will determine the most effective way to
process the claim. If the evidence is sufficient to decide the claim,
the disability claim manager will take necessary action to issue a
decision and, if necessary, effectuate payment. The disability claim
manager will determine what additional evidence is required to
adjudicate the claim and will take steps to obtain that evidence. Such
steps may include asking the claimant to obtain further medical or
nonmedical evidence where feasible, requesting medical evidence
directly from treating sources, or ordering further medical
evaluations.
The disability claim manager will decide whether to defer
nondisability development (e.g., requesting SSI income and resource
information, or developing DI dependents' claims) or do it
simultaneously with development of the disability aspects of the claim.
In making this decision, the disability claim manager will take into
account the type of disability alleged, evidence and other information
presented by the claimant, and other relevant circumstances, e.g.,
terminal illness, homelessness or difficulty in recontacting the
claimant. Because the disability claim manager maintains ownership of
the claim throughout the initial decision-making process, the
disability claim manager will be in the best position to choose the
most efficient and effective manner of providing claimants with timely
and accurate decisions while meeting claimants' individual service
needs.
Although the disability claim manager will be responsible for the
adjudication of an initial claim, the disability claim manager will
call in other staff resources, as necessary. With respect to disability
decisionmaking, the disability claim manager will, in appropriate
circumstances, refer claims to medical consultants to obtain expert
advice and opinion. Similarly, other staff resources will be called
upon for technical support in terms of certain claimant contacts and
status reports; development of nondisability issues including auxiliary
claims or representative payee issues; and payment effectuation.
However, the disability claim manager will make final decisions on both
the disability and nondisability aspects of the claim.
Claimants Will Be Partners in the Processing of Their Disability Claims
Throughout the disability claims process, SSA will encourage
claimants to be full partners in the processing of their claims. To the
extent that they are able, claimants and their families and other
personal support networks will actively participate in the development
of evidence to substantiate their claim for disability benefits. SSA
will provide assistance and/or engage third party resources, when
necessary and appropriate. SSA will keep claimants informed of the
status of their claims, advise claimants regarding what additional
evidence may be necessary, and inform claimants what, if anything, they
can do to facilitate the process.
At the completion of the claims intake interview, the disability
claim manager will issue a receipt to the claimant that will identify
what to expect from SSA and the anticipated timeframes. It will also
identify what further evidence or information the claimant has agreed
to obtain. Finally, it will provide the name and telephone number of
the disability claim manager for any questions or comments which the
claimant may have.
SSA Will Recognize That Some Third Parties Can Develop Complete
Application Packages
Certain third party organizations may be willing to provide a
complete disability application package to SSA. Based on local
management's assessment of service area needs and the availability of
qualified organizations, SSA will certify third party organizations who
are capable of providing a complete application package, including
appropriate application forms and medical evidence necessary to
adjudicate a disability claim. In such claims, SSA will permit the
third party to identify potential claimants, screen for disability and
nondisability criteria, and contact SSA to protect the filing date. The
third party will interview the claimant; complete all applications and
related forms; obtain completed treating source statements; and obtain
additional medical evaluations, when appropriate. Using procedures
agreed on with local management, the third party will submit claims for
adjudication by a disability claim manager. The disability claim
manager may elect to contact the claimant for the purpose of verifying
identity or other claims-related issues, as appropriate. SSA will
monitor such third parties to ensure that quality service is provided
to claimants and to prevent fraud.
Claimants Will Have the Opportunity for a Personal Interview Before SSA
Makes an Initial Disability Denial Decision
When the evidence does not support an allowance, the disability
claim manager will provide the claimant an opportunity for a personal
interview before issuing the initial denial determination. The
interview will be in person, by videoconference, or by telephone, at
the claimant's option and as the disability claim manager determines is
appropriate under the circumstances. In appropriate circumstances, the
predenial interview may follow the initial intake interview. The
purpose of the predenial interview will be to advise the claimant of
what evidence has been considered and to identify what further
evidence, if any, is available that bears on the issues. If such
further evidence exists, the disability claim manager will advise the
claimant to obtain the evidence or, as appropriate, assist the claimant
in obtaining it.
Initial Disability Decisions Will Use a ``Statement of the Claim''
Approach
The initial disability determination will use a ``statement of the
claim'' approach. The statement of the claim will set forth the issues
in the claim, the relevant facts, the evidence considered, including
any evidence or information obtained during the predenial interview,
and the rationale in support of the determination. The statement of the
claim not only reflects the SSA commitment to fully explaining the
basis for its action but also recognizes that claimants need clear
information about the basis for the determination to make an informed
decision regarding further appeal.
Much of the information that will provide the basis for the
statement of the claim will be available on-line as part of the
automated claims processing and decision support system. Adjudicators
will create the statement of the claim and whatever supplementary
information is necessary for a legally sufficient notice to the
claimant based on the information in the decision support system. For
allowance decisions, the statement of the claim will be more
abbreviated than for denial decisions; however, it will contain
sufficient information to facilitate quality assurance reviews and/or
continuing disability reviews. The statement of the claim will be part
of the on-line claim record and will be available to other adjudicators
as the basis and rationale for the Agency action, if the claimant seeks
further administrative review.
Disability Decision Methodology
The Methodology for Deciding Disability Claims Will Promote Consistent,
Equitable, and Timely Disability Decisions
SSA must have a structured approach to disability decisionmaking
that takes into consideration the large number of claims (2.7 million
initial disability decisions in FY 1994) and still provides a basis for
consistent, equitable decisionmaking by adjudicators at each level. The
approach must be simple to administer, facilitate consistent
application of the rules at each level, and provide accurate results.
It must also be perceived by the public as straightforward,
understandable and fair. Finally, the approach must facilitate the
issuance of timely decisions.
The cornerstone of any approach is, of course, the statutory
definition of disability. Under the statute, disability (for adults)
means the: ``* * * inability to engage in any substantial gainful
activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted
or can be expected to last for a continuous period of not less than 12
months * * * An individual shall be determined to be under a disability
only if his physical or mental impairment or impairments are of such
severity that he is not only unable to do his previous work but cannot,
considering his age, education, and work experience, engage in any
other kind of substantial gainful work which exists in the national
economy * * *'' (section 223(d) of the Social Security Act)
The decision-making approach is the foundation on which SSA will
base the claim intake process and evidence collection. The focus will
be, first, to establish a solid medical basis for documenting that an
individual has a medically determinable physical or mental impairment.
Second, once the evidence establishes a medically determinable
impairment, SSA will use additional medical findings to provide a solid
link between the disease entity and the loss of function caused by the
impairment(s).
Disability Decisionmaking for Adult Claims Will Be a Four-Step
Evaluation Process
The disability decision methodology will consist of four steps that
are based on the statutory definition of disability. They are:
Step 1--Is the individual engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2--Does the individual have a medically determinable physical
or mental impairment?
If no, deny.
If yes, continue to Step 3*.
Step 3--Does the individual have an impairment that is included in
the Index of Disabling Impairments?
If yes, allow*.
If no, continue to Step 4.
Step 4--Does the individual have the functional ability to perform
substantial gainful activity?
If yes, deny.
If no, allow*.
*An impairment must meet the duration requirement of the
statute; a denial is appropriate for any impairment that will not be
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
Any individual who is engaging in substantial gainful activity will
not be found disabled regardless of the severity of the individual's
physical or mental impairments. If a claimant is performing substantial
gainful activity at the time a claim is filed, SSA will determine that
the claimant is not disabled based on the demonstrated ability to
engage in substantial gainful activity.
Under the current process, in determining whether a claimant is
performing or has performed substantial gainful activity, SSA generally
considers the amount of the claimant's earnings, less any impairment-
related work expenses. However, there are several threshold levels of
earnings that need to be considered and, depending on the actual amount
earned, SSA evaluates whether a claimant's work is comparable to that
of unimpaired individuals in the community who are doing the same or
similar occupations, or whether the work is substantial gainful
activity based on prevailing pay scales in the community.
Under the new process, SSA will simplify the monetary guidelines
for determining whether an individual (except those filing for benefits
based on blindness) is engaging in substantial gainful activity. In
making this determination, SSA will evaluate the work activity based on
the earnings level that is comparable to the upper earnings limit in
the current process (i.e., $500). A single earnings level will simplify
the evidentiary development necessary to evaluate work activity and
establish the appropriate onset date of disability. SSA will continue
to exclude impairment-related work expenses in evaluating whether a
claimant's earnings constitute substantial gainful activity. SSA will
continue to use separate earnings criteria to evaluate the work
activity of blind individuals as in the current process.
Step 2--Medically Determinable Impairment
Because the statute requires that disability be the result of a
medically determinable physical or mental impairment, the absence of a
medically determinable impairment will justify a finding that the
individual is not disabled.
Under the current regulations, SSA considers, as a threshold
matter, whether an individual has a medically determinable impairment
or combination of impairments that is ``severe.'' A severe impairment
is defined as one that significantly limits the individual's physical
or mental abilities to do work activities such as walking, standing,
sitting, hearing, seeing, understanding, carrying out, or remembering
simple instructions, using judgment, etc.
Under the new approach, SSA will consider whether a claimant has a
medically determinable impairment, but will no longer impose a
threshold severity requirement. Rather, the threshold inquiry will be
whether the claimant has a medically determinable physical or mental
impairment. To establish the presence of a medically determinable
impairment, evidence must show an impairment that results from
anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
SSA will continue to evaluate the existence of a medically
determinable impairment based on a weighing of all evidence that is
collected, recognizing that neither symptoms nor opinions of treating
physicians alone will support a finding of disability. There must be
medical signs and findings established by medically acceptable clinical
or laboratory diagnostic techniques which show the existence of a
physical or mental impairment that results from anatomical,
physiological, or psychological abnormalities which, in the opinion of
the Secretary, could reasonably be expected to produce the symptoms or
substantiate any opinion evidence provided. Depending on the nature of
a claimant's alleged impairments, SSA will consider the extent to which
medical personnel other than physicians can provide evidence of a
medically determinable impairment.
There will be an exception to the requirement that evidence include
medically acceptable clinical and/or laboratory diagnostic techniques.
This will occur when, even if SSA accepted all of the claimant's
allegations as true, SSA still could not establish a period of
disability; under these circumstances, SSA will not require evidence to
establish the existence of a medically determinable impairment. For
instance, if a claimant describes a condition as one that will clearly
not meet the 12-month duration requirement, (e.g., a simple fracture),
SSA will deny the claim on the basis that even if the allegations were
medically documented, SSA could not establish a period of disability.
Step 3--Index of Disabling Impairments
If an individual has a medically determinable physical or mental
impairment documented by medically acceptable clinical and laboratory
techniques, and the impairment will meet the duration requirement, SSA
will compare the claimant's impairment(s) against an index of severely
disabling impairments. In contrast to the Listing of Impairments in the
current regulations, the index will contain fewer impairments and have
less detail and complexity. The index will describe impairments that
will result in death or impairments that are so debilitating that any
individual would be unable to engage in substantial gainful activity
regardless of any reasonable accommodations that an employer might make
in accordance with the Americans with Disabilities Act. The index will
be designed to be equitable, easy to understand, and consistent with
the statutory definition of disability.
The index will function to quickly identify severely disabling
impairments; the index will not attempt to describe ideal medical
documentation requirements for each and every body system as occurs
with the current Listings. The index will consist of descriptions of
specific impairments and the medical findings that are used to
substantiate the existence and severity of the particular disease
entity. The index will not attempt to measure the functional impact of
an impairment on the individual; functional impact will be considered
at Step 4 in the process. The medical findings in the index will be as
nontechnical as possible and will exclude such things as calibration or
standardization requirements for specific tests and/or detailed test
results (e.g., pulmonary function studies or electrocardiogram
tracings). The index will be simple enough so that laypersons will be
able to understand what is required to demonstrate a disabling
impairment in the index. Additionally, SSA will draw no inferences or
conclusions about the effect of a claimant's impairments on his or her
ability to function merely because a claimant's impairment(s) does not
meet the criteria in the index. Finally, SSA will no longer use the
concept of medical equivalence'' in relation to the index, as it now
uses in applying the Listing of Impairments.
Step 4--Ability to Engage in Any Substantial Gainful Activity
In the final step in determining disability, SSA will consider
whether an individual has the ability to perform substantial gainful
activity despite any functional loss caused by a medically determinable
physical or mental impairment. If an individual retains the ability to
perform substantial gainful activity, then an individual does not meet
the statutory definition of disability.
Presently, there are no generally accepted measurement criteria for
determining an individual's ability to function in relation to work-
related activities. Currently, SSA assesses residual functional
capacity by analyzing the objective medical findings and other
available evidence and translating this information into functional
loss and residual capacity for work activities.
Additionally, there are also no definitive sources for identifying
the physical and mental requirements of ``baseline'' work functions
that are required to engage in substantial gainful activity. SSA
currently relies on the Department of Labor definitions regarding the
physical and mental demands of work in the national economy, and relies
on related reference sources and independent experts regarding the
existence of particular occupations and jobs in the national economy.
Under the new process, SSA will define the physical and mental
requirements of substantial gainful activity and, will measure as
objectively as possible whether an individual meets these requirements.
How SSA will achieve this is described in the following sections.
SSA Will Develop Instruments That Provide A Standardized Measure of
Functional Ability
Under the current process, SSA relies on available clinical and
laboratory findings, treating source opinions, the claimant's
description of his or her abilities and limitations, and third party
observations of the claimant's limitations in determining the
claimant's residual functional capacity. Residual functional capacity
is the claimant's remaining capacity for work activities despite the
limitations or functional loss caused by his or her impairments.
Under the new process, SSA will develop, with the assistance of the
medical community and other outside experts from public and private
disability programs, standardized criteria which can be used to measure
an individual's functional ability. These standardized measures of
functional ability will be linked to clinical and laboratory findings
to the extent that SSA needs to document the existence of a medically
determinable impairment that results from anatomical, physiological, or
psychological abnormalities which could reasonably be expected to
produce the functional loss. However, extensive development of all
available clinical and laboratory findings is not necessarily effective
in evaluating an individual's functional ability to perform basic work
activities.
Functional assessment instruments will be designed to measure, as
objectively as possible, an individual's abilities to perform a
baseline of occupational demands that includes the principal dimensions
of work and task performance, including primary physical,
neurophysical, psychological, and cognitive processes. Examples of task
performance include, but are not limited to: Physical capabilities,
such as sitting, standing, walking, lifting, pushing, pulling; mental
capabilities, such as understanding, carrying out, and remembering
simple instructions; using judgment; responding appropriately to
supervisors and co-workers in usual work situations; and responding
appropriately to changes in the routine work setting; and postural and
environmental limitations. Functional assessment instruments will be
designed to realistically assess an individual's abilities to perform a
baseline of occupational demands.
SSA will be primarily responsible for documenting functional
ability using the standardized measurement criteria. In the near term,
SSA will solicit functional information from treating medical sources,
other nonmedical sources, and from claimants in a manner that is
similar to the current process. In the future, the standardized
measurement criteria will be widely available and accepted so that
functional assessments may be performed by a variety of medical
sources, including treating sources. The SSA goal will be to develop
functional assessment instruments that are standardized, that
accurately measure an individual's functional abilities and that are
universally accepted by the public, the advocacy community, and health
care professionals. Ultimately, documenting functional ability will
become the routine practice of physicians and other health care
professionals, such that a functional assessment with history and
descriptive medical findings will become an accepted component of a
standard medical report.
The prospect of universal health coverage may offer a unique
opportunity for SSA to work with the public and private sector to
develop standards that both can use. For example, medical insurance
payors (whether public or private) may want some way of measuring the
effectiveness and necessity of treatment that is prescribed by the
individual's treatment source; SSA will want these same types of
measures to determine how well an individual is able to function
despite his or her impairment(s). Similarly, if all individuals have
treating sources under universal health coverage, SSA can expect that
complete functional assessment measurements will be readily available
from a treating source. Finally, universal health coverage may enable
SSA to access medical records from health care providers who may be
operating under some contractual or other relationship with Federal
agencies and/or a statutory requirement that health care providers
cooperate in providing evidence as a condition of receiving Federal
funds.
SSA will use the results of the standardized functional measurement
in conjunction with a new standard that SSA will develop to describe
basic physical and mental demands of a baseline of work that represents
substantial gainful activity and that exists in significant numbers in
the national economy.
SSA Will Identify Baseline Occupational Demands That Represent
Substantial Gainful Activity
Under the current regulations, after assessing a claimant's
residual functional capacity, SSA evaluates whether the claimant can
meet the physical and mental demands of his or her past relevant work.
Past relevant work is usually work that a claimant performed in the
last 15 years.
If the claimant is unable to perform his or her past work, SSA then
evaluates whether the claimant can perform other work in the national
economy. In making this decision, SSA relies on medical-vocational
guidelines (the ``Grid''). The Grid rules represent major functional
and vocational patterns and reflect the analysis of various vocational
factors (age, education and work experience) in combination with the
claimant's residual functional capacity (which is used to determine the
claimant's maximum sustained work capacity for sedentary, light,
medium, heavy or very heavy work).
In promulgating the Grid rules, SSA has taken administrative notice
of the existence of unskilled jobs that exist in the national economy
at the various functional levels. Therefore, when all the findings of
fact regarding a claimant's functional ability and vocational factors
coincide with the corresponding criterion of a rule, the existence of
other work in the national economy is conclusively established.
However, if any finding of fact does not coincide with the criterion of
a rule, the rules can only provide a framework for decisionmaking. In
these situations, adjudicators must consult vocational resources or
obtain expert testimony to resolve the question of whether other work
exists in the national economy that the claimant can perform.
Under the new approach, SSA will conduct research and, working in
conjunction with outside experts, will specifically identify the
activities that comprise a baseline of occupational demands needed to
perform substantial gainful activity. In the current process, an
example of comparable ``baseline'' criteria are the functional
requirements of unskilled, sedentary work. In establishing the
functional activities that comprise an appropriate baseline of
occupational demands, SSA will ensure that:
(1) The functional activities are a realistic reflection of the
demands of occupations that exist in significant numbers in the
national economy;
(2) The occupations are those that can be performed in the absence
of prior skills or formal job training; and
(3) The baseline of occupational demands that becomes the standard
for evaluating the ability to perform substantial gainful activity
considers any reasonable accommodations that employers are expected to
make under the Americans with Disabilities Act.
The Effect of Age on Ability to Perform Substantial Gainful Activity
The effect of aging on the ability to perform substantial gainful
work is very difficult to measure, especially in the context of today's
world when individuals are living longer than preceding generations.
Despite this change, the demographic characteristics of those preceding
generations continue to provide the framework for disability
decisionmaking because SSA's approach for deciding disability has
changed little since the inception of the DI program.
The statute recognizes that age should be considered in assessing
disability on the assumption that the ability to make a vocational
adjustment to work other than work an individual has previously done
may become more difficult with age. In determining the impact of age,
recognition should be given to the changes that occur with each
succeeding generation. Accordingly, in the new process, SSA will
establish age criterion in relation to the full retirement age. The
full retirement age will gradually increase over time, based on the
recognition that succeeding generations can expect to remain in the
workforce for longer periods than the preceding generation.
In applying age criterion under the new process, an individual who
falls within the prescribed number of years preceding the full
retirement age will be considered as ``nearing full retirement.'' In
establishing what the prescribed number of years should be, SSA will
conduct research and consult with outside experts on the relationship
between age and an individual's ability to make vocational adjustments
to work other than work the individual has done in the recent past.
SSA will rely on the age of the individual in relation to the full
retirement age to decide which of two decision paths to follow as
described in the next two sections.
Individuals Who Are Not Nearing Full Retirement
For an individual who is not nearing full retirement, SSA will
compare the individual's functional abilities against the functional
demands of the baseline work. SSA will no longer rely on the medical-
vocational guidelines and/or expert testimony to identify whether work
exists in the national economy that the claimant can perform. The
ability to perform the baseline work will represent a realistic
opportunity to perform substantial gainful activity that exists in
significant numbers in the national economy and a finding of disability
will not be appropriate.
However, anyone, regardless of age, who cannot perform the baseline
work will be considered unable to engage in substantial gainful
activity, and a finding of disability will be justified. The range of
work represented by less than the baseline will be considered so narrow
that despite any other favorable factors, such as young age or higher
education or training, an individual would not be expected to have a
realistic opportunity to perform substantial gainful work in the
national economy.
For individuals who are not nearing full retirement, the ability or
inability to perform previous work is not a significant factor. These
individuals should be capable of making a vocational adjustment to
other work, as long as they are functionally capable of performing the
baseline work.
Individuals Who Are Nearing Full Retirement
For individuals who are nearing full retirement, SSA will compare
the individual's functional abilities against the functional demands of
the individual's previous work. Individuals nearing full retirement age
can not be expected to make a vocational adjustment to work other than
work they have performed in the recent past. However, consistent with
the statute, if an individual, even one nearing full retirement age, is
capable of performing his or her previous work, SSA will find that the
individual is not disabled.
For those individuals who have no previous work, SSA will compare
the individual's functional abilities to the baseline work, and a
finding of not disabled will be appropriate if the individual is
capable of performing the baseline work. In such claims, the fact that
the individual has no previous work is usually not related to the
existence of his or her impairment(s), and a finding of disability will
not be appropriate for these individuals if they retain the capacity
for the baseline work.
The Effect of Education on Ability to Perform Substantial Gainful
Activity
The statute also recognizes that education may play a role in an
individual's ability to perform substantial gainful activity.
Experience demonstrates that educational level alone, i.e., the
numerical grade level that an individual has attained may not be a good
indicator of ability to function. Education is generally completed in
the remote past when compared to the age at which the majority of
disability claimants file for benefits. Completion of a certain
educational level in the remote past, without any practical application
of that education in recent work activity, has no positive effect on an
individual's ability to perform substantial gainful activity.
In relying on standardized functional assessments, SSA will be
measuring both the individual's physical and mental abilities, and
education will be appropriately reflected in the assessment of an
individual's cognitive abilities. However, further evaluation of a
claimant's educational level will not be required because, in
establishing the functional activities that comprise an appropriate
baseline of occupational demands, SSA will not assume that individuals
have prior skills or significant formal job training. Thus, additional
formal education will have little impact on an individual's ability to
perform the baseline of occupational demands.
SSA Will Rely on Medical Consultants to Provide Necessary Expertise in
the Decisionmaking Process
SSA will continue to rely on medical consultants to provide expert
advice and opinion regarding medical questions and issues that will
arise in deciding disability claims. Disability adjudicators at all
levels of the administrative review process will call on the services
of medical consultants to interpret medical evidence, analyze specific
medical questions, and provide expert opinions on existence, severity
and functional consequences of medically determinable impairments. If a
medical consultant is called on to offer expert advice and opinion, the
medical consultant will provide a written analysis of the issues and
rationale in support of his or her opinion. The written analysis will
be included in the record and will be considered with the other medical
evidence of record by disability adjudicators at all levels of
administrative review. Additionally, medical consultants will assist in
the training of other consultants and disability adjudicators; contact
other health care professionals to resolve medical questions on
specific claims; perform public relations and training with the medical
community; and participate in SSA quality assurance efforts.
Childhood Disability Methodology
As with adults, SSA must have a structured approach to disability
decisionmaking in childhood claims that takes into consideration the
relatively large number of claims and still provides a basis for
consistent, equitable decisionmaking by adjudicators at all levels of
administrative review. The approach for childhood claims must also
derive from the statute. Under the statute,
An individual will be considered to be disabled for purposes of
this title if he is unable to engage in any substantial gainful
activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has
lasted or can be expected to last for a continuous period of not
less than 12 months (or in the case of a child under the age of 18,
if he suffers from any medically determinable physical or mental
impairment of comparable severity). (Section 1614(a)(3)(A) of the
Social Security Act).
Disability Decisionmaking For Childhood Claims Will Be a Four-Step
Evaluation Process
The disability decision methodology for childhood claims will
consist of four steps that are based on the statutory definition of
disability.
As with adults, the approach is one that provides accurate
decisions that can be achieved efficiently and cost-effectively,
primarily by ensuring that documentation requirements are directed
toward the ultimate finding of disability. The four steps are:
Step 1--Is the child engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2--Does the child have a medically determinable physical or
mental impairment?
If no, deny.
If yes, continue to Step 3*.
Step 3--Does the child have an impairment that is included in the
Index of Disabling Impairments?
If yes, allow*.
If no, continue to Step 4.
Step 4--Does the child have the functional ability to perform
activities that are comparable to an adult's ability to engage in
substantial gainful activity?
If yes, deny.
If no, allow*.
*An impairment must meet the duration requirement of the
statute; a denial is appropriate for any impairment that will not be
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
Any child who is engaging in substantial gainful activity will not
be found disabled regardless of the severity of his or her physical or
mental impairments. The guidelines for determining whether a child is
engaging in substantial gainful activity will be identical to the
guidelines for adults. Although the issue of work activity will arise
infrequently in childhood claims, the step is warranted for two
reasons:
(1) The approach for adults and children should be as similar as
possible; and
(2) As a child approaches age 18, it is increasingly likely that
work activity may be an issue.
Step 2--Medically Determinable Impairment
Because the statute requires that disability be the result of a
medically determinable physical or mental impairment, the absence of a
medically determinable impairment will justify a finding that a child
is not disabled. To establish the presence of a medically determinable
impairment, evidence must show an impairment that results from
anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
The same guidelines and rules that apply for adults will apply
equally for children. SSA will continue to evaluate the existence of a
medically determinable impairment based on a weighing of all evidence
that is collected, recognizing that neither symptoms nor opinions of
treating physicians alone will support a finding of disability. There
must be medical signs and findings established by medically acceptable
clinical or laboratory diagnostic techniques which show the existence
of a physical or mental impairment that results from anatomical,
physiological, or psychological abnormalities which, in the opinion of
the Secretary, could reasonably be expected to produce the symptoms or
substantiate any opinion evidence.
SSA will use the same exception for evidence collection in
childhood claims that will be applied in adult claims. If a child has a
medically determinable physical or mental impairment that is not an
exception to further development, SSA will then evaluate whether the
impairment(s) is included in the index of disabling impairments.
Step 3--Index of Disabling Impairments
If a child has a medically determinable physical or mental
impairment documented by medically acceptable clinical and laboratory
techniques and the impairment will meet the duration requirement, SSA
will compare the child's impairment(s) against an index of disabling
impairments. As with adults, the index for childhood claims will
function to quickly identify severely disabling impairments; the index
will not attempt to describe ideal medical documentation requirements
for each and every body system.
The index for childhood claims will consist of descriptions of
specific impairments and the medical findings that are used to
substantiate the existence and severity of the particular disease
entity. As with adults, the childhood index will not attempt to measure
the functional impact of an impairment on the child; functional impact
will be considered at Step 4 in the process. The medical findings in
the index will be as nontechnical as possible and will be simple enough
so that laypersons will be able to understand what is required to
substantiate a disabling impairment in the index. As with adults, SSA
will draw no inferences or conclusions about the effect of a child's
impairments on his or her ability to function merely because a child's
impairment(s) is not included in the index. Additionally, SSA will no
longer use the concept of medical equivalence'' or functional
equivalence in relation to the childhood Index.
Step 4--Comparable Severity to Adult Ability to Engage in Substantial
Gainful Activity
In evaluating disability in adults, SSA will evaluate an
individual's functional ability to perform work-related activities
consistent with the ability to engage in any substantial gainful
activity. The difficulty with evaluating childhood claims is the
standard against which any functional measurement criteria are
compared. For older children, it is relatively easy because at some age
(somewhere between 14 and 18) the standard approaches the adult
standard, i.e., ability to engage in substantial gainful activity.
However, for younger children, the standard can be more difficult to
describe. Under the current process, SSA uses a standard that measures
the degree to which a child engages in age-appropriate activities which
corresponds fairly well with developmental milestones for different age
categories. However, the difficulty with this approach is that it may
not appropriately define how much functional loss or interference with
growth and maturity is comparable to inability to perform any
substantial gainful activity.
Consistent with the adult approach, SSA will develop baseline
criteria for a child's activities that are comparable to an adult's
ability to perform substantial gainful activity. In establishing a
baseline of functional activities, the functional abilities for a child
will represent a realistic comparison to an adult's ability to work.
Functional Assessment Instruments
Consistent with the approach for adult claims, SSA will develop,
with the assistance of the medical community and educational experts,
standardized criteria which can be used to measure a child's functional
ability. These standardized measures of functional ability will be
linked to clinical and laboratory findings to the extent that SSA needs
to document the existence of a medically determinable impairment that
results from anatomical, physiological, or psychological abnormalities
which could reasonably be expected to produce the functional loss.
These functional assessment instruments will be designed to
measure, as objectively as possible, a child's abilities to perform a
baseline of functions that are comparable to the baseline of
occupational demands for an adult. SSA will conduct additional research
to specifically identify activities that are comparable to those that
comprise a baseline of occupational demands needed to perform
substantial gainful activity by adults.
SSA will be primarily responsible for documenting functional
ability using the standardized measurement criteria. Ultimately, the
course of documenting and developing for the functional abilities for
childhood claims will mirror the adult approach.
Comparability Standard
SSA will develop realistic standards which represent activities
that are comparable to an adult's ability to engage in substantial
gainful activity. The standards will focus on a skill acquisition
threshold designed to measure broad areas of skill that are required to
ultimately develop the ability to engage in substantial gainful
activity. If the child is progressing satisfactorily in the development
of these skills, then the child will not have an impairment of
comparable severity and SSA will not find the child disabled.
Evidentiary Development
SSA's Ability To Issue Timely and Accurate Disability Decisions Depends
on the Efficient Collection of Quality Medical Evidence
SSA's ability to provide timely and accurate disability decisions
depends to a significant degree on the quality of medical evidence it
can obtain and the speed with which it can obtain it. The medical
evidence collection process accounts for a considerable portion of the
total time involved in processing disability claims.
Traditionally, the procurement of medical evidence has involved
multiple, often repetitive, requests for information from a variety of
health care providers. Health care providers believe that these
requests burden them with far too much paperwork and offer far too
little in the way of compensation for the time invested. Conversely,
adjudicators often find that this evidence is primarily treatment-
oriented and fails to provide the highly specialized clinical
information required by the current Listings, or the functional
information that is frequently necessary at various points in
disability decision-making process. Health care professionals,
particularly physicians, readily concede that their training is
oriented towards diagnosis and treatment, not the assessment of
function. Thus, the timely collection of medical information depends to
a significant degree on health care providers who have only a
tangential interest and understanding of the disability program, its
requirements, and, most importantly, the vital role that health care
providers' information has in the disability decision process.
Evidence Collection Will Focus on Core Diagnostic and Functional
Information Necessary to a Disability Decision
The goals of the evidence collection process will be to focus
requests for evidence on the critical diagnostic and functional
assessment information necessary for a disability decision and to form
a new partnership with the sources of this information so that it can
be obtained in the most efficient, cost-effective manner. Medical
evidence development will be driven by the four-step approach SSA will
use to decide disability. Two of the core elements of that approach
are: (1) Identifying an individual's medically determinable impairments
(including those that meet the Index of Disabling Impairments
criteria); and (2) assessing the functional consequences of those
impairments. SSA will develop medical evidence that is sufficient to
satisfy the core elements but target evidentiary development so that
SSA obtains only the evidence that is necessary to reach an accurate
decision on the ultimate question of disability.
Treating Sources Will be the Preferred Sources for Medical Evidence
SSA will give primary emphasis to obtaining medical information
from treating sources by way of brief, but specific, diagnostic
information regarding an individual's medically determinable
impairments and the functional consequences of those impairments.
Treating source statements will include diagnostic information about a
claimant's impairments, the clinical and laboratory findings which
provide the basis for the diagnosis, onset and duration, response to
treatment, and the functional limitations that can reasonably be linked
to the clinical and laboratory findings. SSA will develop, in
conjunction with the appropriate health care professionals and other
public and private disability programs, standardized criteria which can
be used to measure, as accurately and objectively as possible, an
individual's functional ability. SSA will also seek health care
providers' assistance in educating the medical community on the
clinical application of these instruments. Once developed and
universally accepted as the appropriate standard by the medical
community, the standardized measurement criteria will be widely
available. If a standardized functional assessment is available from a
treating source, SSA will obtain that information and accept it as
probative evidence. SSA may also request that the treating source or
another examining source perform the standardized functional assessment
at SSA expense.
SSA Will Use a Standardized Form To Request Medical Evidence From
Treating Sources
SSA will develop a standardized form which effectively tailors the
request for evidence to the specific diagnostic and functional
assessment information necessary to make a disability decision. The
standard form will also be available in electronic form to permit
treating sources to submit evidence electronically. Standardizing
requests for evidence in this manner will facilitate the participation
of claimants, representatives and third parties in the evidence
collection process.
The form will permit treating sources to provide necessary
diagnostic and functional assessment information on a single document.
In appropriate circumstances, SSA will accept a treating source's
statement on the standardized form as to these issues without resorting
to the traditional, wholesale procurement of actual medical records.
Depending on the nature and extent of an individual's impairments and
treating sources, statements from multiple medical sources may be
appropriate. In completing standard forms, treating sources will
certify that they have in their possession the medical documentation
referred to in the statement and that said documentation will be
promptly submitted at the request of SSA. The certification approach is
consistent with evidence collection methods used by private disability
insurance carriers, which request specific medical records in
individual claims, as appropriate to the individual circumstances, or
at random as part of a quality assurance program. SSA will monitor
treating source completion of the standardized forms and verify
evidence when appropriate.
SSA Will Provide Incentives for Treating Sources To Cooperate in the
Development of Medical Evidence
SSA will acknowledge the value of treating source information by
establishing a national fee reimbursement schedule for medical
evidence. Additionally, the fee reimbursement schedule will utilize a
sliding-scale mechanism to reward the early submission of medical
information. A national, sliding-scale fee schedule will provide
incentives for treating sources to cooperate in the evidentiary
development process and invest quality time to provide medical
certifications on behalf of their patients.
SSA will focus professional educational efforts and medical
relations outreach at the local and/or regional level to ensure that
treating sources are kept informed of program requirements and made
aware of specific evidentiary needs or problems as they arise in the
adjudication process.
SSA Will Use Consultative Examinations When There is No Treating Source
Able or Willing To Provide Necessary Evidence or There Are Unresolved
Conflicts in the Record
If a claimant has no treating source, or a treating source is
unable or unwilling to provide the necessary evidence, or there is
conflict in the evidence that can not be resolved through evidence from
treating sources, SSA will refer the claimant for an appropriate
consultative examination. Because the standardized measurement criteria
for assessing function will be widely available, consulting sources
will be able to perform functional assessments that, in the absence of
adequate treating source information or where there are unresolved
conflicts in the evidence, will be considered probative evidence.
Depending on the service area, SSA will consider contracting with large
health care providers to furnish consultative examinations for a
specified geographic location.
As part of an ongoing training and medical relations program, SSA
will ensure that providers of consultative examinations are provided
adequate training on disability requirements, both initially and as
program changes occur.
Administrative Appeals Process
The Administrative Appeals Process Will Be Simple and Accessible and
Maintain Public Confidence in the Integrity of the Process
The administrative appeals process will be simplified to increase
the accessibility of the process. The public perceives multiple,
mandatory appeal steps as obstacles to receiving timely, fair, and
accurate decisions. SSA will reduce the number of mandatory appeals
steps in the administrative process. Streamlining the appeals process
in this manner will not only promote more timely decisions but also
ensure that claimants do not inappropriately withdraw from the claims
process based on a perception that it is too difficult or time-
consuming to pursue their appeal rights.
Claimants will be able to fully participate in the administrative
appeals process with or without a representative. SSA will ensure that
claimants are fully advised of their right to representation and SSA
will routinely provide the appropriate referral sources for
representation. SSA will also encourage the early participation of a
representative when the claimant has appointed one and will give the
representative responsibility for developing evidence necessary to
decide a claim. However, the decision whether to appoint a
representative must remain with the claimant and SSA will neither
encourage nor discourage claimants in seeking representation.
The administrative appeals process will function so that it
maintains the public's confidence in the integrity of the system. To
instill such confidence, SSA will provide an initial decisionmaking
process that is thorough and results in fully developed records with
fair and accurate decisions. Additionally, SSA will explain the basis
of a decision in clear and understandable language. Finally, SSA will
ensure that disability claims are decided on the merits of the evidence
and that SSA regulations and policies have been consistently applied at
all levels of administrative review.
As noted previously, the initial disability determination will use
a ``statement of the claim'' approach which will set forth the issues
in the claim, the relevant facts, the evidence considered, including
any evidence or information obtained during the predenial interview,
and the rationale in support of the determination. The statement of the
claim will be part of the on-line claim record and will stand as the
basis and rationale for the Agency action, if the claimant seeks
further administrative review. SSA will standardize claim file
preparation and assembly, including the use of appropriate electronic
records, at all levels of administrative process until such time as the
claims record is fully electronic.
The Next Level of Administrative Appeal Will Be an Administrative Law
Judge Hearing
Because the initial determination will be the result of a process
that ensures fully developed evidentiary records and ample opportunity
for the claimant to personally present additional evidence prior to an
adverse determination, there will be no need for any intermediate
appeal (e.g., reconsideration) prior to the administrative law judge
(ALJ) hearing. If the claimant disagrees with the initial
determination, the claimant may, within 60 days of receiving notice,
request an ALJ hearing.
An Adjudication Officer Will Conduct All Prehearing Proceedings
If a claimant decides to request an ALJ hearing, an adjudication
officer will conduct an interview in person, by telephone, or by
videoconference, and become the primary point of contact for the
claimant. The adjudication officer will have the same knowledge, skills
and abilities as the adjudicators who decide claims initially. The
adjudication officer will also have specialized knowledge regarding
hearings and appeals procedures. The adjudication officer will be the
focal point for all prehearing activities but will be expected to work
closely with the ALJ, medical consultants and the disability claim
manager, when appropriate. The adjudication officer will explain the
hearing process; advise the claimant regarding the right to
representation; provide the appropriate referral sources for
representation; give the claimant, where appropriate, copies of
necessary claim file documents to facilitate the appointment of a
representative; and encourage the claimant to decide about the need for
and choice of a representative as soon as is practical.
The adjudication officer will also identify the issues in dispute
and whether there is a need for additional evidence. If the claimant
has a representative, the representative will have the responsibility
to develop evidence. The adjudication officer will also conduct
informal conferences with the representative, in person or by
telephone, to identify the issues in dispute and prepare written
stipulations as to those issues not in dispute. If the claimant submits
additional evidence, the adjudication officer may refer the claim for
further medical consultation, as appropriate. The adjudication officer
will have full authority to issue a revised favorable decision if the
evidence so warrants. If the adjudication officer issues a favorable
decision, the adjudication officer will refer the claim back to the
disability claim manager to effectuate payment.
The adjudication officer will consult with the ALJ during the
course of prehearing activities, as necessary and appropriate to the
circumstances in the claim. As a preliminary matter, the adjudication
officer will also set a date for the hearing that is 45 days after the
hearing request. The adjudication officer may exercise discretion in
establishing an earlier or later hearing date depending on the
individual circumstances. Electronic access to ALJs' calendars will
facilitate timely scheduling of hearings. The adjudication officer will
refer the prepared record to an ALJ only after all evidentiary
development is complete and the claimant or a representative agrees
that the claim is ready to be heard.
The ALJ will retain the authority and ability to develop the
record. However, use of an adjudication officer realigns most, if not
all, prehearing activities so that the burden of ensuring their
completion rests with other members of the adjudicative team. ALJs'
primary function will be hearing and deciding claims.
The Administrative Law Judge Hearing Will be a De Novo, Nonadversarial
Proceeding
The ALJ hearing will be a de novo proceeding in which the ALJ
considers and weighs the evidence and reaches a new decision.
A de novo hearing is consistent with the role of an ALJ envisioned
under the Administrative Procedure Act. Under that scheme, the ALJ is
an independent decisionmaker who must apply an agency's governing
statute, regulations and policies, but who is not subject to direction
and control by the agency with respect to the decisional outcome in any
individual claim. ALJs are independent triers of fact who perform their
evidentiary factfinding function free from agency influence. At the
same time, the Administrative Procedure Act ensures that an ALJ's
decision is subject to review by the agency, thus giving the agency
full power over policy. Policy responsibility remains exclusively with
the agency while the public has assurance that the facts are found by
an official who is not subject to agency influence.
A hearing before an ALJ will remain an informal adjudicatory
proceeding as it is under the current process. The claimant will have
the right to be represented by an attorney or a non-attorney with the
decision regarding representation made by the claimant alone. An
informal, nonadversarial proceeding is consistent with the public's
strong preference for a simple, accessible hearing process that
permits, but does not require, an attorney. An informal process
facilitates the earlier and faster resolution of the issues in dispute,
thus promoting more timely decisions.
As an independent factfinder in a nonadversarial proceeding, the
ALJ will still have a role in protecting both SSA interests and the
claimant's interests, particularly when the claimant is unrepresented.
However, an improved initial determination process with its focus on
early and comprehensive evidentiary development, predenial personal
conferences, fully rationalized initial decisions, and prehearing
analysis of contested issues should ensure that the Agency position is
fully explored and presented to the ALJ. Moreover, the primary burden
of compiling an evidentiary record will be shifted to the
representative--if one is appointed--or to the claimant (when able to
do so), with assistance (when appropriate), from SSA personnel.
Adjudication officers and other decision writers will assist ALJs
in preparing hearing decisions, using the same decision support system
that supports the preparation of initial disability determinations. A
simplified disability decisional methodology, in conjunction with the
use of prehearing stipulations that frame the issues in dispute, will
result in shorter, more focused hearing decisions. If the ALJ issues a
favorable decision, he or she will refer the claim back to the
disability claim manager to effectuate payment.
The Administrative Law Judge Decision Will Be the Final Decision of the
Secretary Subject to Judicial Review Unless the Appeals Council Reviews
the Administrative Law Judge Decision On Its Own Motion
Under the new process, if a claimant is dissatisfied with the ALJ's
decision, the claimant's next level of appeal will be to Federal
district court. A claimant's request for Appeals Council review will no
longer be a prerequisite to seeking judicial review.
As under the current process, the Appeals Council will continue to
have a role in ensuring that claims subject to judicial review have
properly prepared records and that the Federal courts only consider
claims where appellate review is warranted. Accordingly, the Appeals
Council, working with Agency counsel, will evaluate all claims in which
a civil action has been filed and decide, within a fixed time limit
whether it wishes to defend the ALJ's decision as the final decision of
the Secretary. If the Appeals Council decides to review a claim on its
own motion, it will seek voluntary remand from the court for the
purpose of affirming, reversing or remanding the ALJ's decision.
Favorable Appeals Council decisions will be returned to the disability
claim manager to effectuate payment.
Additionally, the Appeals Council will have a role in a
comprehensive quality assurance system. As part of this system which is
described in greater detail below, the Appeals Council will also
conduct its own motion reviews of ALJ decisions (both allowances and
denials) prior to effectuation. If the Appeals Council decides to
review a claim on its own motion, the Appeals Council may affirm,
reverse or remand the ALJ's decision. The Appeals Council's review will
be limited to the record that was before the ALJ.
Quality Assurance
Quality Assurance Will be a System of Agency Accountability
SSA will be accountable to the public, the ultimate judge of the
quality of SSA service, and SSA will strive to consistently meet or
exceed the public's expectations. SSA will have a comprehensive quality
assurance program that defines its quality standards, continually
communicates them to employees in a clear and consistent manner, and
provides employees with the means to achieve them. SSA will devote
resources to building quality into the system of adjudication to ensure
that the right decision is made the first time. SSA will also
systematically review the quality of the overall system of adjudication
to ensure the integrity of the administrative process and promote
uniform application of agencies policies nationally. Finally, SSA will
measure customer satisfaction against the SSA standards for service.
Ensuring That the Right Decision is Made the First Time Requires an
Investment in Employees
SSA's ability to ensure that the right decision is made the first
time depends on a well-trained, competent, and highly motivated
workforce that has the program tools and technological support to issue
quality decisions.
SSA will make an investment in comprehensive employee training to
ensure that employees have the necessary knowledge and skills to
perform the duties of their positions. SSA will develop national
training programs for initial job training and orientation as well as
continuing education to maintain job knowledge and skills. Such
training will include general communication skills and how to deal
effectively with the public generally, and disability claimants in
particular. National training programs will also address changes to
program policy.
In addition to initial program training, continuing education
opportunities will be made available to employees to enhance current
performance or career development. These opportunities may be in the
form of self-help instruction packages, videotapes, satellite
broadcasts, or non-SSA training or educational opportunities. SSA will
ensure that employees are given sufficient time and opportunity to
complete the required continuing education. Employees will be
encouraged to provide feedback on the value of these continuing
education opportunities, including the quality of training materials,
methods, and instructors.
Employees, other than ALJs (because of Administrative Procedure Act
limitations), who complete initial training and pass a set of
performance evaluations based on national quality standards will
receive a certificate of competence. This certificate will attest that
the employee has successfully completed both initial training and a
probationary period on the job. Certification will be renewed yearly
upon successfully completing required training and having no less than
a fully satisfactory performance rating. Those employees not certified
initially or renewed will be provided an improvement plan with goals
and time targets for improved performance.
In addition to formal program training, SSA will rely on a
streamlined and targeted system of in-line quality reviews and
monitoring of adjudicative practices. The elements include a mentoring
process for new employees and peer review for experienced employees.
SSA will encourage peers to discuss difficult claims or issues and
resolve them informally whenever possible. Peer reviews and mentoring
will not only promote timely and accurate development of disability
claims, but will also foster a spirit of teamwork. They will also
promote earlier identification and resolution of problems with policy
or procedures. As part of this process, managers will be expected to
oversee the adjudication process. They will conduct spot checks at key
points in the adjudication process or perform special reviews based on
profiles of error-prone claims. The goal of these reviews is to provide
immediate, constructive feedback on identified errors to reduce or
eliminate their possible recurrence.
To ensure that adjudicators have the necessary program tools to
issue accurate decisions, SSA will use a single mechanism for the
presentation of all substantive policies used in determining
eligibility for benefits. Additionally, an integrated claims processing
system will provide the necessary technological support for
adjudicators at all levels of the administrative process. Among other
things, the claim processing system will facilitate the preparation of
accurate decisions by providing on-line editing capacity to identify
errors in advance and decision support software to assist in analysis
and decisionmaking.
Although comprehensive employee education and an in-line review
system will build quality into the system of adjudication with the goal
of error prevention, SSA must still monitor quality on a systematic,
national basis. Accordingly, all employees will be subject to and
receive continuous feedback from comprehensive end-of-line reviews as
described in the following section.
Quality Measurement Will Focus on Comprehensive End-of-Line Reviews
Another component of quality assurance is an integrated system of
national postadjudicative monitoring to ensure the integrity of the
administrative process and to promote national uniformity in the
adjudication of disability claims. This system will include
comprehensive review of the whole adjudicatory process including both
disability and nondisability issues, allowances and denials, and at all
levels of decisionmaking. The review will focus on whether accurate
decisions were made at the first possible step in the process. This
type of review will not be aimed at correcting errors in individual
claims but, rather, will be the means to oversee, monitor and provide
feedback on the application of agency policies at all levels of
decisionmaking. Reliance on an integrated claim processing system will
facilitate the selection of a statistically valid sample of claims for
this review.
SSA will use the results from these end-of-line reviews to identify
areas for improvement in policies, processes or employee education and
training. SSA will also use the results to profile error-prone claims
with the goal of preventing errors at the front end.
SSA Will Conduct Surveys to Measure Customer Satisfaction
To measure whether SSA has met or exceeded the public's service
expectations, SSA must measure their level of satisfaction with the
level of service SSA provides. Customer surveys and periodic focus
groups will be the most frequently used methods of determining the
public's views on the quality of SSA service. SSA will also survey
representatives and third parties who provide assistance or act on
claimants' behalf in dealing with SSA. Survey results will be
communicated to staff on a timely basis, both as Agency feedback and
individual feedback, along with any plans to address identified
problems.
SSA will also seek employee feedback on how well SSA has met their
expectations. Employee feedback will be sought on a wide array of
issues including Agency goals and performance indicators, training and
mentoring needs, and the quality of operating instructions. Although
formal mechanisms will be used to obtain feedback periodically, each
employee will be encouraged to provide continuous feedback on how to
make improvements in the process.
Measurements
SSA Will Measure Disability Service From the Perspective of the
Claimant
SSA's management information will be revised to assess the
performance of the Agency as a whole in providing service to claimants
for disability benefits. Management information regarding the
contributions at each step in the process to the final product, as well
as to the work product passed on to other steps will be available. For
example, current component processing time measures will be replaced by
a measure of time from the first point of contact with SSA until final
claimant notification. Meaningful, timely management information will
be facilitated by a seamless claim processing system with a common
database that is used by all individuals who contribute to each step in
the process.
Other measures, such as cost, productivity, pending workload, and
accuracy will be developed or revised to assess the performance of the
Agency as a whole and the participants in the process who contribute to
this performance. Measurements for public awareness, as well as
claimant and employee satisfaction will add to this assessment.
New Process Enablers
Reengineering is dependent upon a number of key factors that
provide the framework for the new process design. Each of these
enablers'' is an essential element in the new disability determination
process.
Process Unification
Under the Social Security Act, the Secretary has been granted broad
authority to promulgate regulations to govern the disability
determination process. In addition to the regulations, SSA publishes
Social Security Rulings and Acquiescence Rulings. Social Security
Rulings are precedential court decisions, policy statements, and policy
interpretations that SSA has adopted as binding policy. Acquiescence
Rulings explain how a decision by a U.S. Court of Appeals will be
applied when the court's holding is at variance with the Agency's
interpretation of a provision of the statute or regulations.
These source documents provide the basic framework for the policies
that regulate eligibility for benefits. Administrative law judges (ALJ)
and the Appeals Council use these source documents in making disability
decisions. However, they are not directly used by decisionmakers at the
first two levels of the process, i.e., initial and reconsideration
determinations. Guidance for these decisionmakers is provided in a
series of administrative publications specifically designed for and
aimed at the audiences responsible for adjudicating these claims.
The Program Operations Manual System instructions provide the
substance of law, regulations, and rulings for adjudication issues in a
structure format that does not necessarily repeat the wording of the
source documents for field offices, State disability determination
services (DDS), the processing centers, and quality assurance
reviewers. The Program Operations Manual System is supplemented by
other administrative issuances to clarify or elaborate specific policy
issues. The Program Operations Manual System also provides basic
operating instructions to the initial, reconsideration and quality
components responsible for processing claims. The Hearings, Appeals,
and Litigation Law Manual provides operating instructions and summaries
of court decisions to hearing offices and the Appeals Council.
Neither the Program Operations Manual System or the Hearings,
Appeals, and Litigation Law Manual is binding on ALJ decisionmaking
because this material is not considered Agency policy under the
Administrative Procedures Act. Only those regulations and
interpretative rulings published in the Federal Register, in accordance
with the Administrative Procedures Act guidelines, can be binding on
ALJs. Other decisionmakers are bound by interpretative guidance in the
Program Operations Manual System and supplemental issuances. This
situation fosters the perception that different policy standards are
used at different levels of decisionmaking in the claims process.
SSA will develop a single presentation of all substantive policies
used in the determination of eligibility for benefits. All
decisionmakers will be bound by these same policies. These policies
will be published in accordance with the Administrative Procedures Act.
In addition, to facilitate the flow of work in the new process, a
single operating manual will be developed.
Public and Professional Education
Public and professional education is essential for the proper
understanding of and participation in the disability claims process.
The goal is to ensure that those individuals and groups involved in the
disability process have a better understanding of SSA disability
programs, their medical and nonmedical requirements, and the nature of
the decisionmaking process.
SSA will make information widely available for the general
population. Pamphlets, factsheets, posters, videos, information on
diskettes and on computer bulletin board systems will be developed.
This information will be written in a simple, straight forward and
understandable manner. It will be available in many languages and
dialects and will accommodate vision and hearing impaired individuals.
Videotapes will be available to show in SSA offices, welfare offices
and in places where medical care is provided. It will explain the
definition of disability, stressing the durational and level-of-
severity requirements while giving real life examples. Insured status
requirements for SSA disability insurance (DI) and income and resource
limitations for supplemental security income (SSI) will be explained in
general terms.
This same information will be distributed to third parties who may
be referral sources for disability claims. It will serve to provide
them with basic information about medical and nonmedical eligibility
criteria and the options available for filing claims.
SSA will work with nationally and locally interested and involved
groups to develop direct lines of communications about the disability
process and program. These efforts will not be limited to providing
information, but will include opening and maintaining a dialogue about
the disability process as part of an ongoing organizational
relationship.
Professionals who work with the disabled population will require
more detail. The current ``Understanding SSI'' booklet will be enhanced
to include more information on the disability aspects of the SSI
program--including the requirements and process, as well as the options
available to claimants or interested third parties to speed up the
process. A similar booklet for the DI program will be developed. These
booklets will serve as training manuals and reference tools, and will
include information and examples about providing functional
assessments. Special efforts will be made to have coverage of these
booklets included in courses which are part of a social service
delivery curriculum at the post-secondary and graduate levels.
SSA will conduct outreach efforts with the legal community, to
ensure that information about the disability programs is widely
available to the organized bar and the Federal judiciary. Policy
documents, regularly updated electronically, and rules of
representation will be available at forums sponsored by the organized
bar and in initial orientation and continuing legal education programs
designed for Federal judges.
Treating physicians, medical providers and other treating
professionals need up-to-date information on medical evidence
requirements. SSA will conduct educational outreach with the medical
community to provide them with a better understanding of the SSA
disability programs, the medical and functional requirements for
eligibility, and the best ways to provide medical information needed
for decisionmaking. In addition to the use of printed materials, SSA
will arrange briefings and training sessions in association with
medical organizations and societies at the local, State and national
levels, as well as through hospital staff meetings.
Those medical providers who conduct consultative examinations for
SSA will need ongoing training regarding changes in the disability
program. SSA will prepare training programs for this audience which
will utilize written, audiotape, videotape, and computerized training
methods.
Claimant Partnership
As part of their partnership with SSA, claimants will be encouraged
to actively participate at all levels of the adjudication process and
will be fully informed of their rights and responsibilities. SSA's
interaction with claimants will facilitate claimant responsibility and
active participation in the processing of their claims. The resources
of interested and capable third parties will be garnered to assist
claimants and SSA in fulfilling their partnership responsibilities.
The majority of claimants are able to complete simple forms, attend
appointments, and obtain medical and nonmedical documentation, either
on their own or with the assistance of third parties. Other claimants
are unable to accomplish some of these tasks, even with the assistance
of third parties. Still others have substantial difficulty fulfilling
any of these tasks, and may have no third party to assist them. Given
the range of claimant capabilities, SSA will retain ultimate
responsibility for development of claims when claimants are not
formally represented.
What SSA Will Do
SSA's interaction with claimants will focus on enabling their
participation in the process. Understandable public information
materials and application packets will be widely available.
Explanations of the program, the process, and claimant responsibilities
will be furnished at the point individuals first make contact with SSA.
SSA will also work with third parties, such as family members and
community-based organizations, to provide additional claimant support.
In addition, SSA will provide ongoing assistance and appropriate
status information throughout the process. The opportunity for personal
contact with the disability claim manager will be afforded to each
claimant prior to the issuance of an initially unfavorable decision. A
claimant will be advised of evidence that has been considered in making
the disability determination and provided an opportunity to present
additional evidence for consideration.
Claimants will be provided the opportunity to fully participate in
the appeals process. Decision rationales, appeal rights, and
representation rights will be explained in clear, understandable
language.
What Claimants Will Do
Early, ongoing dialogue between claimants and SSA will ensure that
claimants have access to information and resources they need to
actively pursue their claims and make informed choices.
Claimants will be asked to do more to facilitate development of
supporting information when they are able, particularly with respect to
medical evidence. When they file for disability benefits, claimants
having had medical treatment will be asked to request that their
treating sources complete standardized forms. Information about this
requirement will be publicized in the general community and given to
claimants and third parties when they first contact SSA. Third parties
will be encouraged to assist claimants who are unable to fulfill this
obligation on their own. However, when necessary, a disability claim
manager will assist claimants in obtaining evidence.
To encourage the release of evidence by treating medical sources,
SSA will network with the treating source community to overcome the
lack of understanding and possible resistance to providing patient
information. SSA will develop fax, E-mail, and other electronic means
for physicians to provide direct certification information.
There will be situations where claimants have no treating sources,
or where treating sources provide insufficient medical evidence to make
a disability determination. SSA will work with willing treating sources
and other medical providers to assist in developing medical evidence
(including testing and examination) in these circumstances.
SSA will encourage private insurers and public agencies that refer
claimants to SSA as a condition of receiving other benefits to provide
medical evidence for these individuals.
Claimants will be able to fully participate in the appeals process
with or without a representative. During the appeal process, claimants
and/or their representatives will have primary responsibility for
compiling an evidentiary record. SSA will provide appropriate
assistance for unrepresented claimants.
Assistance to Claimants
Many claimants today rely on other individuals; private and public
organizations; and for-profit and nonprofit organizations to pursue
their claims. Although they assist claimants, these individuals and
organizations do not serve as official representatives. In most
instances, those who assist in the process have the best interests of
the claimant in mind. However, some individuals and organizations have
been instrumental in attempts to defraud programs or take unfair
advantage of claimants. In the future, SSA will develop ongoing
relationships with community organizations to ensure that competent
third-party resources are available to assist the claimants.
Examples of resources that SSA will help develop include:
--Transportation and escort services for indigent claimants and those
who experience difficulty in getting to consultative examinations. This
would include a combination of volunteer services and reimbursement for
transportation on a contract basis. These services will be immediately
available as the need dictates.
--Enhancement of medical provider capacity to identify potentially
eligible patients, secure claims and provide medical evidence. This
type of activity has been successfully demonstrated through the use of
seed monies from SSA in the SSI outreach program. An additional
financial benefit to the providers will be realized through concurrent
Medicaid eligibility for patients.
--Software with compatible format design which will allow direct input
of claims-related information to SSA. This will be available to
claimant advocates and medical providers ensuring the rapid and
accurate transmission of information. After a certification process,
eligible users will be kept apprised of software, procedural, and
policy changes. SSA will perform ongoing document verification to
ensure the integrity of claims submitted by such users.
SSA will have an ongoing demonstration program that provides funds
for truly innovative projects that test models for national
implementation.
In order to expedite the referral of potentially eligible
individuals, SSA will develop productive working relationships with
Federal, State and local programs that serve individuals with
disabilities. While eligibility requirements vary significantly for
programs such as Food Stamps, Aid to Families with Dependent Children,
General Assistance, foster care and adoption assistance, and Veterans
Benefits, effective working relationships can be built around
agreements that expand sharing of authorized information and awareness
of program requirements.
Other programs will be able to use SSA-developed decisional support
systems to evaluate potentially eligible persons prior to referral.
This information will be transferred to SSA through compatible
databases. To further enhance these relationships, disability claim
managers will be available in remote locations, such as Department of
Veterans Affairs homeless program sites, where the workload warrants
their presence. With appropriate information available at these sites,
the on-site disability claim manager will be able to complete the
entire initial application process, with access to other program
experts through information systems. Local managers will be encouraged
to develop and maintain appropriate working relationships with local
Federal, State and third-party resources.
The Payoff Will be Greater Customer Satisfaction
Active participation by claimants, supported by SSA's efforts and
the contributions of third parties will result in a fundamental shift
in claimant expectations and satisfaction with the SSA disability
process. From the SSA perspective, the results will be better service
to customers through timely, fully supported decisions rendered at all
decisional levels; better use of SSA resources focused on helping those
who need assistance; and greater public confidence in the disability
adjudication process.
Workforce Maximization
Teamwork
The teamwork concept is a fundamental ingredient in the new
process. The disability claim manager will be the focal point at the
initial claim level, assisted by technical and medical support staff.
The adjudication officer will be the focal point at the prehearing
level, relying on technical and medical support staff, as well as
interacting with the disability claim manager and the administrative
law judge (ALJ), as necessary. The ALJ will be the focal point at the
hearing level, receiving support from technical and medical support
staff, and also interacting with the adjudication officer and
disability claim manager, as necessary.
Each team member will have at least a basic familiarity with all
the steps in the process and an understanding of how he/she complements
another's efforts. Everyone will achieve a greater sense of
participation, closure, and accomplishment because of shared
responsibility for performing the whole process. Team members will
maintain ownership of the process and the outcomes. The teams will
function effectively and efficiently because:
--All members will have electronic access to the claim throughout the
process and thus be better able to engage in meaningful discussions
with the claimant.
--Handoffs, rework, and non-value steps will be significantly reduced
and fewer employees will be involved in shepherding each claim through
the process. This will enhance SSA's capacity to provide world-class
service by allowing employees to devote more time to each claimant,
providing more personalized service.
--Team members will be knowledgeable but will also be able to draw upon
each other's expertise on complex issues.
--Improved automated systems will enable members of the team to work
together using a shared data base even when they are not co-located.
--Communication between team members and other disability claim
managers will encourage consistent application of disability policy.
--Customer service is the primary focus at all steps of the process and
an integral part of the teams' goals. This focus and commitment will
increase claimant satisfaction.
--Team members will work closely with social service and medical/
professional agencies and advocacy groups in the service area to
improve their ability to obtain the necessary medical and functional
information to appropriately evaluate disabling conditions.
--Varying levels of job complexity will provide the opportunity for
personal development, growth, and learning.
Disability Claim Managers
Disability claim managers will be responsible for intake of DI and
SSI disability/blindness benefit claims, development of all evidence
(medical and nonmedical) required to adjudicate those claims, final
adjudication of claims, ongoing communication with claimants, and
issuance of notices and/or payment actions. In carrying out these
responsibilities, disability claim managers will work in a team
environment with medical and nonmedical experts who provide advice and
assistance with complex case adjudication, as well as support personnel
who handle more routine aspects of case development and payment
effectuation. Tasks will be facilitated by a fully automated intake
process, developmental and decisional expert system applications,
personalized automated notices, and automated payment computations.
Disability claim managers will be able to:
--Provide claimants with current and accurate information about their
claims;
--Anticipate documentation needs and eliminate development that is not
necessary in favorable determinations;
--Eliminate time lost and rework caused by frequent handoffs and
queues;
--Access expert advice through shared databases, thus eliminating the
need to transfer files;
--Provide claimants with complete information if their claims are
proposed for denial and enhance claimants' ability to rebut such
outcomes easily and early in the process; and
--Effectuate payment quickly, thus avoiding the need for recontacts and
verification of nondisability factors of eligibility.
Adjudication Officers
Adjudication officers will be responsible for claims from the point
of receiving hearing requests until they are ready to be heard by ALJs.
In carrying out their responsibilities, adjudication officers will work
in a team environment with medical and nonmedical experts, requesting
advice and counsel from ALJs as necessary.
Adjudication officers will be able to:
--Address the claimants' questions and concerns regarding their claims;
--Identify and discuss issues in dispute with claimants and determine
the need for additional evidence. If the claimant is represented,
conduct personal conferences with the representative and prepare
written stipulations as to those issues not in dispute;
--Review claim records prior to hearings and issue revised decisions if
additional information or evidence so warrants or refer claims for
medical consultation; and
--Take responsibility for all evidentiary development and refer
prepared records to the ALJs.
Administrative Law Judges
Administrative law judges (ALJ) will be responsible for hearing and
deciding appeals. ALJs will receive support from technical and medical
personnel, including decision writers. ALJs will also work with
adjudication officers and disability claim managers as necessary.
ALJs will be able to:
--Review and focus on fully developed claims records prior to hearings;
--Deal with claimants who have already made informed decisions
regarding representation before they appear at hearings; and
--In most circumstances, close the record at the conclusion of
hearings, deliberate on issues and render prompt decisions.
BILLING CODE 4190-29-P
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Workforce Enrichment/Empowerment
The work in the new process will raise job satisfaction and
increase employee skills in the following way:
Employees involved with the initial level of claims will perform
multiple tasks instead of singular activities, thus their roles will
expand to encompass more of the ``whole'' job. This increases the sense
of accomplishment as employees experience the direct relationship
between their actions and the final product. Those at the prehearing
step will also be able to do more of the ``whole'' job, including
taking action to allow claims much earlier in the process. For medical
consultants and ALJs, tasks will be eliminated that are not
commensurate with professional skill levels. Employees will feel more
of a sense of ownership for the services they perform as a member of a
team focused on serving claimants.
Entry level positions will be developed in which employees work as
part of the team while gaining experience and qualifying for greater
responsibility. Adequate resources and sufficient training and
mentoring will allow them to acquire the skills they need to process
the claim from intake through adjudication rather than guessing what
someone else needs or using the current all-encompassing approach to
information gathering.
The new process will rely heavily on increased employee empowerment
applying information technology and professional judgment to complete
tasks more effectively and efficiently without constant checking,
direction and micro-management. Recognition and reward processes will
be revised to emphasize contributions to team outcomes and acquisition
of knowledge bases. Continuous quality improvement activities will
foster ongoing incremental process change.
Representatives: Fees, New Rules and Standards of Conduct
The Social Security Act and implementing regulations have long
recognized the representational rights of claimants and have provided
an administrative framework designed to ensure that claimants will have
access to the legal community in the pursuit of their claims. Since the
inception of the disability program, representatives have played a
significant role in the disability process. The rate of representation
in SSA disability claims has risen from approximately 55% in fiscal
year (FY) 1982 to 75% in FY 1993. Focus groups of claimants and the
general public have indicated that the disability program is too
complex to understand and the process too fragmented and difficult for
them to navigate alone. While many claimants resent having to pay a
representative to establish entitlement to government-sponsored
benefits, they feel that they have no choice if they want to be
successful in this pursuit. While the rate of representation has risen,
so too has the average fee for representation. The average fee received
by representatives has jumped from approximately $1,500 in FY 1987 to
$2,500 in FY 1993, further adding to the dismay of claimants. As more
claimants seek representation and fees continue to climb, SSA has a
heightened responsibility to monitor representational activity and to
safeguard the interests of claimants. The proposed process will utilize
new rules of representation and standards of conduct to ensure that
representatives, as key players in the disability process, fulfill
their responsibilities and adequately serve the needs of the claimants
they represent.
Under the present statutory and regulatory scheme, representatives
are not permitted to charge and collect a fee in any case without first
obtaining the approval of the Secretary. There are two distinct
procedures available to representatives for obtaining fee approval. The
``fee petition'' method requires the representative to itemize the
services rendered and the time expended. The Secretary must evaluate
each individual petition and determine the reasonable fee, considering
such factors as case complexity, time expended, skills needed, and the
results obtained. There is no maximum fee set by law for this
procedure.
The second method, commonly referred to as the ``fee agreement
procedure'', involves an agreement between the claimant and the
representative whereby the fee is agreed to be no more than 25% of the
retroactive benefits due, or $4,000, whichever is less. The agreement
must be executed and submitted to the Secretary prior to the
determination of the claim. While there is a maximum fee under this
procedure, the Secretary does not have to conduct an individual
evaluation of the reasonableness of the fee unless either the claimant,
the representative, or the administrative law judge (ALJ) files a
protest of the fee. The fee may be reduced by the Secretary only on the
basis of evidence of the failure of the representative to adequately
represent the interests of the claimant or on the basis of evidence
that the fee is clearly excessive for the services rendered. Under
limited circumstances, the representative may ask the Secretary to
increase the fee.
In addition to approving all fees under both DI and SSI of the
Social Security Act, there are withholding and direct payment of fee
provisions that apply only to DI claims where an attorney is involved.
Specifically, the Secretary must withhold and pay to the attorney the
lesser of (1) 25% of the retroactive benefits due the claimant, or (2)
the fee approved by the Secretary under either the fee petition or fee
agreement procedures. The intent of this procedure is to provide an
incentive for attorneys to accept Social Security claims work in order
to increase claimant access to attorneys. In FY 1993, SSA paid nearly
$300 million in fees to attorneys out of claimants' retroactive DI
benefits. This withholding and payment provision does not apply to SSI
claims because Congress did not find it appropriate to reduce a
claimant's benefits in order to pay an attorney in a means-test
program. However, even though SSA does not withhold and pay attorneys
fees in these cases, it is estimated that SSI claimants paid over $133
million in fees to their representatives in FY 1992. Thus, the total
cost to claimants for representation in 1993 approached the $500
million mark.
Since the inception of the fee agreement procedure in 1991, fee
agreements have been rapidly replacing fee petitions as the vehicle for
procuring agency approval of fees. SSA received 52,297 fee agreements
in FY 1992, representing 39% of all fee approval requests. In FY 1993,
fee agreements jumped to 87,395, accounting for 63% of all fee approval
requests. Fees are generally higher under the fee agreement procedure,
averaging $2,800 in FY 1993 as compared to an average fee of $2,200 for
fee petitions. One of the factors causing higher fees under the fee
agreement procedure is the lengthy processing time for disability
claims; the longer it takes to issue a decision, the greater the
retroactive benefits due the claimant. Under the fee agreement
procedure, the fee is based on the amount of retroactive benefits due,
and there may be little or no correlation to the time expended by the
representative or the skills involved in rendering representational
services. By eliminating fragmentation and handoffs, the proposed
process will significantly reduce processing time. SSA will issue
decisions faster, the amount of resulting retroactive benefits will be
reduced, and resulting fees will likewise be reduced.
However, as the fee agreement procedure continues to claim an ever-
increasing share of the total number of fee requests filed each year,
more and more fees will be based upon a predetermined, mathematical
formula rather than by an independent evaluation of the quality of
services rendered. In order to maintain the emphasis on quality in
representational matters, the proposed process will adopt new
representation rules and standards of conduct to effectively safeguard
the rights and interests of claimants. These new regulations will:
--Establish qualifications for representatives, attorneys and non-
attorneys, to ensure that claimants receive competent representation;
--Define the duties and responsibilities of representatives, including
the duty to fully develop the record in a timely manner and to respond
to requests to submit evidence;
--Establish a code of professional conduct for representatives in all
matters before SSA, including conduct at prehearing conferences,
hearings, and interaction with SSA employees and claimants generally;
--Provide a forum for claimants to air their grievances and file
charges against representatives for failure to provide adequate
representation or otherwise violating the rules of representation and
standards of conduct;
--Provide meaningful sanctions against representatives, including
suspension and disqualification from appearing before the agency in a
representative capacity, for violating any of the provisions contained
in the rules of representation and standards of conduct.
Without disturbing the statutory intent of facilitating claimant
access to representatives, the simplified and user-friendly new process
may well result in more claimants pursuing their claims without
representation. However, the issue of representation will remain a
matter of personal choice. In addition, the proposed process will
reduce the trend of inflationary fees by eliminating the artificially
high retroactive benefits that result from excessively long processing
times. Finally, while current statutes and regulations attempt to
protect claimants from fee abuses, they fall short of extending to
claimants the assurances which they need most: that the representatives
they retain will be qualified, will have the obligation to fully
develop the record on their behalf, will adequately represent their
interests, and will be accountable for misconduct or dereliction of
duty. The new rules and standards of conduct provide the framework for
these assurances.
Information Technology
Information technology will be a vital element in the redesign of
the disability claim process. To the fullest extent possible, SSA will
take advantage of the ``Information Highway'' and those technological
advances that can improve the disability process and help provide
world-class service. Existing Agency design plans for Intelligent
Workstation/Local Area Network (IWS/LAN) and a Modernized Disability
System are critical enablers for successful implementation of the
proposed process redesign. Reengineering of the disability process is
on the critical path of the design and development of the Modernized
Disability System and implementation of IWS/LAN.
The Modernized Disability System and IWS/LAN will provide an
integrated system to support the entire reengineered disability
process. This system will provide electronic connectivity throughout
the process. Current SSA systems that support disability processing
operate independently of each other. Field offices, DDSs and hearing
offices all have their own systems. The DDSs have their own baseline
automation systems, but for the most part can only use the systems
within the particular State on that State's machines. Likewise, hearing
offices have a disability processing system that applies only to claim
processing inside the hearings and appeals organization. Each
organization independently inputs claim information into their systems
and no automated information can be passed outside the organization for
subsequent, much less parallel, claim processing.
The reengineered process relies on the ability to build a single
electronic claim record as it goes from point to point in the
disability process. This includes the ability for any facility to
process the medical and nonmedical segments of claims for another
facility. This is the primary benefit of the IWS/LAN and Modernized
Disability System architectures. Both architectures are a prerequisite
for enabling reengineering of the entire disability process.
The Enabling Platform
The IWS/LAN architecture and Modernized Disability System design
will support a major objective of the redesigned disability process-
seamless, reengineered electronic processing of disability claims from
the first contact with the claimant to the final decision, including
all levels of administrative appeal. All employees will use the same
hardware, the same claim assignment and scheduling software, the same
claim processing software, the same case control system, the same
fiscal and accounting software, the same integrated quality assurance
functionality, and the same management information system throughout
all stages of the process. Therefore, data will need to be input and
validated one time only, leading to more consistent decisions in
establishing both the medical and nonmedical aspects of DI and SSI
claims. All employees will also have access to decision support systems
for those complex entitlement decisions. Since all facilities will be
able to access the same record, all SSA representatives will be able to
respond to inquiries from the same base of information. This will
produce more consistent and accurate Agency responses to inquiries.
SSA will continue to move aggressively toward the goal for complete
electronic, paperless processing with all aspects of the claims
process. Key tenants of reengineered electronic, paperless processing
will be encouraging electronic information exchanges with medical
evidence providers--and then keeping information received
electronically in that same (or a similar) digitized format for claim
processing, use of cost effective scanning/imaging of decision
supporting paper records, abstraction and/or summarization of key,
paper-based information by employees via direct keying, and finally,
direct keying of information into the claim processing system by
employees, third parties, and/or claimants. Direct keying of
information into the electronic file will be minimized whenever
possible by reliance on data propagation from other SSA files and
comprehensive database support throughout the claims processing
systems.
Although full realization of a completely automated system will be
a long-term initiative, a number of aspects of the redesigned process
will be quickly realized and made possible by IWS/LAN and Modernized
Disability System support in the very near future.
Redesign of Access to Services
Information technology will be applied in several ways to enhance
the claimants' and representatives' access to services and information
under the new process. Through reengineering, claimants will be able to
conduct business with SSA via telephone, self-help workstations,
kiosks, videoconferencing, and electronic data transfer at SSA
facilities and other satellite locations. SSA will provide TV/VCRs and/
or kiosks in SSA facilities and public places where there is a high
concentration of potential customers to dispense information about SSA
programs, the requirements for eligibility, and the information
requirements for filing an application. The better informed the
customers, the better prepared they are at the time of the interview.
This reduces recontacts and allows the customer to more fully
participate in the timely pursuit of their claim.
Waiting rooms will be equipped with self-help workstations housed
in private cubicles. They will help to pre-screen program eligibility
and furnish application requirement information for walk-in claimants.
These workstations can also be used as front-end interviewing devices
that collect preliminary application information from claimants. The
preliminary information will be used to access SSA databases to gather
all known information on the claimant, including earnings history and
any prior filings.
Application information will include the telephone numbers from
which claimants or representatives will make telephone inquiries. SSA
office telephone systems will be equipped with automatic number
identification technology (also known as ``caller ID''). Using this
technology, SSA will be able to provide improved service by responding
to telephone inquiries with increased assurance that the caller is the
claimant or representative.
Customer Self-Help Redesign
An efficient paper application form designed to be easily read and
indexed by scanning equipment will be widely available as part of a
comprehensive consumer information publication about the disability
program that will be stocked in SSA facilities and other appropriate
community-based locales. Self-help instructional material will also be
mailed to some applicants who inquire about disability benefits by
calling SSA. Up-front completion of the form will not be a requirement
of filing, but will enhance the intake process for applicants. The
Modernized Disability System will have the capability to accept scanned
information from the application form and integrate all relevant
information into the electronic file.
In addition, an electronic application form will be made available
to claimants with access to a personal computer and modem using an SSA
bulletin board service or through other publicly available bulletin
board services. The information will be completed and returned
electronically to SSA via an agreed upon electronic filing method.
Finally, as previously mentioned, some claimants will begin the
application process by completing a brief electronic application form
using SSA self-help workstations in SSA offices and other community-
based locations.
Enhanced Third Party Support
SSA will conduct forums and produce video and computer-based
training materials for third parties who wish to participate in
assisting customers to file applications and gather medical evidence.
Wherever possible, physicians and health care organizations, advocates,
community counseling services, and other professionals who regularly
provide assistance to SSA claimants will be supplied with SSA software
to electronically complete Agency forms. The data will be transferred
to SSA using agreed upon methods. As long as these parties comply with
certain stipulations, SSA will supply updates to software and
procedures, and/or establish an SSA bulletin board from which these
third parties can download current software.
SSA will allow representatives access to electronic claim folders.
This access will be limited to the authorized representative (attorney
or non-attorney) of the claimant and will be allowed from self-help
workstations at an SSA facility, or via an agreed upon electronic data
transfer method.
Evidence Collection Redesign
Medical Evidence of Record is to the disability process what the
earnings record is to the Retirement and Survivors' Insurance program.
SSA will marshall its resources for an ``Evidence Modernization
Project'' as was successfully done for the Earnings Modernization
Project. The success of Earnings Modernization was due, in no small
part, to the partnership SSA established with the employer community to
streamline and focus the wage reporting requirements. The redesigned
disability process approach provides for similar partnership with
medical providers and the necessary streamlining of evidence collection
requirements.
SSA will expand its acceptance of interpretive data from the
medical community. Instead of relying solely on actual medical records,
SSA will focus on obtaining certifications of the diagnostic and
functional information needed to make disability determinations. These
standardized certifications will be designed to solicit from the
treating source the specific information needed and enable SSA to
process the information in a timely and accurate manner.
Electronic standardized treating source information will be
transmitted from physicians to SSA and associated with the appropriate
electronic record. If additional medical evidence is needed and it is
not already electronic, it will be scanned and stored digitally, or it
may be abstracted and stored electronically. ``Fax ID'' and ``caller
ID'' will be established with all parties submitting evidence or who
have rights to legitimately request evidence. As was done during
Earnings Modernization with the employer community, SSA will take
advantage of the expanding use of computer applications by medical
providers by working with software vendors that currently service the
medical community to include an application for treating source
reporting in office automation software.
The paper version of the standardized treating source form will be
designed so that the data can be read by scanning equipment into SSA
claims processing systems. The form will be designed to support the
structure of the Modernized Disability System.
A single vendor payment system utilized by all appropriate
employees will be used to pay certain evidence providers for
information which they provide SSA to aid in making a disability
determination. To further paperless processing, SSA will adopt a
``signature on file'' policy for the claimant's evidence release
authorization to eliminate routing of paper medical release forms.
SSA will also set up information exchanges with other Federal and
State agencies and major medical providers using pin/password access to
data stores as well as caller/fax ID to conduct information exchange
over the telephone.
Reengineered Tools For Decisionmakers
The ability of decisionmakers to conduct thorough interviews and
evidence evaluation, and timely and accurate claims adjudication is
predicated on the implementation of the functionality provided by the
IWS/LAN hardware and software components, and the decision support
features of the Modernized Disability System. The IWS/LAN environment
provides access from the decisionmakers' desktop to electronic policy
and procedures, multiple/simultaneous information processing and
retrieval sessions with SSA claims processing systems, simultaneous
access to both intelligent workstation-based office automation software
and SSA claims processing systems, and access to modern information-
handling and transfer technologies such as fax. With all of the tools
at the decisionmakers' fingertips, time is not wasted in logging on and
off claim processing systems to get to other claim processing systems
or office automation applications, nor is time lost by having to log
off the system in order to leave the workstation to research manual
reference materials.
Expert system software will be included in SSA claims processing
systems to assist disability decisionmakers in the analysis and
evaluation of complex eligibility factors, and to ensure that the
correct procedures for disability evaluation are followed. While
conducting interviews, disability decisionmakers will use the decision
support features of the Modernized Disability System which ask specific
questions based on claimants' alleged impairments.
This will provide more personalized service for claimants since the
decision support questions will be tailored to their particular
impairments. The decision support system will use the accumulated data
of the electronic record to automatically produce ``statement of the
claim'' summaries and decision rationales used throughout the
determination process.
Where disability decision team members cannot be physically co-
located, they can remain in communication by using two-way TV and other
videoconferencing technologies. Handoffs, and the queues associated
with each handoff, can also be minimized by the use of expert systems
because much of the specialized knowledge that a task requires will be
electronically stored in the knowledgebase of the expert system and
immediately available. Therefore, the number of situations where
employees will have to handoff claims to other employees having more
technical expertise will be reduced.
Expert systems will also be developed to improve the delivery of
disability policy. Disability policy will be developed and stored in a
format that can be integrated into computer systems as the source of
context-sensitive help screens and decision-support messages. SSA
components responsible for disability policy will be responsible for
updating the system with policy language revisions that do not require
programming changes.
Quality Assurance and Management Information Redesign
Quality assurance features fully supported by the Modernized
Disability System will be integrated throughout the new process. For
example, the national end-of-line quality review sample will be
electronically selected and automatically routed to appropriate staff.
In-line programmatic quality assurance, enhanced by the use of decision
support systems, will be programmed into the computer applications and
will help to identify errors of both oversight and substance, and also
support routine analysis to aid in avoiding future similar errors. An
on-line technical review will occur each time information is added to
the electronic record.
Quality assurance and productivity measures will be incorporated in
a new, total-process management information system. Meaningful, timely
management information for the disability process is dependent on a
seamless data processing system used by all components which affords a
common case control system and a common data base. SSA's claim
processing systems integrated on an Agency-wide IWS/LAN platform will
provide this seamless environment.
The Modernized Disability System management information design
supports the new process goal of providing access from a desktop
computer to total-process management information data no more than 24
hours old. In addition to the routine, published national reports
generated from the management information system, other reports needed
by national or local entities, or individual employees will be
preformatted and system-generated on demand. Managers and empowered
employees will have the flexibility to change parameters and to access
the full data base, permitting comparison of peer performance and trend
analysis. The system would also permit custom, ad hoc reports for
special studies or immediate special purpose activities with access to
the full data base. Tools including user-friendly report generator
software and statistical forecasting and modeling applications will be
available on the intelligent workstation to assist users in the data
analysis.
Appendix I--Reengineering Design Partners
Director, SSA Process Reengineering Program
Rhoda Davis--Office of the Commissioner, Baltimore, MD.
Disability Process Reengineering Team
William Anderson--Office of Disability, Baltimore, MD.
Mary Ann Bennett--Office of Budget, Baltimore, MD.
Bryant Chase--Office of the Deputy Commissioner for Systems, Baltimore,
MD.
Kayla Clark--Office of Hearings and Appeals, Seattle, WA.
Judith Cohen--Office of Supplemental Security Income, Baltimore, MD.
Judge Alfred Costanzo, Jr.--Office of Hearings and Appeals, Pittsburgh,
PA.
Kelly Croft--Office of Workforce Analysis, Baltimore, MD.
Mary Fischer Doyle--Office of Hearings and Appeals, Falls Church, VA.
Virginia Lighthizer--Chicago Region, Detroit Conner Branch Office,
Detroit, MI.
Rebecca Manship--Disability Determination Service, Sacramento, CA.
Mary Meiss--Office of Hearings and Appeals, Philadelphia, PA.
Michael Moynihan--Office of Disability and International Operations,
Baltimore, MD.
Donna Mukogawa--Office of the Regional Commissioner, Chicago, IL.
William Newton, Jr.--Office of Disability and International Operations,
Baltimore, MD.
Ralph Perez--Atlanta Region, Miami South District Office, Miami, FL.
Dr. Nancie Schweikert--Disability Determination Section, Nashville, TN.
Ronald Sribnik--Office of Regulations, Baltimore, MD.
Sharon Withers--Philadelphia Region, Welch District Office, Welch, WV.
Special Thanks to
Linda Kaboolian--Kennedy School of Government, Harvard University,
Cambridge, MA.
Miriam Kahn--Process Reengineering Staff, Baltimore, MD.
Kenneth Nibali--Process Reengineering Staff, Baltimore, MD.
Leonard Ross--Office of Workforce Analysis, Baltimore, MD.
John Shaddix--Office of Telecommunications, Baltimore, MD.
Sandi Sweeney--Process Reengineering Staff, Baltimore, MD.
Latesha Taylor--Process Reengineering Staff, Baltimore, MD.
Process Reengineering Program Executive Steering Committee
Shirley Chater--Commissioner, SSA.
Lawrence Thompson--Principal Deputy Commissioner, SSA.
Rhoda Davis--Director, Process Reengineering Program, SSA.
Dennis Brown--Moderator, Association of OHA Analysts.
Bruce Bucklinger--President, OHA Managers' Association.
Robert Burgess--President, National Association of Disability
Examiners.
Mary Chatel--President, National Council of Social Security Management
Associations, Inc.
Herbert Collender--President, SSA/AFGE National Council of Payment
Center Locals (Council 109).
Renato DiPentima--Deputy Commissioner for Systems, SSA.
John Dyer--Deputy Commissioner for Finance, Assessment and Management,
SSA.
Richard Eisinger--Senior Executive Officer, SSA.
George Failla--Director, Office of Information Resources Management,
SSA.
Gilbert Fisher--Assistant Deputy Commissioner for Programs, SSA.
Howard Foard--Assistant Deputy Commissioner for Policy and External
Affairs, SSA.
Hilton Friend--Acting Associate Commissioner for Disability, SSA.
John Gage--President, SSA/AFGE SSA Headquarters (Local 1923).
Randolph Gaines--Acting Associate General Counsel, SSA.
Robert Green--SSA Regional Commissioner, Boston.
Joseph Gribbin--Associate Commissioner for Program and Integrity
Reviews, SSA.
James Hill--President, National Treasury Employees Union (Chapter 224).
Arthur Johnson--Chief Spokesperson, SSA/AFGE General Committee.
Charles Jones--Director, Michigan Disability Determination Services.
David Knoll--President, SSA National Federation of Federal Employees
Council of Consolidated Locals.
Demos Kuchulis--President, National Association of Senior Social
Security Attorneys .
Antonia Lenane--Chief Policy Officer, SSA.
Huldah Lieberman--Assistant Deputy Commissioner for Operations, SSA.
Rose Lucas--President, SSA/AFGE National Council of Data Operations
Centers (Council 221).
James Marshall--President, SSA/AFGE National Council of SSA/OHA Locals
(Council 215).
Larry Massanari--SSA Regional Commissioner, Philadelphia.
Francis O'Byrne--President, Association of Administrative Law Judges,
Inc.
Ruth Pierce--Deputy Commissioner for Human Resources, SSA.
Daniel Skoler--Associate Commissioner for Hearings and Appeals, SSA.
Witold Skwierczynski--President, SSA/AFGE National Council of SSA Field
Operations Locals (Council 220).
Earl Tucker--President, SSA/AFGE National Council of Social Security
Regional Offices, Program Integrity Review (Council 224).
Janice Warden--Deputy Commissioner for Operations, SSA.
Andrew Young--Deputy Commissioner for Programs, SSA.
Appendix II--Methodology
Business Process Reengineering
The Process Reengineering Program is the culmination of a rigorous
SSA investigation of the reengineering efforts and methodologies of
those companies, public organizations, academic institutions, and
consulting firms with the most ``hands on'' experience in this field.
The positive findings from this detailed review, combined with concerns
about existing business processes within SSA and the quality of SSA
service to the public, led management to the conclusion that a process
reengineering effort was critical to the SSA objective of providing
``world-class'' administration and service.
Based largely on analysis of what has worked best in the private
and public sectors, a customized reengineering methodology was
developed within SSA. It uses a reengineering team approach that
combines a strong ``customer'' focus with classic management analysis
techniques, and computer modeling and simulation, to intensely review a
single business process. The objective is not to make small,
incremental improvements in the various pieces of the process, but to
redesign it as a whole, from start to finish, so that it becomes many
times more efficient and, in so doing, significantly improves SSA
service to the public.
A senior SSA manager was selected to serve as Director of the
Process Reengineering Program. The Director leads all SSA process
reengineering efforts, is the primary liaison with the Commissioner and
Executive Staff, nominates topics for examination, chairs project
steering committees, and directs a small professional staff and
revolving group of managers/consultants.
SSA uses special, multi-disciplinary teams of individuals to
conduct reengineering analyses and identify the best ways to redesign
and significantly improve processes. Teams are comprised of outstanding
employees, all of whom are subject matter experts in operational,
programmatic, policy, systems, administrative, and other areas relevant
to the business process.
Reengineering teams focus on identifying those procedural and
policy changes to the process that will: make it more claimant and
service oriented; greatly increase productivity and process speed; take
advantage of opportunities offered by new technology; and improve the
empowerment and professional enrichment of the employees who are part
of the process. Although teams follow the same basic reengineering
protocol, continual customization is both expected and encouraged.
Disability Process Reengineering
Project Employees within SSA and DDS at all levels recognize that
there are significant problems with the disability claims process. They
are dissatisfied with the long processing times and high backlogs which
result in less than satisfactory service to claimants. The disability
process reengineering project has allowed those who have long worked in
the process, and with claimants and their representatives, to
investigate the causes of current problems. With considerable input
from other employees and those outside the process, they have developed
the proposal for solving those problems.
The Secretary of the Department of Health and Human Services, Donna
Shalala, and the Commissioner of Social Security, Shirley Sears Chater,
have placed improvements in the disability process as critical to the
delivery of world-class service by SSA. They have strongly supported
the work of the project team. Their adoption of the proposal will
depend on the response of the employees and the public to it.
An Executive Steering Committee was formed to meet on a regular
basis to provide advice to the Commissioner on development of the
disability reengineering process change proposal, and to ensure that
support occurred at the highest levels of the Agency. The Executive
Steering Committee established the parameters and expectations for the
project. The expectation goals were driven by targets set forth in the
Agency Strategic Plan and are based on percentages of service and/or
productivity:
Parameters and Expectations for Reengineering the Disability
Determination Process (9/15/93)
Definition of Process
The ``process'' to be reengineered is the initial and
administrative appeals system for determining an individual's
entitlement to Social Security and Supplemental Security Income
disability payments. It includes all actions from an individual's
initial contact with SSA through payment effectuation or final
administrative denial. The system for determining whether an individual
continues to be entitled to receive disability payments is not part of
this ``process.''
Rationale: The process to be reengineered must be defined broadly
to increase the opportunity for improvement. The continuing disability
review system is not included because it is conceptually and
practically distinct from the initial disability determination process.
Parameters
Every aspect of the process except the statutory definition of
disability, individual benefit amounts, the use of an administrative
law judge as the presiding officer for administrative hearings, and
vocational rehabilitation for beneficiaries, is within the scope of
this reengineering effort. However, analysis and ideas for change
should proceed and be presented on two tracks: Improvements achievable
without changes in statute or regulations and innovations that may
require such change.
Rationale: The timing of legislative or regulatory change is beyond
SSA's control. Such change could not reasonably be expected to be
implemented in less than 2 years. However, limiting the reengineering
effort to aspects of the process not requiring change in statute or
regulations was rejected as limiting too greatly the possibility of
major improvement/innovation in the process. The two-track approach
provides for both shorter term incremental improvements and longer
term, more radical change.
Expectations
1. Unless otherwise specified here, the recommendations for change
should be consistent with the goals and objectives set forth in the
Agency Strategic Plan.
2. Recommendations for change, taken as a whole, should not cause
changes in benefit outlays unless as a necessary result of improvements
in service, such as more timely processing and payment of claims.
3. Process changes should improve service and/or productivity, on a
combined basis, by at least 25 percent by the end of FY 1997 over
levels projected in the FY 1994 budget (it would require about an
additional $500 million currently to realize such improvement) and
decisional accuracy should not decrease. By FY 2000 additional actions,
including any necessary statutory and regulatory changes, should
provide a further 25 percent improvement.
The Executive Steering Committee facilitated good ongoing
communications between components and the Team, and communicated the
need and reason for reengineering the disability process. They were
familiar with the current process problems and were kept apprised of
research completed by the Team. In February, the Executive Steering
Committee was expanded to include the Presidents of the American
Federation of Government Employees, the National Federation of Federal
Employees, and the National Treasury Employees Union locals, councils
and chapters representing SSA employees; and the Presidents of the SSA/
DDS professional and management associations recognized by SSA as
having an interest in disability issues.
Upon receipt of this proposal, the Executive Steering Committee
will make an impact assessment, cognizant of competing pressures and
implementation challenges. During the dialogue period, the Executive
Steering Committee will share and discuss the proposal, provide
feedback, and identify implementation questions. Based on the comments
received and issues identified, they will provide advice on the next
steps.
The 18 members of the Disability Reengineering Team, all of whom
are SSA or State DDS employees, have varied and extensive backgrounds
in all aspects of the disability program. Team members attended a high
quality, intensive 3-day SSA reengineering methodology training
session, and completed extensive reading assignments on reengineering.
Some Team members visited organizations who had reengineered their
business processes to learn about successes as well as opportunities
for improvement.
The Team used the following methods to obtain the information
necessary to develop a redesigned disability process.
Briefings
Members of the Team received extensive briefings from:
--All SSA components that work with any aspect of the disability
process; and
--Dr. Frank S. Bloch, Professor of Law and Director of the Clinical
Education Center at Vanderbilt, who discussed the results of his study
comparing disability programs and processes of the United States,
Canada, and Western Europe. His work encompasses eligibility
requirements and program goals, benefit award structure and short-term
benefits, administrative organization, and procedures for claim
processing and appeals.
Scan Visits
The Team made fact-finding visits to numerous SSA and DDS offices,
and to other public and private organizations throughout the country
who have an interest in working with SSA to improve the disability
process. Team members conducted numerous telephone interviews with
representatives of offices/groups whom they could not personally visit.
They also publicized surface/electronic mail addresses and fax and
voice telephone numbers for those who were not contacted or had
additional information to provide.
Prior to site visits/contacts, Team members provided those
organizations and individuals with general information about the
reengineering effort, key research areas, and some unconventional ideas
about the disability process so that the interviewees would have an
opportunity to think about process issues. The Team encouraged
interviewees to provide open and honest opinions, suggestions, and
ideas.
Appendix III contains a list of the sites visited and telephone
interviews conducted.
Focus Groups
A series of 12 focus groups were held throughout the country to
obtain input from members of our claimant population and the general
public regarding their experiences with and expectations of the SSA
disability process. The focus groups provided the Team valuable
information about claimants' expectations and preferences, as well as
concerns about the current process. Appendix III contains a list of the
focus group sites and composition.
Benchmarking
``Internal benchmarking'' refers to the identification and
understanding of site-specific best practices that currently exist
within the Agency and is focused on the improvement and standardization
of internal operations. The Team completed this phase of benchmarking
by reviewing lists of sites engaging in ``best practices'' which were
submitted by various SSA components, and visiting or telephoning as
many of these SSA and DDS offices as possible.
``External benchmarking'' is essentially the same, except the hunt
for best practices and proven process innovations is expanded to
comparable companies and organizations outside of SSA. It is focused
outside the organization and is concerned with the relative performance
of one specific function or process. Appendix III contains the
companies/organizations the Team used as benchmarking partners.
A valuable part of the benchmarking exercise was the opportunity to
validate assumptions related to the disability process, note issues
that required further investigation, and identify potential improvement
opportunities.
Process Analysis
The Team utilized a document prepared by the SSA Office of
Workforce Analysis in April 1993 which outlines the ``as-is''
disability claim and appeal processes of SSA. The document contains a
description of claim processing tasks performed by line-employees in
the seven operational components that deal with the disability claim
process.
Team members conducted studies on issues such as claimant burden
time, gap analysis, and administrative costs. They also collected,
reviewed, and researched an extensive amount of existing procedural
guides, laws/regulations, studies conducted by internal and external
components, processing time and quality management information,
workflows, cost data, etc.
Intensive deliberations, concept debates, and analysis on ideas for
change were instrumental in the creation of the redesigned process.
Computer Modeling
Computer models are close representations of work processes that,
if properly constructed, allow for better understanding, testing or
forecasting, and study. Team members worked with modeling professionals
in SSA and the private sector to build the models used to develop
assumptions about a redesigned process. The assumptions used for the
proposal are shown in appendix IV.
Models were built to represent both the current and proposed
processes. These models helped the Team predict the best features and
performance of the new disability process; to better judge the
magnitude of change from one process to another; and to do some ``what-
if-nothing-changes'' analysis to get a feel for the impact of
inactivity.
Proposal
The dominant product of the entire effort--this proposal--outlines
the best process improvement and process innovation ideas from the
Team. The proposal as written by the Team, will be presented to the
Executive Steering Committee, and will be made widely available within
SSA and the DDS community, as well as to the broadest possible public
for comment.
Appendix III--Research
Logistic Accomplishments
Sites Visited: 421
States Visited: 33
Individual Interviews: 3,600+
Specific Sites
35 SSA central office components
10 regional offices, OHA ROs and ROPIRS
7 DHHS regional OGC offices
37 State DDSs
64 field offices
28 hearing offices
9 processing centers and other large installations
10 teleservice centers
14 area director offices
181 sites ``external'' to SSA and DDSs
6 union/management associations
Telephone Interviews
31 field offices
1 teleservice center
3 area director offices
4 hearing offices
26 DDSs
46 sites external to SSA and DDSs
BILLING CODE 4190-29-P
TN15AP94.023
TN15AP94.024
TN15AP94.025
TN15AP94.026
TN15AP94.027
TN15AP94.028
TN15AP94.029
TN15AP94.030
TN15AP94.031
TN15AP94.032
TN15AP94.033
TN15AP94.034
TN15AP94.035
BILLING CODE 4190-29-C
Appendix IV--Model Assumptions
Computer software packages were used to model and simulate the
effects the changes in this proposal will have at both the micro (local
office) and macro (national) level. Some of the general guidelines and
assumptions used for the proposed process are listed below.
Due to increased public information programs, claimants will be
better prepared with respect to information and documentation needs
prior to filing their claim.
The time that disability claim managers spend interviewing will be
reduced as a decision support system will assist them in asking the
claimant impairment-specific medical and nonmedical questions. Based on
triage decisions they make throughout the interview, the disability
claim managers will ask the claimant only the questions that are
pertinent to the decisionmaking process.
The application and medical certification forms will be scanned or
electronically transferred and associated with the electronic record. A
disability claim manager will only key identifying information from the
application form into the electronic record.
Claim files will be much smaller in size as SSA accepts medical
certification statements in lieu of extensive medical documentation.
Time to obtain medical evidence will decrease as collection focuses
on core diagnostic and functional information needed to make a decision
and uses a standardized form.
Changes to the current process, such as the disability claim
manager concept, the predenial interview, and fully rationalized
disability decisions, will increase claimant satisfaction with SSA's
decisional process and ultimately decrease the appeal rate and number
of refilings.
A decision support system and an electronic record will assist
adjudicators to prepare notices of decision.
The percentage of claimants represented will decrease as the
processing time decreases, claimant participation increases, and
increased customer service leads to a higher level of claimant
satisfaction and understanding of the process.
Guidelines and assumptions used for the proposed process include
those listed below.
A brief description of each task is provided. The task time, shown
in minutes, is the estimated time it will take employees to complete
the described work. The lapse time, shown in work days, represents the
amount of time between actions. Three numbers are provided: the middle
number represents the most common task or lapse time, while the first
and third numbers represent the low and high extremes. The task and
lapse times shown represent times likely when the proposed process is
fully up and running.
Percentages are shown to represent frequency of occurrences.
BILLING CODE 4190-29-P
TN15AP94.036
TN15AP94.037
TN15AP94.038
TN15AP94.039
TN15AP94.040
BILLING CODE 4190-29-C
Appendix V--Next Steps
Proposal for an Implementation Blueprint
Building a redesigned disability claim process will not be an easy
task--impacts will be felt by almost everyone internal and external to
SSA who is involved in the disability claim process. Claimants, their
representatives, disability advocate organizations, professional
associations, SSA and DDS employees and employee representatives will
feel the effects of the transition to a new way of doing business.
There will be a vast number of decisions to be made about the way
the new process will be built and its infrastructure designed. Timing
of the myriad decisions is crucial to ensure that required
organizational, budgetary, human resource, technological, logistical,
and regulatory changes occur in the proper sequence.
The Team has developed a proposal that outlines the most
significant redesign implementation steps. The steps are grouped
according to areas of impact. Some of the steps will be sequential
while others will be simultaneous.
I. Organization
SSA will develop an organizational structure that ensures
coordination and effective support of the entire disability claim
process. An implementation team will be established to plan and
coordinate the general aspects of the redesign changes with existing
SSA components, States, unions, and professional associations.
In addition to implementing the proposed process, the
implementation team will be responsible for determining the impacts on
other business processes. Some of these impacts may require changes in
other processes.
The following steps will be completed in order to achieve these
goals:
--Obtain executive approval to proceed with implementation
--Develop disability process management structure/organization/
ownership
--Build implementation team
--Develop plan for change management
--Develop method for processing current work while implementation takes
place
--Outline interdependent steps of implementation
--Analyze risk factors to be encountered in meeting timeframes
--Create clear objectives to provide rapid recognition of improvement/
success
--Establish tangible success scorecard
--Establish major milestones and managerial checkpoints for
implementation
--Monitor progress and adjust implementation schedules accordingly for
future sites
--Complete first implementation phase
--Analyze success of first phase, make necessary implementation changes
and prepare for additional implementation sites
--Complete full implementation
II. Communications
SSA will develop a comprehensive communications plan that
systematically and logically addresses the needs of everyone associated
with the disability claim process and enhances the implementation of
the redesigned process. The following steps will be completed in order
to achieve this goal:
--Determine who will need to be notified of the new process and at what
intervals
--Develop models needed to assist staff, claimants and stakeholders to
visualize the new organization, new roles, new responsibilities
--Select communications media, including new methods or modes
--Determine communications tools to be used in providing continuing
updates throughout the implementation process
--Design communications plan
--Schedule communications releases
--Begin media campaign to describe new process
--Begin media campaign to describe interim measures to get to new
process
--Notify stakeholders, employees, and other interested parties of
initial sites selected and implementation schedule
--Announce achievement of successfully completed milestones
III. Program Management
A. Costs
SSA will determine the full cost of the redesigned disability claim
process, its implementation and its related impact. The following steps
will be completed in order to achieve this goal:
--Estimate cost of new process operation
--Obtain necessary funding for first-phase operating expenses
--Estimate initial implementation costs
--Obtain necessary funding for first-phase implementation costs
--Determine impact of new process on current DDS budgets and indirect
costs to the States and take necessary resulting actions
--Develop method for tracking and monitoring implementation costs
--Monitor process and implementation costs, making adjustments as
necessary
B. Management Information
SSA will develop the means to gather, analyze and report the
information required to operate the redesigned disability claim
process. The following steps will be completed in order to achieve this
goal:
--Establish management information needs for oversight agencies
--Establish management information needs for SSA
--Establish management information needs for implementation site
employees
--Design and test validity of new management information reporting
mechanisms
--Institute new management information system
C. Quality
As an important element in the redesigned process, SSA will develop
new methods for assuring the delivery of world-class service. The new
methods will be integrated with training, policy, and management
information facets of the redesigned process. The following steps will
be completed in order to achieve this goal:
--Design quality control process
--Test and validate quality control process
--Establish quality feedback mechanisms
--Institute new quality control process
D. State Roles
SSA will analyze comments received during the 60-day dialogue
period and make determinations regarding State roles. The following
steps will be completed in order to achieve this goal:
--Identify where DDS employees fit in the new process
--Determine regulatory and statutory changes needed
--Negotiate changes under current statute and regulations for
implementation sites
IV. Human Resources
A. Training
Major changes arising out of the new way of doing business mandate
that employees be fully trained to meet the needs of the new process.
Much training will be done on a large scale in short periods of time.
Alternate training media, e.g., satellite training, self-paced
computer-based training, videotape training, etc. will be used to reach
large audiences effectively. The following steps will be completed in
order to achieve this goal:
--Assign lead for developing, organizing and managing the training
program
--Determine national and site-specific training needs
--Determine what instructions need to be written
--Ascertain format for training materials
--Develop means to ensure current work is completed while training
takes place
--Establish training timetable
--Determine teaching resource needs and source of those resources
--Obtain instructor resources
--Obtain training supplies
--Secure necessary training facilities
--Plan and coordinate training sessions
--Begin training
--Monitor training results and make adjustments as necessary
--Complete all initial training activities
B. Personnel
SSA will effectively prepare for and, to the extent possible,
minimize negative effects of the transition to the redesigned process
on employees. Plans will consider the effect on the work environment,
career enhancements, job responsibilities, possible workforce shifts,
and performance evaluation. The following steps will be completed:
--Determine volume and qualifications of staff needed to perform new
process
--Create, modify, or eliminate job types for the new process
--Develop change management assistance for employees
--Develop performance monitoring systems and incentives
--Determine tools employees need to perform new process
--Develop position descriptions and performance plans
--Establish long-term plan to ensure national availability of qualified
staff
--Analyze staff availability at implementation sites for new process
and old process
--Determine anticipated costs of moving personnel to work sites,
temporarily and/or permanently
--Determine staffing needs
--Obtain necessary funding to move staff
--Obtain tools for employees
--Establish local management and key staff teams
--Select remaining staff
--Move staff as necessary
--Begin new process
V. Statutory/Regulatory/Policy
A. Policy
Extensive policy changes will take place prior to and during
process implementation. As regulatory and statutory modifications
occur, procedural re-writes will address their impact on SSA claim
processing policy. New, more effective means of organizing and issuing
Agency policy will be used to accomplish these tasks. The following
steps will be completed in order to achieve these goals:
--Ascertain what procedures and workflows need to be modified,
eliminated, or established
--Determine appropriate policy and procedure format(s)
--Develop screens and forms to be incorporated in new process
--Determine methods for policy and procedure dissemination
--Develop method for monitoring policy implementation
--Design new workflow
--Write procedures needed to nationally implement immediate changes
--Issue new procedures
--Monitor, analyze and re-write procedures as necessary
--Write procedures to support regulatory and statutory changes
--Issue long-term procedures
--Monitor, analyze, and re-write procedures as necessary
B. Statutory/Regulatory
A large number of regulations and statutory sections will need to
be modified to support the implementation of the redesigned process.
SSA will develop faster, more effective means for gaining the necessary
changes. The following steps will be completed in order to achieve this
goal:
--Write necessary regulations to support new process
--Propose elimination of unnecessary regulations
--Obtain final approval for regulatory changes
--Seek changes to necessary statutes to support new process
--Congressional approval of statutory changes
--Establish methods for statutory and regulatory change dissemination
--Disseminate statutory and regulatory changes to all necessary parties
VI. Logistics
A. Implementation sites
Implementation will impact the physical work environment. Decisions
on number, location, size, and layout of offices will be designed into
the implementation plan. The following steps will be taken:
--Ascertain type of sites needed
--Analyze demographic, geographic, and fiscal considerations for site
selection
--Select site management team to orchestrate site preparation
--Determine number of first-implementation sites
--Recommend implementation sites
--Receive implementation site approval
--Evaluate implementation facilities for necessary space and layout
modifications
--Determine new or additional equipment and furniture needs at
implementation sites
--Evaluate supplies and forms needed for new process
--Obtain funding for site work, supplies and equipment
--Prepare site and equipment leases
--Order supplies and forms needed for new process
--Order new equipment
--Complete site preparation work at implementation facilities
--Install equipment
--Deliver supplies and forms to sites
--Deliver new employees' possessions
B. Technology
Increased use of automated processes; decisional support software;
electronic claimant records; electronic interaction between SSA,
claimants, and the medical community; and telecommunications in the
redesigned process dictates that SSA expand and accelerate the current
comprehensive technology design plan. The following steps will be
completed to achieve these goals:
--Review and modify pertinent Agency tactical plans
--Analyze impact of change on computer programs currently being used or
planned in SSA
--Reevaluate hardware and software needs
--Modify existing SSA software to support the new process
--Develop and validate new software
--Procure hardware
--Install necessary hardware
--Install software
--Test hardware and software, making necessary adjustments
--Implement new systems
Summary of Current Statutory and Regulatory Provisions Affected by the
New Disability Process
Title II of the Social Security Act--
Disability Determinations: Section 221(a) through (j)--Disability
Insurance Benefit Payments (Definition of Disability): section
223(d)(5)(B).
Title XVI of the Social Security Act--
Meaning of Terms (Aged, Blind, or Disabled Individual): section
1614(a)(3)(G)--Administration: section 1633.
Regulations (parts 404, 416 and 422)
The following sections of subpart G of Reg. No. 404 and subpart C
of Reg. No. 416:
Secs. 404.610/416.310 What makes an application a claim for
benefits.
Sec. 404.614 When an application or other form is considered filed.
Sec. 416.325 When an application is considered filed.
The following sections of subpart J of Reg. No. 404 and subpart N
of Reg. No. 416:
Secs. 404.900/416.1400 Introduction.
Secs. 404.902/416.1402 Administrative actions that are initial
determinations.
Secs. 404.904/416.1404 Notice of the initial determination.
Secs. 404.905/416.1405 Effect of an initial determination.
Secs. 404.907/416.1407 Reconsideration--general.
Secs. 404.908/416.1408 Parties to a reconsideration.
Secs. 404.909/416.1409 How to request reconsideration.
Secs. 404.913/416.1413 Reconsideration procedures.
Sec. 416.1413a Reconsiderations of initial determinations on
applications.
Secs. 404.929/416.1429 Hearing before an administrative law judge--
general.
Secs. 404.930/416.1430 Availability of a hearing before an
administrative law judge.
Secs. 404.932/416.1432 Parties to a hearing before an
administrative law judge.
Secs. 404.933/416.1433 How to request a hearing before an
administrative law judge.
Secs. 404.935/416.1435 Submitting evidence prior to a hearing
before an administrative law judge.
Secs. 404.936/416.1436 Time and place for a hearing before an
administrative law judge.
Secs. 404.938/416.1438 Notice of a hearing before an administrative
law judge.
Secs. 404.939/416.1439 Objections to the issues.
Secs. 404.940/416.1440 Disqualification of the administrative law
judge.
Secs. 404.941/416.1441 Prehearing case review.
Secs. 404.944/416.1444 Administrative law judge hearing
procedures--general.
Secs. 404.946/416.1446 Issues before an administrative law judge.
Secs. 404.948/416.1448 Deciding a case without an oral hearing
before an administrative law judge.
Secs. 404.955/416.1455 The effect of an administrative law judge's
decision.
Secs. 404.960/416.1460 Vacating a dismissal of a request for a
hearing before an administrative law judge.
Secs. 404.961/416.1461 Prehearing and posthearing conferences.
Secs. 404.967/416.1467 Appeals Council review--general.
Secs. 404.968/416.1468 How to request Appeals Council review.
Secs. 404.969/416.1469 Appeals Council initiates review.
Secs. 404.970/416.1470 Cases the Appeals Council will review.
Secs. 404.971/416/1471 Dismissal by the Appeals Council.
Secs. 404.972/416.1472 Effect of dismissal of request for Appeals
Council review.
Secs. 404.973/416.1473 Notice of Appeals Council review.
Secs. 404.976/416.1476 Procedures before Appeals Council on review.
Secs. 404.977/416.1477 Case remanded by the Appeals Council.
Secs. 404.979/416.1479 Decision of Appeals Council.
Secs. 404.981/416.1481 Effect of Appeals Council's decision or
denial of review.
Secs. 404.982/416.1482 Extension of time to file action in Federal
district court.
Secs. 404.992/416.1492 Notice of a revised determination or
decision.
Secs. 404.993/416.1493 Effect of revised determination or decision.
The following sections of subpart P of Reg. No. 404 and subpart I
of Reg. No. 416:
Secs. 404.1501/416.901 Scope of subpart.
Secs. 404.1502/416.902 General definitions and terms for this
subpart.
Secs. 404.1503/416.903 Who makes disability and blindness
determinations.
Secs. 404.1505/416.905 Basic definition of disability.
Secs. 404.1511/416.911 Definition of a disabling impairment.
Secs. 404.1512/416.912 Evidence of your impairment.
Secs. 404.1513/416.913 Medical evidence of your impairment.
Secs. 404.1515/416.915 Where and how to submit evidence.
Secs. 404.1517/416.917 Consultative examination at our expense.
Secs. 404.1519/416.919 The consultative examination.
Secs. 404.1519a/416.919a When we will purchase a consultative
examination and how we will use it.
Secs. 404.1519k/416.919k Purchase of medical examinations,
laboratory tests, and other services.
Secs. 404.1519m/416.919m Diagnostic tests or procedures.
Secs. 404.1519n/416.919n Informing the examining physician or
psychologist of examination scheduling, report content, and
signature requirements.
Secs. 404.1519q/416.919q Conflict of interest.
Secs. 404.1519s/416.919s Authorizing and monitoring the
consultative examination.
Secs. 404.1519t/416.919t Consultative examination oversight.
Secs. 404.1520/416.920 Evaluation of disability in general.
Secs. 404.1520a/416.920a Evaluation of mental impairments.
Secs. 404.1521/416.921 What we mean by an impairment(s) that is not
severe.
Secs. 404.1522/416.922 When you have two or more unrelated
impairments--initial claims.
Secs. 404.1523/416.923 Multiple impairments.
Sec. 416.924 How we determine disability for children.
Sec. 416.924a Age as a factor of evaluation in childhood
disability.
Sec. 416.924b Functioning in children.
Sec. 416.924c Other factors we will consider.
Sec. 416.924d Individualized functional assessment for children.
Sec. 416.924e Guidelines for determining disability using the
individualized functional assessment.
Sec. 404.1525/416.925 Listing of impairments in Appendix 1.
Secs. 404.1526/416.926 Medical equivalence.
Sec. 416.926a Equivalence for children.
Secs. 404.1527/416.927 Evaluating medical opinions about your
impairment(s) or disability.
Secs. 404.1529/416.929 How we evaluate symptoms, including pain.
Sec. 416.931 The meaning of presumptive disability or presumptive
blindness.
Sec. 416.932 When presumptive payments begin and end.
Sec. 416.933 How we make a finding of presumptive disability or
presumptive blindness.
Sec. 416.934 Impairments which may warrant a finding of presumptive
disability or presumptive blindness.
Secs. 404.1545/416.945 Your residual functional capacity.
Secs. 404.1546/416.946 Responsibility for assessing and determining
residual functional capacity.
Secs. 404.1560/416.960 When your vocational background will be
considered.
Secs. 404.1561/416.961 Your ability to do work depends upon your
residual functional capacity.
Secs. 404.1562/416.962 If you have done only arduous unskilled
physical labor.
Secs. 404.1563/416.963 Your age as a vocational factor.
Secs. 404.1564/416.964 Your education as a vocational factor.
Secs. 404.1565/416.965 Your work experience as a vocational factor.
Secs. 404.1566/416.966 Work which exists in the national economy.
Secs. 404.1567/416.967 Physical exertion requirements.
Secs. 404.1568/416.968 Skill requirements.
Secs. 404.1569/416.969 Listing of Medical-Vocational Guidelines in
Appendix 2.
Secs. 404.1569a/416.969a Exertional and nonexertional limitations.
Secs. 404.1574/416.974 Evaluation guides if you are an employee.
Secs. 404.1575/416.975 Evaluation guides if you are self-employed.
Secs. 404.1584/416.984 Evaluation of work activity of blind people.
Appendix 1 Listing of Impairments.
Appendix 2 Medical-Vocational Guidelines.
The entire subpart Q of Reg. No. 404 and the entire subpart J of
Reg. No. 416.
The following sections of subpart R of Reg. No. 404 and subpart O
of Reg. No. 416:
Secs. 404.1700/416.1500 Introduction.
Secs. 404.1703/416.1503 Definitions.
Secs. 404.1705/416.1505 Who may be your representative.
Secs. 404.1707/416.1507 Appointing a representative.
Secs. 404.1710/416.1510 Authority of a representative.
Secs. 404.1715/416.1515 Notice or request to a representative.
Secs. 404.1720/416.1520 Fee for a representative's services.
Secs. 404.1725/416.1525 Request for approval of a fee.
Secs. 404.1728/416.1528 Proceedings before a State or Federal
court.
Secs. 404.1730/416.1530 Payment of fees.
Secs. 404.1735/416.1535 Services in a proceeding under title II of
the Act.
Secs. 404.1740/416.1540 Rules governing representatives.
Secs. 404.1745/416.1545 What happens to a representative who breaks
the rules.
The following sections of subpart B of Reg. No. 422:
Sec. 422.130 Claim Procedure.
Sec. 422.140 Reconsideration of initial determination.
The following sections of subpart C of Reg. No. 422:
Sec. 422.203 Hearings.
Sec. 422.205 Review by Appeals Council.
Sec. 422.210 Court review.
The following sections of subpart F of Reg. No. 422:
Sec. 422.505 Applications and related forms for retirement,
survivors, and disability insurance benefit programs.
Sec. 422.525 Where applications and other forms are available.
Sec. 422.527 Private printing and modification of prescribed
applications and other forms.
Appendix VI--Examples of Forms and Publications
Disability Information Packets
All forms that a claimant will need to file an application for
benefits will be contained in the disability information packet which
SSA will make available to the public. Claimants may obtain these
packets by visiting or calling any local SSA office or calling the
toll-free 800 telephone number. SSA will also make these packets
available at other public locations such as post offices, public
libraries, and local, State and Federal offices. Bulk supplies of the
packets will also be available to third parties who play a role in the
intake process. The information packet will contain two forms--an
application and a medical certification form. During the Team's
research, which included benchmarking activities, it was discovered
that other government agencies and private organizations successfully
utilize this approach.
Application Form
This is a ``starter'' form that serves the purpose of initiating
the application process. It will solicit basic identification data
regarding the claimant as well as information concerning the nature of
the benefits sought (i.e., DI, SSI, children's, widow's, etc.). The
application form will ask for minimal information, will be easily
understood, and will require little or no assistance. The claimant's
signature will be required on the form to meet the legal requirements
of a formal ``application''.
Medical Certification Form
This form is for completion by the claimant's primary treating
source. Rather than systematically collecting all medical evidence of
record, SSA will use this form to solicit core diagnostic and
functional information from the treating source. The form will use both
narrative and ``check box'' formats to elicit identification of each of
the claimant's medically determinable impairments; the objective data
(signs, symptoms, clinical and laboratory findings) supporting the
diagnoses; the treatment prescribed and response; the onset and
expected duration of the impairments; and an assessment of the
claimant's ability to perform work-related activities. The treating
source signature certifies that the information is accurate and based
upon records within their possession, which they agree to promptly
furnish if requested.
The medical certification concept is similar to that used by many
private disability insurance carriers, workers' compensation programs
throughout the country, and the Canadian Government. The SSA medical
report builds upon the concept of the forms used by other organizations
to target the specific information called for in the new process.
SSA Publications
SSA rules, pamphlets, factsheets, flyers, posters, and other
materials, will be printed and available for distribution throughout
the country at designated public places accessible to claimants,
representatives, the medical community, public and private social
service agencies, third parties, and advocacy groups. This will ensure
that these partners in the new process can be well informed and will
allow SSA to achieve its goal of providing world-class service to its
customers.
Appendix VII--Process Change Recommendations That Were Outside the
Parameters
In conducting the internal and external scans, the Reengineering
Team received many ideas and suggestions for change. The ideas that
follow are recurring suggestions for change that the Reengineering Team
did not consider because they exceeded the scope of the Team's mission
or the parameters established by the Executive Steering Committee. They
may be considered for further study or action by SSA or Congress, as
appropriate. Inclusion here does not constitute endorsement by the
Reengineering Team.
Time-Limited Benefits
Consider time-limited benefits which would subject individuals,
whose impairments are expected to improve or where medical improvement
is possible, to automatic benefit termination after a specified time.
Duration of entitlement would depend on the nature of the impairment,
i.e., the timeframe could vary according to the impairment the same way
the current continuing disability review diary duration does.
Individuals would be notified at the time their claims are allowed how
long they will receive benefits. Before the automatic termination of
benefits, SSA would notify individuals when benefits would end, and
explain that they must refile or submit new medical information that
confirms they continue to meet the definition of disability. Time-
limited benefits would counteract the mindset that disability benefits
are permanent. To be successful, time-limited benefits would have to be
linked to a return to work program or participation in vocational
rehabilitation services.
Integration of Mandatory Vocational Rehabilitation Services for
Claimants
Consider focusing more resources on enforcing vocational
rehabilitation participation, and discussing rehabilitation and return
to work earlier in the application process. At the time of an initial
determination, a vocational rehabilitation program should be prescribed
and required for the claimant to follow during the period of
entitlement. Special efforts should be made so that rehabilitation
agencies would work with disabled children, drug addicts, and
alcoholics. If SSA determines that the rehabilitation program is not
proceeding as scheduled, a new decision, based on current information,
would be made regarding the claimant's ability to successfully continue
and complete the rehabilitation program.
Changes in Payment of Benefits to Certain SSI Claimants
Consider providing benefits to some SSI claimants in the form of
program support rather than cash. For example, some children might
benefit from a system for vouchering or crediting funds for medical or
therapeutic treatment, remedial education, and/or job training. This
would present an opportunity for disabled children to get additional
assistance with education, learn job skills and maximize their
potential. Disabled child recipients should be required to stay in
school, or if homebound, continue in an educational program as a
requirement to continue receiving benefits. Similarly, for adults
receiving disability based on substance addiction, a system could be
established for vouchering or crediting funds for medical or
therapeutic treatment, education, job training, and for food, clothing,
and lodging.
Incentives for the Medical Community to Provide Evidence on Their
Patients or to be Consultative Examination Providers
To enhance SSA's ability to obtain needed medical evidence,
consider enacting legislation to require release of medical information
to SSA without the need for a signed consent form or based on signature
in file and to require timely release of any physician or hospital
records produced or maintained by a Medicare/Medicaid provider.
Legislation should also be enacted to allow physicians to repay their
federally funded medical school loans by working as consultative
examination providers or SSA medical consultants. SSA should also
consider seeking a special tax credit system for reimbursement to
medical providers for evidence of record on their patients. Physicians
who opt for this new tax credit would be required to participate in
training on completion of forms and to submit timely and accurate
information.
Establish One Court to Handle All SSA Disability Cases
Consider supporting the establishment of a new Federal court of
appeals with sole jurisdiction for reviewing the final decision of the
Secretary in disability cases. District courts would no longer have
jurisdiction in disability cases.
Eliminate SSA's Involvement With Representative Payees
Consider providing direct payment to all adult claimants unless
they have a legal representative or have been found legally
incompetent. SSA would no longer develop for capability or make
determinations as to whether benefits are being used in an individual's
best interests.
Change the Administrative Law Judge Position to a Hearings Officer
Position
There are a number of Federal agencies whose administrative appeals
processes use hearing officers or administrative judges who are not
appointed as administrative law judges pursuant to the Administrative
Procedure Act. Because the SSA hearing process is nonadversarial and
informal, it was suggested that there is no need for an Administrative
Procedure Act-protected administrative law judge.
Eliminate the Two-Year Waiting Period for Medicare
DI claimants must be eligible for disability benefits for two years
before they can qualify for Medicare, while in most States SSI
claimants receive Medicaid concurrently with the SSI award. Claimants
who file for both DI and SSI may receive Medicaid coverage with SSI,
but may lose it when DI payments begin after the end of the 5-month
waiting period. In many cases, the claimant's primary concern is for
medical care; enabling access to appropriate medical care could lead to
or speed up medical recovery.
Require Claimants to Establish That Employers Have Made all the
Accommodations Required Under the Americans With Disabilities Act
The Americans with Disabilities Act defines an individual with a
disability as someone who has, or is perceived to have, or who has a
history of a physical or mental impairment that substantially limits
one or more major life activities. Any employer with 25 or more
employees (15 or more employees as of June 26, 1994) is prohibited from
discriminating against qualified job applicants and employees with
disabilities. Qualified individuals are those who can perform the
essential functions of the job they hold or desire, with or without
reasonable accommodations. Consider requiring individuals who are
qualified under the Americans with Disabilities Act to have a signed
statement from their former employer which outlines the steps that have
been taken to make reasonable accommodations for the disability.
Provide Presumptive Disability Payments in DI Claims
Consider providing presumptive disability benefits to DI claimants.
Presumptive disability benefits are now provided prior to final
decision to SSI claimants who are likely to be allowances. These
payments can be given for up to six months and, if the claimant is
denied, no repayment of the benefit is required. There is a growing
number of DI claimants with the same financial needs as SSI claimants.
Establish a Family Maximum for SSI Benefits
Consider establishing a family maximum for SSI benefits as exists
in DI. With the increasing number of children receiving SSI disability
benefits, consideration should be given to equalizing Federal cash
support to DI and SSI families.
Eliminate the Waiting Period for DI Benefits
Consider eliminating the five-month waiting period. The same
definition of disability is used for both DI and SSI claimants, yet DI
claimants must serve a five-month waiting period before they are
eligible for DI disability benefits.
Limit Payment of Disability Benefits to Residents of the United States
Consider ceasing the payment of disability benefits to people who
reside outside the United States. The vocational factors that are
considered in determining ability to work are based on the United
States national job economy and it should not be assumed that an
individual would meet the SSA definition of disability in another labor
market.
Change the Earnings Amounts for Determining Trial Work Period Months
Consider setting more reasonable levels for determining trial work
period months to encourage claimants to attempt returning to work.
Use a Single Earnings Test for All Claimants
Consider standardizing the annual work test for all claimants under
age 65. This would serve as an incentive for claimants to return to
work and reduce the number of work issue continuing disability reviews
that need to be developed.
Reduce the Number of Actions Required to Process Multiple Benefit
Payments on One Social Security Number
Issuance of multiple payments on one social security number is very
labor intensive. To simplify the process, consider adopting one of the
following options: Issue a single check for all benefits due on the
beneficiary's account number to the beneficiary and require him/her to
disburse monies to the auxiliaries; pay total family benefits to the
head of the household (if other than the beneficiary) which would
eliminate multiple checks, multiple letters, and multiple payment
actions dealing with the family unit; or pay a flat rate for each
auxiliary. This would eliminate the need to calculate auxiliary
benefits on each account.
Change the Definition of Disability to Eliminate the Consideration of
Age, Education, and Previous Work in Determining Disability
Reconsider the definition of disability so that only medical
factors are considered. With the enactment of the ADA, the number of
job opportunities and the availability of services to people with
disabilities has been greatly enhanced and determining disability
should be based on a strict medical test.
[FR Doc. 94-8265 Filed 4-14-94; 8:45 am]
BILLING CODE 4190-29-P
