94-22491. Process Reengineering Program; Disability Reengineering Project Plan  

  • [Federal Register Volume 59, Number 180 (Monday, September 19, 1994)]
    [Unknown Section]
    [Page 0]
    From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
    [FR Doc No: 94-22491]
    
    
    [[Page Unknown]]
    
    [Federal Register: September 19, 1994]
    
    
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    DEPARTMENT OF HEALTH AND HUMAN SERVICES
     
    
    Process Reengineering Program; Disability Reengineering Project 
    Plan
    
    Agency: Social Security Administration, HHS.
    
    Action: Announcement of the plan for a new disability claim process.
    
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    SUMMARY: The Social Security Administration (SSA) announces a plan to 
    redesign the claim process for Social Security Disability Insurance and 
    Supplemental Security Income (SSI) disability benefits. This notice 
    contains the plan, as well as background information. The aim of the 
    plan is to achieve dramatic improvements in service to claimants filing 
    for disability benefits and restore public confidence in SSA's 
    disability programs.
    
    FOR ADDITIONAL COPIES CONTACT: Social Security Administration, PO Box 
    17052, Baltimore, MD 21235, (410) 966-8255. The plan is available in 
    alternative formats for visually impaired individuals. Please use this 
    same telephone number to request a copy of the plan in an alternative 
    format.
    
    SUPPLEMENTARY INFORMATION:
    
    Background--What is the Process Reengineering Program?
    
        SSA began an Agency-wide program of Process Reengineering in the 
    summer of 1993. The Process Reengineering Program is one way that SSA 
    is seeking to improve its overall delivery of service to the public.
        The Process Reengineering Program essentially asks the question, 
    ``If SSA had the opportunity today to design its processes, what would 
    they look like?'' In other words, ``how would we design a process if we 
    were starting over?'' The Programs objective is to fundamentally 
    rethink and radically redesign SSA's processes to achieve dramatic 
    improvements in critical measures of performance such as quality of 
    service, speed and efficiency. The ultimate goal 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 private 
    companies, public organizations, academic institutions, and consulting 
    firms with ``hands on'' experience. The positive findings from that 
    investigation, combined with concerns about the impact of current and 
    projected workloads, led SSA to conclude that a disability claims 
    process reengineering effort was critical to its objectives of 
    providing world-class service to the public and restoring public 
    confidence in its disability programs.
        Based on analysis of what has worked best in other organizations, 
    SSA developed a customized reengineering methodology. This methodology 
    used a team approach (composed of SSA and State Disability 
    Determination Service (DDS) employees) and combined a strong customer 
    focus with classic management analysis techniques to intensely review a 
    single business process. While the reengineering team was comprised of 
    employees who were knowledgeable about the current disability process, 
    the methodology focused heavily on obtaining the views of a broad 
    segment of individuals, groups and organizations involved both 
    internally and externally to the process.
    
    What Does the Disability Reengineering Project Address?
    
        Despite the outstanding efforts of SSA and State DDS employees 
    throughout the country, the Agency continues to have difficulty 
    providing a satisfactory level of service to claimants filing for 
    disability benefits. 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 
    Fiscal Year (FY) 1995, it is estimated that SSA will forward 2.9 
    million initial disability claims to the DDSs for disability 
    determinations--a 69 percent increase over FY 1990 levels. Similarly, 
    the number of requests for an administrative law judge hearing on 
    denied claims is expected to increase to 542,000, a 75 percent increase 
    over FY 1990 levels. Recent management initiatives to improve service 
    through resource reallocations and productivity enhancements have not 
    been sufficient to deal successfully with the workload demands and it 
    is expected that disability processing times and backlogs will continue 
    to grow under the present process.
        The result is that many claimants have to wait much too long at 
    each stage of 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 focused on 
    the process of filing for 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 portion of the SSI program.
        The parameters set for this first project restricted the team from 
    proposing any changes to the statutory definition of disability or the 
    amount of benefits for which individuals are eligible. The project also 
    did not address vocational rehabilitation, work incentives or 
    continuing disability reviews as these issues are being addressed by 
    SSA in other ways.
    
    How Was the Disability Process Reengineering Project Accomplished?
    
        The Disability Process Reengineering Project began in October 1993 
    when a team of 18 Federal and State employees came together for the 
    purpose of reengineering the initial and administrative appeals system 
    for determining an individual's entitlement to Disability Insurance and 
    SSI disability payments. After completing their initial tasks of 
    analyzing the current process, obtaining process improvement 
    recommendations from over 3,600 individuals and groups internal and 
    external to the disability claim process, benchmarking with public and 
    private sector organizations to identify ``best practices,'' and 
    modeling theoretical processes via computer, the team presented an 
    initial proposal on March 31, 1994. (A copy of this proposal was 
    published in the Federal Register, Vol. 59, No. 73, on Friday, April 
    15, 1994.) The team distributed the proposal widely throughout SSA, the 
    State DDSs, and to interested public and private individuals and 
    organizations and asked the audience for reactions to the proposal, 
    items of concern, and additional ideas for improvement.
        During the comment period that began on April 1, 1994, and ended on 
    June 14, 1994, the team received over 6,000 written responses from SSA 
    and DDS employees, employee unions, professional associations, members 
    of the public, claimant representatives, physicians, State governors, 
    claimant advocacy groups, Federal entities, and other interested 
    parties. Members of the team read and analyzed every one of the 
    comments so that no idea, reaction or nuance would be overlooked. Group 
    employee feedback discussions were held in over 80 sites across the 
    country to facilitate dialogue with almost 2,000 SSA and DDS employees. 
    In addition, team members conducted briefings and spoke with more than 
    3,000 individuals about their reactions to the proposal during this 
    period. A public forum was also held in Washington, D.C. A summary of 
    the comments received is provided in Appendix III of the attached plan.
        After considering all comments, the team reviewed the breadth of 
    the initial proposal to determine concepts that needed to be revised, 
    language that needed to be clarified, and details that needed to be 
    added. On June 30, 1994, the team submitted its revised proposal to the 
    Commissioner of Social Security. Subsequently, after careful 
    consideration, on September 7, 1994, the Commissioner released SSA's 
    Plan for a New Disability Claim Process. Accepting all of the concepts 
    contained in the team's June 30 revised proposal as SSA's plan, the 
    Commissioner released the redesign plan with the understanding that 
    certain concepts (primarily aspects of the simplified disability 
    methodology) would require extensive research and testing before 
    determining how quickly they could be implemented.
    
    What Service Improvements Does the Plan for a New Disability Claim 
    Process Offer?
    
        The Commissioner established five primary objectives against which 
    SSA will measure the success of a redesigned disability claim process:
    
    -- The process is user friendly for claimants and those who assist 
    them;
    -- The right decision is made the first time;
    -- Decisions are made and effectuated quickly;
    -- The process is efficient; and
    -- Employees find the work satisfying.
    
        By focusing on these objectives, the redesigned process replaces an 
    existing process that is slow, labor-intensive, and paper reliant with 
    a seamless claim process that makes better use of technology, 
    eliminates fragmentation and duplication, promotes more flexible use of 
    resources, and results in dramatic improvements in public service. With 
    the redesign plan, SSA has embarked on an era of change that will 
    revitalize and streamline the way it delivers disability claim service 
    to the public to achieve greater quality, speed and efficiency.
        Specific customer focused improvements that the plan will offer 
    include a process that will:
         Be a user-friendly, more accessible and customer focused 
    process, that ensures benefits are paid to all eligible individuals as 
    quickly as possible. Case processing times will be cut in half once the 
    new process is fully implemented;
         Provide complete and accurate consumer-oriented 
    information to applicants throughout the process and allow individuals 
    who are able to be full partners in the processing of their claim;
         Utilize modern technology and highly skilled and trained 
    employees to deliver high-quality service in an accountable, cost-
    efficient manner;
         Implement a comprehensive quality assurance program that 
    continually strives to improve operational excellence and the level of 
    service that disability applicants receive; and
         Use education and training opportunities to enrich 
    employees jobs, increase their job satisfaction and quality of work 
    life.
        A detailed description of the redesigned disability claim process 
    is included in the attached plan.
    
    What Happens Next?
    
        SSA will move quickly to begin implementing the redesigned 
    disability claim process. Some new process features, involving research 
    and changes to regulations and computer systems, necessitate a phased-
    in approach. Other new process features can be implemented in the near-
    term and, when combined with special short-term initiatives to address 
    case backlogs, will result in better service for individuals currently 
    filing for disability benefits. The goal is to make near-term, visible 
    improvements while at the same time building for long-term results.
        SSA will make an unprecedented effort to conduct a full and open 
    dialogue with both SSA and non-SSA audiences as the Agency moves 
    through the implementation phase. The Agency will use all appropriate 
    modes of communication to ensure that necessary information about 
    implementation activities is regularly and widely disseminated and will 
    develop appropriate feedback channels to permit the meaningful exchange 
    of information.
    
        Dated: September 7, 1994.
    Rhoda M. G. Davis,
    Director, Process Reengineering Program.
    
    Message From the Commissioner
    
    Social Security Administration's Plan for a New Disability Claim 
    Process
    
        It was 10 months ago that I challenged this Agency to restore 
    public confidence in its programs, provide world-class service to its 
    customers, and ensure a nurturing environment for its employees. While 
    there is much left to be done to meet these goals, I am proud to say 
    that with the release of this document we have reached a major 
    milestone toward meeting the challenges I set forth.
        This document lays the foundation for the new disability claim 
    process. It is a solid foundation upon which to build--it provides a 
    broad description of the new process, with the detailed elements of the 
    process to be developed.
        The new design gives us the opportunity to develop relationships 
    with the public and our employees that are based on open communication, 
    partnership, and the belief that our customers need to be provided as 
    much information as possible about the process and the program. I 
    believe this new design holds the potential to provide the world-class 
    service I pledged to furnish the American people--it will be user-
    friendly, it will ensure the right decision is made the first time, it 
    will allow decisions to be made and effectuated quickly, and it will be 
    an efficient process. Just as importantly, the new design will also 
    provide our employees with a nurturing environment through empowerment, 
    education, challenge, career opportunity, and professionalism.
        As the discussions about our reengineering effort and the future of 
    the disability claim process evolved, I listened to the issues and 
    opinions and the hopes and fears that have been expressed. I heard from 
    SSA and State employees, the public, members of Congress, 
    representatives of other Federal agencies, State officials, union 
    representatives, and various experts in the disability field. I believe 
    that everyone wants something better for the American people. I am 
    convinced that we must be bold in our efforts. Therefore, I have chosen 
    to accept the recommendations of the Agency's Disability Process 
    Reengineering Team which were presented to me on June 30, 1994, with 
    the full understanding that certain aspects of the decisional 
    methodology will require extensive research and testing to determine 
    whether they can be implemented. Because those aspects of decisional 
    methodology that deal with functional assessment, baseline of work, and 
    the evaluation of age require much study and deliberation with experts 
    and consumers, we are making no conclusions about their ultimate place 
    in the disability process. Our implementation plans include the 
    research needed to begin in this area. As more is known, we will 
    reevaluate our planning assumptions. Until then, the concept of a 
    single person as the disability claim manager for all cases cannot be 
    fully implemented. Instead, we will seek ways of working in teams to 
    provide claimants with the level of service they seek.
        The cost of redesigning our disability claim process will not be 
    inexpensive; however, the tangible savings will be worth the 
    investment. The workyear savings will allow us to use current staff to 
    accomplish other pressing workloads and activities of the Agency while 
    avoiding new hiring to replace all those who retire or otherwise leave 
    on their own accord. Thus, we will be able to do our part to reduce the 
    Federal workforce overall. Additionally, with these savings will come 
    such intangibles as improved customer service, an empowered and better 
    trained workforce, and increased public confidence in the process.
        It is now time for us to move forward with concrete actions to 
    begin the actual redesign of the way we do business in our disability 
    programs. On July 12, 1994, I announced that Charles A. (Chuck) Jones, 
    the Director of the Michigan Disability Determination Service, had 
    accepted the challenge of managing the implementation of SSA's plan to 
    reengineer the disability process. In that role, he will be responsible 
    for the overall leadership and coordination of the redesign 
    implementation. He will establish timelines and priorities and will 
    provide direction to component efforts as well as to task management 
    teams. As Implementation Manager, Chuck will report directly to me and 
    the Principal Deputy Commissioner.
        During the discussions of the Team's proposal, I heard several 
    consistent underlying themes about how our new design should be 
    implemented: we must unify the process; we need enabling information 
    technology; we need to ensure the safety of employees; we must 
    continuously deliver effective training; we must retain the existing 
    Federal/State relationship; and we must develop a simpler methodology 
    for making disability decisions. I am absolutely committed to turning 
    these needs into realities as we move ahead. Some will not be easy, and 
    all will take time and money; however, all will need to be addressed if 
    we are to achieve the successful outcome of the redesign.
        As implementation plans are developed and task teams are brought 
    together, we will continue to assess all related activities against the 
    five primary objectives of our redesigned process:
    
    --making the process ``user friendly'' for claimants and those who 
    assist them;
    --making the right decision the first time;
    --making the decision as quickly as possible;
    --making the process efficient; and
    --making the work satisfying for employees.
    
        However, this work will not be done in isolation-- internally, we 
    will continue to seek advice on these issues from our Advisory Group, 
    comprised of SSA and DDS executives and union and association leaders. 
    Externally, we will continue to publicly inform all who are interested 
    and create opportunities for dialogue and consultation.
        Special thanks are extended to the Disability Process Reengineering 
    Team whose recommendations are the result of an unprecedented endeavor 
    for this Agency, and I dare say for most Federal agencies. The Team's 
    thousands of hours of interviews, research, analysis, computer 
    modeling, feedback sessions, and revisions have created a daring image 
    for us of what can be if we truly seek to provide world-class service. 
    We must accept their challenge and begin the arduous task of bringing 
    to reality what is now only a concept.
        The next few years will be challenging for all of us as we build 
    our redesigned process, but that will not be a new experience for those 
    of you who are employees of SSA and the State DDSs. You have been 
    called upon in the past to rise to the occasion and have always more 
    than met the challenge; your flexibility, resourcefulness, 
    professionalism, and just plain hard work are legendary. Now more than 
    ever, I will need you to be bold and help build a better future for 
    those who seek our services.
    Shirley S. Chater,
    Commissioner of Social Security.
    
    Case for Action
    
    Overview
    
        SSA and the State Disability Determination Services (DDSs) have 
    always striven to provide high-quality, responsive service to the 
    public. In recent years, the disability insurance (DI) and Supplemental 
    Security Income (SSI) claims workload has been the Agency's most 
    challenging problem. SSA has been faced with unprecedented workload 
    increases in both the DI and SSI programs which have severely strained 
    its resources. Despite improvements in productivity by employees in 
    field offices, DDSs, hearing offices, the Appeals Council and the 
    processing centers over the last several years, SSA has had difficulty 
    providing a satisfactory level of service to claimants for disability 
    benefits. SSA recognizes that, in an era of spending limitations and 
    competing social spending priorities, placing more and more resources 
    into the current process is not a viable alternative.
        Additionally, demographic changes in the general population and in 
    the SSA claimant population present challenges as well as opportunities 
    as SSA strives to provide world-class service to its customers. Despite 
    the workload and demographic changes, however, the procedures for 
    processing disability claims have not changed in any important way 
    since the beginning of the DI program in the 1950's and many of the 
    Agency's current practices are based, in large part, on procedures 
    begun 40 years ago. Disability process changes that have evolved over 
    time tend to reflect small, incremental improvements designed to 
    address various pieces of the overall process. It has become 
    increasingly clear that incremental improvements are no longer 
    sufficient to achieve the level of service that will make a substantial 
    difference to disability claimants. Thus, SSA needs a longer-term 
    strategy for addressing service delivery problems in the disability 
    claim process.
    
    Workload and Operations Trends
    
        Over the last several years, as workloads have increased 
    dramatically, the disability process has been placed under increasing 
    stress. The upward trend in the number of claims and the number of 
    beneficiaries awarded is reflected as follows:
    
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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 Fiscal Year (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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        The high workload level is expected to continue and will adversely 
    affect SSA's ability to timely process initial disability claims and 
    appeals. Recent management initiatives to improve service through 
    resource reallocations and productivity enhancements have not been 
    sufficient to deal successfully with the workload demands and it is 
    expected that disability processing times and backlogs will continue to 
    grow under the present process. In FY 1995, it is estimated that 2.9 
    million initial disability claims will be forwarded to DDSs for 
    disability determinations--a 69 percent increase over FY 1990 levels. 
    Similarly, in FY 1995, annual requests for administrative law judge 
    (ALJ) hearings will rise to 542,000, a 75 percent increase over FY 1990 
    levels. The average time to process an initial disability claim (the 
    combined average for both DI and SSI claims) is expected to rise to 154 
    days in FY 1995; the average time from ALJ hearing request to decision 
    is expected to rise to 342 days in the same period.
    
    Demographic Trends
    
        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 new 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 limited or no 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. Homeless individuals and others with special 
    needs have strained the delivery system. These claimants require 
    significant intervention and assistance to navigate the disability 
    claim 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 granted 
    this assistance and three-fourths of those grantees were still 
    receiving assistance when they applied for disability benefits. SSA has 
    the opportunity to develop productive relationships with these social 
    service 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 the ways it interacts with providers of claims-related 
    information and evidence.
    
    The Current Process
    
        The procedures in the current process have not changed in any 
    significant way since the 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 SSI program and added this to the 
    responsibilities of SSA. SSA adopted the DI disability determination 
    procedures for SSI blind and disabled claims.
    
    Slow, Manual Process
    
        In the current process, a disability claim passes through from 1 to 
    4 decisional paths to receive a favorable decision. The initial claim, 
    reconsideration, ALJ hearing and Appeals Council review levels all 
    involve multi-step uniform procedures for evidence collection, review, 
    and decisionmaking.
    
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        The process starts at the initial level when an individual first 
    applies for DI and/or SSI 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 DDSs 
    where medical evidence is developed and a final decision is made 
    regarding the existence of a medically determinable impairment which 
    meets the definition of disability. The decision is made by an 
    adjudicative team consisting of a disability specialist and a program 
    physician.
        After possible quality assurance review in the DDS or in the SSA 
    regional Disability Quality Branch, the claim is returned to the field 
    office; denials are retained pending possible appeal. In FY 1993, 39 
    percent of initial claims were allowed and sent to 1 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 effectuation and folder 
    retention. A sample of these are reviewed after payment for 
    nondisability quality assurance. According to SSA's computer-based 
    processing time measurements, an initial claim currently takes an 
    average of about 100 days to process from the time of filing until a 
    decision is made. However, from the claimant's perspective, a better 
    understanding of how long the process takes comes from a 1993 study 
    conducted by SSAs 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. During this period, 
    16 to 26 employees will handle the claim.
        The claimant may request reconsideration of the initial decision 
    within 60 days of receiving the denial notice. In FY 1993, claimants 
    requested reconsideration in 48 percent of denied claims. Local field 
    office personnel receive the reconsideration request, update necessary 
    information, and forward the claim file to the DDS for review, possible 
    medical development, and a medical decision. The reconsideration 
    decision 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 a 
    processing center; the remaining denials are forwarded to the field 
    office for retention, pending possible further appeal. According to 
    SSAs computer-based processing time reports, the average 
    reconsideration takes about 50 days--however, according to the Office 
    of Workforce Analysis study, a claimant has now been involved with the 
    disability process for roughly 8 months from the initial contact with 
    SSA, and up to 36 different employees could have handled the claim.
        A claimant can request a hearing before an ALJ within 60 days of 
    receiving an unfavorable reconsideration decision. In FY 1993, 
    claimants requested an ALJ hearing in about 75 percent of all 
    reconsideration denials. By this time, 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 level. Local field office personnel receive the request for 
    hearing and forward 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 decision.
        DI claims allowed at the hearing level are sent to a processing 
    center for payment effectuation and adjudication of claims for 
    dependents, and storage. 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 pending a 
    possible request for review. According to computer-based reports, the 
    hearing process takes about 265 days. 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.
        If dissatisfied with the hearing decision, a claimant (or 
    representative) may request Appeals Council review within 60 days of 
    receiving the ALJ decision. In FY 1993, about 23 percent of hearing 
    decisions were unfavorable. 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 
    deny or dismiss a request for 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 claims are sent to a processing center 
    or field office for further action as in hearing cases. 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.
        At least part of the 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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    Complex, Confusing Process
    
        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. Claimants often do not understand what happens to the claim 
    after initial contact with SSA and view multiple requests for medical 
    information with annoyance. Often claimants do not understand how the 
    decision was made and, therefore, believe that it was reached 
    arbitrarily. 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.
        SSA employees, claimants, and other interested parties all agree 
    that the current 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. 
    Quality reviews and Appeals Council reviews are often mentioned as 
    areas where opportunities exist for streamlining and improving the 
    current process.
        Claimants and their representatives have learned their chances for 
    a favorable decision improve if they appeal their claim to an ALJ. The 
    public, in particular, believes that it is necessary to hire an 
    attorney to maneuver through the appeals process, and voices resentment 
    at having to do so. Higher allowance rates at the ALJ level lead to the 
    perception that different adjudicative standards apply at the initial 
    and appeals levels. A variety of factors may be contributing to this. 
    The facts of many cases change over time as a claimants 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.
    
    Contributors to Complexity
    
        The collection of medical evidence presents problems as the case is 
    developed, accounting for a considerable portion of the total time 
    involved in disability claim processing. Health care providers who are 
    a claimants treating source often do not understand the requirements 
    for establishing disability, and find medical evidence request forms 
    confusing and repetitive. They believe that evidence requests burden 
    them with far too much paperwork and offer far too little in the way of 
    compensation for the time invested. Adjudicators often find that 
    evidence is primarily treatment-oriented and fails to provide either 
    the highly specialized clinical findings or the functional information 
    that is required by the regulations. 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 
    by disability decisionmakers is complex and controversial. The current 
    sequential evaluation process, which was originally designed to 
    identify and evaluate cases in a simple, rapid and consistent fashion 
    has grown increasingly complex as the result of court decisions and 
    changes in medical technology. This complexity has, in turn, 
    contributed to the increasing difficulty and fragmentation in other 
    portions of the disability process, including intake, evidence 
    collection, and appeals.
        For example, the Listings of Impairments was originally designed to 
    highlight readily identifiable disabling impairments. Many of the 
    Listings have since evolved into complex and highly detailed diagnostic 
    requirements, demanding specialized medical evidence that may not be 
    readily available from treating sources. Some, but not all, of the 
    Listings consider the functional consequences of an impairment; however 
    functional considerations vary significantly among the Listings. 
    Additionally, in assessing an individuals functional abilities at the 
    later steps in the sequential evaluation, adjudicators collect and 
    analyze evidence from a multitude of different, and often conflicting, 
    sources including: objective clinical and laboratory findings; treating 
    source opinions and other third-party statements considered to be 
    consistent with the objective evidence; and the individuals description 
    of his or her limitations. The development of extensive medical 
    evidence in every case impedes timely and efficient decisionmaking. The 
    varying approaches to assessing a claimants functional ability that are 
    required at different steps in the sequential evaluation, along with 
    the nature and types of evidence that adjudicators may rely on to 
    assess function often lead to different interpretations of the same 
    evidence by different adjudicators. Vocational rules originally 
    designed to provide a structured approach to decisionmaking have grown 
    increasingly complex, leading to varying interpretations and 
    inconsistent decisions.
    
    Fragmented Process
    
        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 from 
    the courts 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 components 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.
    
    The Need for a Redesigned Disability Claim Process
    
        Concerns about the Agency's business processes generally, and the 
    quality of service in the disability claim process in particular, led 
    SSA leadership to the conclusion that a disability process 
    reengineering effort was critical to the SSA goal of providing world-
    class service to its customers. The National Performance Review, headed 
    by the Vice President, directed improvement of the SSA disability 
    process as a key service initiative for the Federal government.
        Leading private sector organizations have used process 
    reengineering to identify and quickly put in place dramatic 
    improvements in their operations. The objective of a reengineering 
    review is to fundamentally rethink and radically redesign a business 
    process from start to finish, so that it becomes many times more 
    efficient and, as a result, significantly improves service to the 
    organization's customers. By focusing on the disability claim process 
    as a single business process, SSA hoped to cut across the 
    organizational lines and multiple components that handle the many 
    pieces of the disability process.
    
    Redesign Technique
    
        A project team composed of 18 Federal and State employees, under 
    the direction of an SSA senior executive, assembled at SSA Headquarters 
    in October 1993 to conduct the disability claim process reengineering 
    review. With the guidance of an Executive Steering Committee the Team 
    was challenged to fundamentally rethink the way SSA processes 
    disability claims. The Team's initial findings and proposal, issued in 
    March 1994, for a redesigned disability claim process were widely 
    shared during a 60-day public comment period. Based on the comments 
    received, the Team presented a revised proposal to the Commissioner of 
    Social Security on June 30, 1994. After extensive consultation with 
    individuals and organizations in the internal and external disability 
    community, the Commissioner accepted the Team's recommendations for a 
    redesigned disability process. A summary of the methodology used to 
    redesign the disability claim process is included in Appendix I.
    
    New Process Goals and Expectations
    
        The Commissioner established five primary objectives against which 
    SSA will measure the success of a redesigned disability claim process:
    
    --The process is user friendly for claimants and those who assist them;
    --The right decision is made the first time;
    --Decisions are made and effectuated quickly;
    --The process is efficient; and
    --Employees find the work satisfying.
    
        By focusing on these objectives, the redesigned process replaces an 
    existing process that is slow, labor-intensive, and paper reliant with 
    a seamless claim process that makes better use of technology, 
    eliminates fragmentation and duplication, promotes more flexible use of 
    resources, and results in dramatic improvements in public service. With 
    the redesigned process, SSA has embarked on an era of change that will 
    revitalize and streamline the way it delivers disability claim services 
    to the public to achieve greater quality, accuracy, speed and 
    efficiency. A detailed description of the redesigned disability claim 
    process is presented in the following section.
    
    Description of the New Process
    
    Overview
    
        Claimants for disability benefits under the new process will be 
    provided a full explanation of SSA's programs and processes at the 
    initial contact with SSA. Claimants will be offered a range of options 
    for filing a claim and conferring with decisionmakers, using various 
    modes of technology to interact with SSA. Claimants, who are able to do 
    so, along with third parties and representatives who act on their 
    behalf, will assist in the development of their claims, deal with a 
    single contact point in the Agency, and have the right to a personal 
    interview with decisionmakers at each level of the process. The number 
    of steps will be consolidated and the issues on appeal will be focused. 
    If the claim is approved, the effectuation of payment to the claimant, 
    eligible dependents and the representative will be streamlined.
    
    BILLING CODE 4190-29-P
    
    TN19SE94.070
    
    
    BILLING CODE 4190-29-C
        The new process will result in correct decisions at the earliest 
    possible point in the process. A correct disability decision is one 
    that appropriately considers whether an individual does or does not 
    meet the factors of entitlement for disability as defined by SSA's 
    statute, regulations, rulings and policies. Correct decisions in the 
    new process depend on: a simplified decision methodology that provides 
    a common frame of reference for deciding disability at all levels of 
    the process; consistent direction and training to all adjudicators; 
    enhanced and targeted collection and development of medical evidence; 
    an automated and integrated claim processing system that will assist 
    adjudicators in evidence gathering, analysis and decisionmaking; and a 
    single, comprehensive quality review process across all levels. The 
    goal of the new process is to guide all adjudicators at all levels of 
    the process, who will be using the same standards for decisionmaking, 
    to making correct decisions in an easier, faster, and more cost-
    effective manner.
        A disability claim manager will handle most aspects of the 
    disability claim at the initial level, 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 evidentiary 
    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 new process will enable the current work force to handle an 
    increased number of claims, freeing the most highly specialized 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 new process will 
    facilitate employees' ability to do the total job by providing 
    technology and the training and support to use that technology. [For 
    ease of reference, references in this plan to ``SSA'' or ``employees'' 
    include both Federal and State employees who participate in the 
    disability process.]
    
    Process Entry and Intake
    
    Customized Intake and Entry
    
        The disability claim 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. Every effort will be made to provide 
    services to meet the needs of culturally diverse, non-English speaking 
    claimants. SSA will also be flexible in providing modes of access to 
    the claim process that best meet the needs of claimants and the third 
    parties and representatives who act on their behalf. SSA will provide 
    claimants with a single point of contact for all disability claim-
    related business. Finally, SSA will ensure that the disability 
    decisionmaking process promotes timely and accurate decisions.
    
    Making Program Information Available
    
        SSA will make available to the general public comprehensive 
    information packets about the DI and SSI disability programs. [For ease 
    of reference, references in this plan to the SSI Disability Program 
    include the Program for those who are blind.] 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. 
    The packets may be customized locally to include referral information 
    about other programs and resources for legal representation. The goal 
    is to target the information to likely beneficiaries and to ensure that 
    potential claimants and other 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. This should result in reduction of general inquiries from 
    members of the public unfamiliar with SSA disability programs and 
    increase the number of claimants who enter the disability process 
    knowledgeable and prepared to assume responsibility for pursuing their 
    claims.
        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 who are able to do so 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 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).
    
    Claimants Will Choose Mode of Entry
    
        The disability claim entry process will be multi-faceted, allowing 
    claimants and third parties and representatives who assist them the 
    maximum flexibility in deciding how they will participate in the 
    process. Claimants may choose to enter the disability claim 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 claim 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 claim processing system to 
    protect the claimant's filing date and schedule an appointment for a 
    claim 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 claim 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 claim 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 claim 
    intake interview. Depending on an individual's circumstances, such 
    accommodation may involve: Referral to the nearest location for 
    obtaining a disability 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 claim intake and development; however, face- to-
    face interviews will not be required in every claim. 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. Every effort will be made to 
    provide services to members of the public who have limited knowledge of 
    English.
        Similarly, local managers will modify the claim 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.
        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 claim process without considerable 
    intervention. As appropriate, outreach efforts may be facilitated 
    through videoconferencing, teleconferencing or other electronic methods 
    of obtaining and processing claim information to provide timely service 
    despite claimants' geographic or social isolation.
    
    Disability Claim Manager
    
        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 medical and nonmedical aspects of the disability programs 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, including medical and technical 
    support personnel, to provide advice and assistance in the claim 
    process.
        Disability claim managers will rely on an automated claim 
    processing system that will permit them to: Gather and store claim 
    information; develop both medical and nonmedical evidence; share 
    necessary facts in a claim with medical consultants and specialists in 
    nonmedical or technical issues; analyze evidence and prepare well-
    rationalized decisions on both medical and nonmedical issues; and 
    produce clear and understandable notices that accurately convey all 
    necessary information to claimants. In making decisions, disability 
    claim managers will use a simplified decision methodology that 
    effectively streamlines evidence collection, and will rely on standards 
    for decisionmaking that are used at all levels of the process.
        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 programs to the 
    claimant, including the definition of disability and how SSA determines 
    if a claimant meets 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 the claimant access 
    to the decisionmaker and allow for ongoing, meaningful dialogue between 
    the claimant and the disability claim manager.
    
    Scope of Duties
    
        The broad scope of the disability claim manager's duties and 
    responsibilities, as outlined above and discussed in more detail in the 
    following sections, presupposes a well-trained, skilled, and highly 
    motivated workforce that has the program tools and technological 
    support to issue quality decisions. Although disability claim managers 
    will work exclusively within the disability programs, they will perform 
    multiple tasks instead of singular activities, enabling them to 
    experience the direct relationship between their actions and the final 
    product. Varying levels of job complexity provide the opportunity for 
    personal development, growth, and learning.
        In carrying out their duties and responsibilities, disability claim 
    managers will work in a team environment with internal medical and 
    nonmedical experts, who provide advice and assistance for complex case 
    adjudication, as well as technical and other clerical personnel who may 
    handle more routine aspects of case development and payment 
    effectuation. Where disability team members cannot be physically co-
    located, they can share information via the automated claim processing 
    system and remain in communication using telephones or 
    videoconferencing. Each disability team member will have at least a 
    basic familiarity with all the steps in the process and an 
    understanding of how he or she complements another's efforts; team 
    members will be able to draw upon each other's expertise on complex 
    issues.
        In this team environment, and with the proper training, program 
    tools (a simplified decision methodology and one set of standards for 
    decisionmaking) and technological support, one individual should be 
    able to handle the duties and responsibilities of the disability claim 
    manager. An individual employee as the disability claim manager is 
    basic to the objective of a single point of Agency contact for 
    claimants.
        However, in the near term, it may be necessary to consider whether 
    the duties of a disability claim manager may be more appropriately 
    carried out by more than one individual and, therefore, whether it is 
    necessary to expand the ``disability team'' described above to include 
    additional employees. Claim complexity, customer service needs, and 
    service area location may dictate a need for flexibility in delineating 
    the specific duties of the individuals who comprise the members of the 
    disability team. In the near term, apprentice positions will be 
    developed in which employees perform one or more duties of the 
    disability claim manager while gaining experience and qualifying for 
    greater responsibility. As the program tools and technological support, 
    which are the underpinnings of the new process, are fully implemented, 
    it is envisioned that team duties and positions will be modified and 
    consolidated as necessary to fully realize the goal of an individual 
    employee as disability claim manager.
    
    Process Flexibility
    
        The disability claim manager will conduct a thorough screening of 
    the claimant's medical and nonmedical eligibility factors. If the 
    claimant appears ineligible for either disability program based on the 
    claimant's allegations and evidence presented or available at the time 
    of the claim intake interview, the disability claim manager will 
    explain this to the claimant. However, the decision regarding whether 
    to file an application will be the claimant's alone and the disability 
    claim manager will not discourage a claimant from filing an 
    application. If the claimant decides not to file a claim, the 
    disability claim manager will follow existing procedures for closing 
    out an oral inquiry.
        If the claimant decides to file, the disability claim manager will 
    complete appropriate application screens from the automated and fully 
    integrated (DI and SSI) claim processing and decision support system. 
    Impairment-specific questions will assist the disability 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 the 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 if the claimant is able 
    to do so, requesting medical evidence directly from treating sources, 
    or ordering further medical evaluations. As in the current process, SSA 
    will pay for the reasonable cost of providing existing medical 
    evidence. If the claimant has a formal representative, the 
    representative will have the responsibility to develop medical and 
    nonmedical evidence.
        The disability claim manager will decide whether to defer 
    nonmedical development (e.g., requesting SSI income and resource 
    information, or developing DI dependents' claims) or do it 
    simultaneously with development of the medical 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. SSA will develop guidelines to assist the 
    disability claim manager in determining when expert medical advice is 
    appropriate. 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 medical 
    and nonmedical aspects of the disability claim.
    
    Claimant Partnership
    
        Throughout the disability claim process, SSA will encourage 
    claimants to be full partners in the processing of their claims. Many 
    claimants are able to obtain the documentation necessary to develop 
    their record, either on their own or with the assistance of a third 
    party. Others have substantial difficulty doing so, 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.
        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 claim 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, including any difficulty in obtaining the 
    information the claimant agreed to obtain.
    
    Third Parties
    
        Certain third-party organizations may be willing to provide a 
    complete disability application package to SSA. Based on local 
    managements assessment of service area needs and the availability of 
    qualified organizations, SSA will recognize 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 medical and 
    nonmedical 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. SSA will monitor such third 
    parties to ensure that quality service is provided to claimants and to 
    prevent fraud. SSA may establish rules, standards, and procedures for 
    third-party interaction with claimants and SSA. Third parties may be 
    required to undergo periodic program, procedural or software training, 
    and may be required to meet standards for staffing and automation 
    support. In individual cases, disability claim managers may elect to 
    contact the claimant for the purpose of verifying identity or other 
    claim-related issues, as appropriate. SSA will also perform ongoing 
    document verification on a sample basis to assure the integrity of 
    claims submitted by third parties. The automated claim processing 
    system will facilitate effective monitoring of the claim-taking and 
    evidence submission practices of third parties by permitting random 
    and/or targeted selection of claim files involving specific third 
    parties or specific types of evidence.
    
    Personal Interview With Claimant
    
        When the evidence does not support an allowance, the disability 
    claim manager will issue a predecision notice advising the claimant of 
    what evidence has been considered and providing the opportunity to 
    submit further evidence, if any, and/or the opportunity for a personal 
    interview within 10 calendar days. The predecision notice will further 
    advise the claimant that if he or she does not submit evidence or 
    request a personal interview within the 10 days, the claim will be 
    decided based on the evidence of record. If the claimant requests a 
    personal interview, the disability claim manager will conduct the 
    interview in person, by videoconference, or by telephone, as the 
    disability claim manager determines is appropriate under the 
    circumstances. In appropriate circumstances, this predecision interview 
    may be held concurrently with the initial intake interview. If the 
    claimant identifies further available evidence, the disability claim 
    manager will advise the claimant to obtain the evidence if the claimant 
    is able to do so or, as necessary, assist the claimant in obtaining it. 
    The claimant will be advised of the specified timeframes for submitting 
    additional evidence.
        In preparing the predecision notice, the disability claim manager 
    will rely on existing information available on-line as part of the 
    automated claim processing and decision support system. As part of the 
    evidence gathering process, the disability claim manager will have 
    previously analyzed all the medical and non-medical information 
    gathered, and entered the pertinent data into the electronic claim 
    record. The decision support system will use the accumulated data in 
    the electronic record to assist the disability claim manager in 
    producing the predecision notice.
    
    ``Statement of the Claim''
    
        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 as a result of the predecision 
    notice, and the rationale in support of the determination. The 
    statement of the claim not only reflects SSAs 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.
        As with the predecision notice, 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 claim 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 Agencys action, 
    if the claimant seeks further administrative review.
        In making initial disability determinations, disability claim 
    managers will rely on standards for decisionmaking that are used at all 
    levels of the process. SSA will develop a single presentation of all 
    substantive policies used in the determination of eligibility for 
    benefits and all decisionmakers will be bound by these same policies. 
    These policies will be published in accordance with the Administrative 
    Procedure Act. Expert systems will be developed to facilitate the 
    development and delivery of disability policy as an integrated part of 
    the automated claim processing system.
    
    Disability Decision Methodology
    
    Promoting Consistent, Equitable, and Timely 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.
        As described further below, the goal of the new decisionmaking 
    approach is to focus decisionmaking on the functional consequences of 
    an individual's medically determinable impairment(s). The new process 
    will assess an individual's functional ability, assess it once in the 
    process, do it directly rather than indirectly, and rely on 
    standardized functional assessment instruments to do so. By focusing on 
    function, the new approach will permit both providers of medical 
    evidence and adjudicators at all levels of the process to use a 
    consistent frame of reference for deciding disability, regardless of 
    the diagnosis. It will also facilitate evidence collection by lessening 
    the need for voluminous medical records and, instead, look at the 
    consequences of medical findings, i.e., function. Ultimately, 
    adjudicators will make correct decisions in an easier, faster, and more 
    cost-effective manner.
        The cornerstone of the new 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. . .'' (Sec. 223(d) of the 
    Social Security Act).
    
    Four-Step Evaluation Process for Adults
    
        The new decisionmaking approach is the foundation on which SSA will 
    base the claim intake process and evidence collection. The focus will 
    be, first, to document the medical basis for concluding that an 
    individual has a medically determinable physical or mental impairment. 
    Second, once the evidence establishes a medically determinable 
    impairment(s), decisionmakers will, in most cases, use additional 
    medical findings to determine the link between the disease or 
    impairment and the loss of function.
        The disability decision methodology will consist of four steps that 
    flow from 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 included in the 
    Index of Disabling Impairments i.e., an impairment that clearly 
    restricts functional ability to a degree that the individual is unable 
    to engage in substantial gainful activity without measuring the 
    individual's functional ability?
        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. Under the new approach, SSA will 
    simplify the monetary guidelines for determining whether an individual 
    who is an employee (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. Additionally, SSA 
    will continue to exclude impairment-related work expenses in evaluating 
    whether an individual's earnings constitute substantial gainful 
    activity. SSA will continue to evaluate whether work activity is done 
    under special conditions and/or is subsidized. Finally, SSA will 
    continue to use separate earnings criteria to evaluate the work 
    activity of blind individuals in the DI program 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 new approach, decisionmakers will 
    consider whether an individual has a medically determinable impairment 
    or combination of impairments, but will no longer impose a threshold 
    ``severity'' requirement. Rather, the threshold inquiry will be whether 
    the individual has a medically determinable physical or mental 
    impairment or combination of impairments. 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.
        Decisionmakers 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 that the individual 
    has a medically determinable impairment or combination of impairments. 
    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 or combination of 
    impairments. Depending on the nature of an individual's alleged 
    impairment(s), 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 individual'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 an individual 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, the 
    decisionmaker will compare the individual's impairment(s) against an 
    index of severely disabling impairments. The index will describe 
    impairments so severely debilitating that, when documented, can be 
    presumed to equal a loss of functional ability to perform substantial 
    gainful activity without assessing the individual's functional ability. 
    The index will be consistent with the statutory definition of 
    disability by limiting the presumption of inability to perform 
    substantial gainful activity, without considering age, education and 
    previous work, to a relatively small number of claims with the most 
    severe disabilities. Individual functional ability will be assessed in 
    all other cases in a consistent manner at Step 4 in the process.
        Because the index will permit severely disabling impairments to be 
    identified quickly and easily, it will only 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 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 easy to understand and 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 conclusions 
    about the effect of an individual's impairments on his or her ability 
    to function merely because an individual's impairment(s) does not meet 
    the criteria in the index. Finally, SSA will no longer need the concept 
    of ``medical equivalence'' in relation to the index. Because 
    impairments included in the index are presumed to limit functional 
    ability so as to preclude substantial gainful activity without 
    reference to an individual's age, education and previous work, a 
    combination of impairments, or an impairment closely related to one 
    that is in the index, would be found disabling when an individual's 
    functional ability is assessed. Therefore, rules for determining 
    equivalence for impairments in the index will not be necessary.
    Step 4--Ability to Engage in Any Substantial Gainful Activity
        The majority of disability claims will be evaluated using a 
    standardized approach to measuring functional ability to perform 
    substantial gainful activity. This standardized approach will 
    realistically measure an individual's functional ability to do the 
    principal dimensions of work and task performance. The approach will be 
    known and accepted in the medical community. It will be universally 
    used by public and private disability programs in which benefits are 
    based on the ability to perform work-related duties. Standardizing the 
    approach to assessing individual functional ability will facilitate 
    consistent decisions regardless of the professional training of the 
    decisionmakers in the disability process.
        In using a standardized approach to measuring functional ability, 
    SSA will be assessing the individual's physical and mental abilities to 
    perform work-related activities. Individualized assessments of 
    functional ability will also consider the effects of the individual's 
    education. Once the individualized assessment of functional ability is 
    made, the individual's age will determine whether his or her functional 
    ability is compared against the demands of the individual's previous 
    work or against a ``baseline'' of occupational demands. The baseline 
    will describe a range of work-related functions that represent work 
    that exists in significant numbers in the national economy that does 
    not require prior skills or formal job training.
    
    Standardized Measure of Functional Ability
    
        SSA will develop, with the assistance of the medical and advocacy 
    community and other outside experts from public and private disability 
    programs, standardized instruments or protocols 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 or combination of impairments. 
    However, extensive development of all available clinical and laboratory 
    findings will not always be necessary 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 individuals abilities to perform a baseline 
    of occupational demands that includes the principal dimensions of work 
    and task performance, including primary physical, 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. To the extent that 
    current regulations already set forth guidelines for evaluating an 
    individual's ability to perform certain of these tasks, they will be 
    utilized in the new process.
        Functional assessment instruments will be designed to realistically 
    assess an individuals abilities to perform a baseline of occupational 
    demands. To the extent possible, objective measures of function will be 
    developed. However, a realistic and individualized assessment of 
    function may require, in addition to objective measures of function, a 
    standardized means or standardized tools for collecting information 
    regarding an individuals perceptions of his or her functioning, the 
    effect of symptoms, including pain, and the individuals activities of 
    daily living. Functional assessment instruments may also require 
    impairment-specific measures to account for the episodic nature of 
    certain impairments or to meet a more general need for longitudinal 
    information.
        SSA will be primarily responsible for documenting functional 
    ability using the standardized functional assessments. In the near 
    term, SSA will solicit information on which to base a functional 
    assessment 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 functional assessments 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 individuals 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.
        Disability insurance payers have incentives to participate in the 
    research necessary to develop standardized functional assessments and 
    some private insurers have already expressed interest in working with 
    SSA in this effort. Standardized functional assessments will not only 
    provide SSA with the functional information necessary to make 
    disability decisions; functional measurements will also assist in 
    developing provider reimbursement levels relating to rehabilitation and 
    in assuring quality in rehabilitation programs by permitting assessment 
    of the relationship between rehabilitative interventions and outcomes. 
    Ultimately, the use of the same functional assessment measurements by 
    both SSA and medical insurance payers will facilitate the cooperation 
    and participation of the medical community in developing, refining, and 
    implementing them.
    
    Baseline Occupational Demands
    
        SSA will use the results of the standardized functional assessment 
    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.
        To develop the new approach, SSA will conduct research and will 
    work in conjunction with outside experts and consumers to specifically 
    identify the activities that comprise a baseline of occupational 
    demands needed to perform substantial gainful activity. The baseline 
    will describe a range of work-related functions that represent work 
    that exists in significant numbers in the national economy. In 
    establishing the work-related functions 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; 
    and 2) the occupations are those that can be performed in the absence 
    of prior skills or formal job training.
        The Department of Labors Advisory Panel for the Dictionary of 
    Occupational Titles (DOT) has made recommendations for developing a new 
    DOT by 1996 which will be a data base system that collects, produces, 
    and maintains accurate, reliable, and valid information on all 
    occupations in the national economy. This new system will provide 
    comprehensive occupational data that includes, but is not limited to: 
    physical demands of work; sensory/perceptual requirements; cognitive 
    job demands; physical working conditions; and job characteristics such 
    as pace or intensity of work, and the scope of interactions with 
    others. The development of a national data base with detailed 
    occupational information should assist SSA in conducting the initial 
    research necessary to identify a baseline of occupational demands that 
    represents work existing in significant numbers in the national 
    economy. It should also provide a mechanism to ensure that the baseline 
    of occupational demands remains current and reflects changes in the 
    national economy over time.
    
    Effect of Education
    
        The statute 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. For example, 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. Similarly, completion of a certain grade level does not 
    necessarily represent mastery of the subject matter.
        In relying on standardized functional assessments, SSA will be 
    measuring an individual's ability to perform the principal dimensions 
    of work and task performance, including primary physical, 
    psychological, and cognitive processes, and the positive effects of 
    education will be appropriately reflected in the assessment of an 
    individual's cognitive abilities. Thus, evaluation of a claimant's 
    educational level will be done as an integral part of establishing the 
    functional ability of that individual. The baseline of occupational 
    demands will not reference prior skills or significant formal job 
    training.
        The issue of whether literacy and/or specific communication or 
    language skills will be a factor in disability evaluation depends on 
    the extent to which such skills are occupational demands of work 
    existing in significant numbers in the national economy. In conducting 
    the necessary research to identify the occupational demands of baseline 
    work that represents work existing in significant numbers in the 
    national economy, SSA will need to consider whether literacy or 
    specific communication and language skills are required as occupational 
    demands.
    
    Effect of Age
    
        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 an 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 age.'' 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 Not Nearing Full Retirement Age
    
        For an individual who is not nearing full retirement age, SSA will 
    compare the individual's functional abilities against the functional 
    demands of the baseline work. 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 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 age, 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 Nearing Full Retirement Age
    
        For individuals who are nearing full retirement age, SSA will 
    compare the individuals functional abilities against the functional 
    demands of the individuals 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 individuals functional ability to the range of work-related 
    functions that represent work that exists in significant numbers in the 
    national economy, i.e., baseline work, and a finding of not disabled 
    will be appropriate if the individual is capable of performing the 
    baseline work. In such claims, when the fact that the individual has no 
    previous work is not related to the existence of his or her 
    impairment(s), a finding of disability will not be appropriate if the 
    individual retains the functional ability to perform a range of work-
    related functions that represent work that exists in significant 
    numbers in the national economy. In contrast, those individuals who 
    have significant functional limitations caused by a medically 
    determinable impairment and lack of education would not be able to 
    perform a range of work-related functions that represent work existing 
    in significant numbers in the economy. Such individuals would be found 
    disabled, as they are today.
    
    Medical Consultant Expertise
    
        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. 
    Additionally, on a national basis, SSA may identify specific types of 
    issues that may require a medical opinion. 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; carry 
    out public relations and training with the medical community; and 
    participate in the quality assurance program.
    
    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).'' 
    Sec. 1614(a)(3)(A) of the Social Security Act)
        Of course, any decision approach for childhood claims must be 
    consistent with the Supreme Courts interpretation of this statutory 
    language in Sullivan v. Zebley, 493 U.S. 521 (1990).
    
    Four-Step Evaluation Process for Children
    
        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. To the extent possible, the 
    approach for childhood claims should mirror the adult approach. 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 an impairment(s) of comparable severity 
    to an impairment(s) that would prevent an adult from engaging in 
    substantial gainful activity?
        If yes, allow.*
        If no, deny.
    
        *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 or combination of 
    impairments, 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 or combination of 
    impairments, 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.
        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 or combination of impairments documented by medically 
    acceptable clinical and laboratory techniques and the impairment(s) 
    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 
    describe impairments so severely debilitating that the impairment is of 
    comparable severity to an impairment that would prevent an adult from 
    engaging in substantial gainful activity without assessing the child's 
    functional ability. As with adults, individual functional ability in 
    childhood claims will be assessed in a consistent manner at Step 4 in 
    the process.
        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. 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 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 an Impairment(s) That Would Prevent an 
    Adult From Engaging in Substantial Gainful Activity
        Consistent with the approach for adult claims, SSA will develop, 
    with the assistance of the medical community and educational experts, 
    standardized instruments 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 or combination of impairments. The functional assessment 
    instruments will be designed to measure, as objectively as possible, a 
    child's ability to function independently, appropriately, and 
    effectively in an age-appropriate manner. Ultimately, the course of 
    documenting and developing for functional abilities in childhood claims 
    will, to the extent possible, mirror the adult approach. However, SSA 
    will consider whether it is appropriate to defer the development of 
    standardized functional assessment instruments for use in childhood 
    claims until it gains experience in the development, refinement and use 
    of such instruments for adults.
        SSA will use the results of the standardized functional assessments 
    to determine whether a child has impairment(s) of comparable severity 
    to an impairment(s) that would prevent an adult from engaging in 
    substantial gainful activity, as in the current process.
    
    Medical Evidence Development
    
    Timely and Accurate Decisions
    
        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.
        The new process will eliminate multiple, repetitive requests for 
    information from health care providers. Health care providers will be 
    relieved of requests for information that burden them with far too much 
    paperwork and will be compensated for the time invested in providing 
    information.
    
    Core Diagnostic and Functional Information Focus
    
        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 used 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. The decisionmaker will develop medical evidence that is 
    sufficient to satisfy the core elements but target evidentiary 
    development to obtain only the evidence necessary to reach an accurate 
    decision on the ultimate question of disability.
    
    Treating Source Preference
    
        SSA will give primary emphasis to obtaining medical information 
    from treating sources that provides 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. Depending on the nature and 
    extent of an individual's impairments and treating sources, statements 
    from multiple medical sources may be appropriate. Once the standardized 
    measurement criteria described earlier are widely available, a 
    standardized functional assessment available from a treating source 
    will be accepted as probative evidence. Treating sources or another 
    examining source may perform the standardized functional assessment at 
    SSA's expense.
    
    Standardized Request Form
    
        SSA will develop a standardized form which effectively tailors a 
    request for evidence to the specific diagnostic and functional 
    assessment information necessary to make a disability decision. Such 
    information includes but is not limited to 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. Treating sources will be 
    encouraged to submit such information 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 in summary form on a 
    single document. In appropriate circumstances, SSA will accept a 
    treating source's statements on the standardized form as to history and 
    diagnosis, 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, without resorting to the traditional, 
    wholesale procurement of actual medical records. In completing 
    standardized 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 does not relieve treating sources 
    from providing objective evidence in support of their diagnoses and 
    opinions; rather it is designed to streamline the collection of 
    necessary evidence. The approach is also consistent with evidence 
    collection methods used by private disability insurance carriers, which 
    request specific medical records in individual claims, when necessary 
    and appropriate to the individual circumstances, or at random as part 
    of a quality assurance program.
        Treating source completion of the standardized forms will be 
    monitored to prevent fraud. Decisionmakers will verify treating source 
    statements by obtaining underlying medical records when appropriate. 
    The automated claim processing system will facilitate effective 
    monitoring of the evidence submission practices of individual treating 
    sources by permitting random and/or targeted selection of claim files 
    involving that treating source for quality assurance and program 
    integrity reviews.
    
    Treating Source Incentives
    
        As in the current process, SSA will pay for the reasonable cost of 
    providing existing medical evidence. SSA will acknowledge the value of 
    treating source information by establishing a national fee 
    reimbursement schedule for medical evidence. The fee reimbursement 
    schedule will utilize a sliding-scale mechanism to reward the early 
    submission of medical information; additionally, the sliding scale will 
    be adjusted to reflect the quality of the evidence received. 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 provide resources to focus professional educational 
    efforts and medical relations outreach at the local and/or regional 
    level to ensure that treating sources are given up-to-date information 
    on program requirements and made aware of specific evidentiary needs or 
    problems as they arise in the adjudication process. SSA will conduct 
    educational outreach on the national level on an ongoing basis with the 
    medical community to provide 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.
    
    Consultative Examination
    
        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, the decisionmaker 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. Those medical providers 
    who conduct consultative examinations for SSA will also 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.
    
    Administrative Appeals Process
    
    Simple, Accessible Process
    
        To eliminate the public perception that multiple, mandatory appeal 
    steps are 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 will not only 
    promote more timely decisions but also ensure that claimants do not 
    inappropriately withdraw from the claim 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 instill public 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, the claimant will be given the basis of a decision in 
    clear and understandable language. Finally, SSA will ensure that its 
    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 as a result of the predecision 
    notice, 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's 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.
    
    First Appeal Level
    
        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 ALJ hearing. If the 
    claimant disagrees with the initial determination, the claimant may, 
    within 60 days of receiving notice, request an ALJ hearing.
    
    Adjudication Officer
    
        When a claimant requests 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 procedures. The adjudication officer will be the focal point 
    for all prehearing activities but will work closely with the ALJ, 
    medical consultants and the disability claim manager, when appropriate.
        The adjudication officer will provide the claimant an in-depth 
    understanding of the hearing process, with particular focus on the 
    right to representation. To prevent delays caused by a lack of 
    understanding of this right, the adjudication officer will again 
    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 be available to 
    answer the claimant's questions and concerns regarding the hearing 
    process.
        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. If the claimant has a representative, 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 and 
    opinion, as appropriate.
        The adjudication officer will have full authority to issue a 
    revised favorable decision if the evidence so warrants. This will 
    ensure that allowance decisions are expedited and not delayed until a 
    formal hearing before an ALJ. If the adjudication officer issues a 
    favorable decision, the adjudication officer will refer the claim to a 
    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 routinely schedule a date for the hearing that is a 
    standard number of days after the hearing request. Standardizing the 
    hearing date process will facilitate claimant understanding and reduce 
    the possibility of non-appearance at the hearing. It will also enable 
    representatives to plan their schedules when taking on a case. The 
    adjudication officer may exercise discretion in establishing an earlier 
    or later hearing date depending on the individual circumstances and the 
    ALJ's calendar. Electronic access to ALJs' calendars, as established by 
    individual ALJs, will facilitate timely and appropriate 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. With 
    completely developed claims before them, ALJs will be able to 
    concentrate their efforts on conducting more hearings and rendering 
    decisions faster.
    
    Hearing Proceedings
    
        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 advance 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 later review by the agency, thus giving the 
    agency full authority 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, a representative. 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 
    claimants interests, particularly when the claimant is unrepresented. 
    However, an improved initial determination process with its focus on 
    early and comprehensive evidentiary development, predecision notices 
    and opportunity for personal interviews, 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 necessary) from SSA 
    personnel. This will permit the ALJ, in most circumstances, to close 
    the record at the conclusion of the oral hearing, deliberate on the 
    issues, and render prompt decisions.
        In making disability decisions, ALJs will rely on the same 
    standards for decisionmaking that are used by the disability claim 
    managers and adjudication officers. 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 to a disability claim manager to effectuate 
    payment.
    
    Final Decision of the Secretary
    
        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 reviews 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. The Secretary's 
    authority for seeking voluntary remand prior to the Secretary's filing 
    of an answer to the civil action is currently provided for in 
    Sec. 205(g) of the Act. Favorable Appeals Council decisions will be 
    returned to the disability claim manager to effectuate payment. The 
    number of civil actions requiring substantive action by the Appeals 
    Council will be relatively small because, in the new process, ALJ 
    decisions will be the result of a fully developed evidentiary record 
    where the factual and legal issues have been focused for final 
    resolution.
        Additionally, the Appeals Council will have a role in a 
    comprehensive quality assurance system. As part of the in-line review 
    component of this system, which is described in greater detail below, 
    the Appeals Council will conduct its own motion reviews of ALJ 
    decisions (both allowances and denials) and dismissals 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, or vacate the dismissal. The Appeals Council's review will be 
    limited to the record that was before the ALJ.
        The Agency will establish appropriate mechanisms to respond to 
    claimant allegations of ALJ misconduct or bias. To the extent that the 
    allegations of ALJ misconduct may affect the final decision in a claim, 
    the Agency will consider whether an appropriate mechanism includes some 
    form of final Agency review at the claimant's request.
    
    Quality Assurance
    
    System of Agency Accountability
    
        SSA will be accountable to the public, the ultimate judge of the 
    quality of SSA service, and 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.
        The quality assurance program will have three primary components: 
    1) substantial resources to ensure that the right decision is made the 
    first time; 2) comprehensive and systematic reviews of the quality of 
    the decisionmaking process at all levels; and 3) measures of customer 
    satisfaction against the SSA standards for service.
    
    Investment in Employees
    
        SSA's ability to ensure that the right decision is made the first 
    time depends on a well-trained, skilled, 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 all 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. Consistent program policy training will be provided to 
    disability decisionmakers at all levels of the process.
        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. Employee feedback on the 
    value of these continuing education opportunities, including the 
    quality of training materials, methods, and instructors, will be used 
    to continually improve training programs.
        In addition to formal program training, SSA will rely on a targeted 
    system of in-line quality reviews and monitoring of adjudicative 
    practices for all employees. The elements include a mentoring process 
    for new employees, peer review for experienced employees and management 
    oversight at key points in the adjudicative process. SSA will create 
    mechanisms that facilitate peer discussions of difficult claims or 
    issues. Quality reviewers and policy makers will participate in these 
    types of discussions. 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. 
    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. 
    Payment errors on claims detected during in-line reviews will be 
    corrected before a claimant is notified of the decision.
        As noted previously, under the Administrative Procedure Act, the 
    ALJ is an independent decisionmaker who must apply an agency's 
    governing statute, regulations and policies, but who is not subject to 
    advance direction and control by the agency with respect to the 
    decisional outcome in any individual claim. Accordingly, a system of 
    peer review, mentoring and management oversight in advance of the ALJ's 
    decisionmaking is inappropriate. However, the ALJ decision may be 
    subject to final agency review. Therefore, as part of the in-line 
    quality assurance process, ALJ decisions (both allowances and denials) 
    and dismissals will be subject to review by the Appeals Council on its 
    own motion prior to effectuation of the ALJ's decision or dismissal.
        Several key features previously described in this plan are critical 
    to ensuring that adjudicators have the necessary program tools to issue 
    accurate decisions. A single presentation of all substantive policies 
    used in determining eligibility for benefits must be in place. 
    Additionally, an automated and integrated claim processing system will 
    provide the necessary technological support for adjudicators at all 
    levels of the administrative process. Expert systems will be developed 
    to integrate disability policy into the claim processing system. Among 
    other things, the claim processing system will facilitate claims 
    taking, evidence development, and the preparation of accurate notices 
    and decisions by providing on-line editing capacity to identify errors 
    in advance and decision support software to assist in analysis and 
    decisionmaking. The processing system will help to identify errors of 
    both procedure 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.
        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 monitor that quality on a systematic, national 
    basis. Accordingly, all employees (including ALJs) will be subject to 
    and receive continuous feedback from comprehensive end-of-line reviews 
    as described in the following section.
    
    End-of-Line Reviews
    
        A second necessary 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 at all levels of the process. This 
    system of quality measurement will include comprehensive reviews of the 
    whole adjudicatory process. At a minimum, a comprehensive end-of-line 
    quality measurement system must: be statistically valid; review both 
    allowances and denials in equal proportion; review the entire 
    disability claim process, both the medical and nonmedical aspects; and 
    review claims decided at all levels of the adjudicatory process.
        These end-of-line reviews will focus on whether correct decisions 
    were made at the earliest possible point 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. 
    However, erroneous decisions detected during end-of-line reviews will 
    be subject to existing reopening regulations. Reliance on an integrated 
    claim processing system will facilitate the selection of a 
    statistically valid sample of claims at all levels of the process for 
    this review.
        An integrated claim processing system will permit the selection of 
    other postadjudicative samples of claims as SSA deems necessary to 
    effectively test new operational procedures or monitor specific 
    procedures in the administrative process; oversee the implementation of 
    new program policy regulations and initiatives; and monitor both 
    internal and external claims development practices to prevent fraud.
        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.
    
    Customer Satisfaction Surveys
    
        A final component of quality assurance is measuring customer 
    satisfaction. To measure whether SSA has met or exceeded the public's 
    service expectations, SSA must measure the public's level of 
    satisfaction with the level of service SSA provides. Customer surveys 
    (including feedback cards) 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 and Management Information
    
    Service Perspective
    
        SSA's measures of performances 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.
        Management information will be current and accessible from an 
    intelligent workstation. In addition to 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 employees 
    will have the flexibility to change parameters and to access the full 
    data base, permitting comparisons of performance and trends analysis. 
    The management information system will also permit customized, 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.
    
    New Process Enablers
    
        Reengineering is dependent on 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 process.
    
    Process Unification
    
        Under the Social Security Act, the Secretary is granted broad 
    authority to promulgate regulations to govern the disability 
    determination process. In addition to regulations, SSA publishes: 1) 
    Social Security Rulings, which are precedential court decisions and 
    policy statements or interpretations that SSA has adopted as binding 
    policy, and 2) Acquiescence Rulings, which 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. ALJs and the Appeals Council rely on the regulations 
    and rulings in making disability decisions. However, guidance for 
    decisionmakers at the initial and reconsideration levels is provided in 
    a series of administrative publications, including: 1) the Program 
    Operations Manual System instructions which provide the substance of 
    the statute, regulations, and rulings in a structured format and 2) 
    other administrative issuances which clarify or elaborate specific 
    policy issues. The use of different source documents by adjudicators 
    fosters the perception that different policy standards are being 
    applied at different levels of decisionmaking in the disability claim 
    process.
        To ensure that SSA provides consistent direction to all 
    adjudicators regarding the standards for decisionmaking, SSA will 
    develop a single presentation of all substantive policies used in the 
    determination of eligibility for benefits. These policies will be 
    published in accordance with the Administrative Procedures Act and all 
    decisionmakers will be bound by these same policies.
    
    Public and Professional Education
    
        Public and professional education is essential to ensure that 
    individuals and other groups involved in the disability process have a 
    proper 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 with the goal of reducing general inquiries from members of 
    the public unfamiliar with SSA disability programs and increasing the 
    number of claimants who enter the disability process knowledgeable and 
    prepared to assume responsibility for pursuing their claims. Pamphlets, 
    factsheets, posters, videos, information on diskettes and on computer 
    bulletin board systems will be developed and presented in a simple, 
    straightforward and understandable manner. Information will be 
    available in many languages and dialects and will accommodate vision 
    and hearing impaired individuals.
        SSA will work with national and local groups involved in the 
    disability programs to develop direct lines of communications. These 
    efforts will be aimed not only at providing information but also at 
    creating ongoing organizational relationships to maintain a dialogue 
    about the disability process.
        SSA will also 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.
        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.
    
    Claimant Partnership
    
        SSA's interaction with claimants will focus on enabling their 
    participation in the process. SSA will also work with third parties, 
    such as family members and community-based organizations, to provide 
    additional claimant support.
        Understandable public information materials and comprehensive 
    information packets will be widely available. Explanations of the 
    programs, the decisionmaking process, and claimant responsibilities 
    will be widely available and furnished at the point individuals first 
    make contact with SSA. Claimants, who are able to do so, will be asked 
    to do more to facilitate development of supporting information, 
    particularly with respect to medical 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 
    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.
        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; enhancement of medical provider capacity to identify 
    potentially eligible patients, secure claims and provide medical 
    evidence; and software with compatible format design which will allow 
    direct input of claim-related information to SSA. 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. Other programs will be able to use SSA-developed 
    decisional support systems to evaluate potentially eligible persons 
    prior to referral and to transfer information to SSA through compatible 
    databases. Local managers will be encouraged to develop and maintain 
    appropriate working relationships with local Federal, State and third-
    party resources.
        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 and workforce empowerment are fundamental ingredients in 
    the new process. In carrying out their duties and responsibilities, 
    adjudicators will work in a team environment with internal medical and 
    nonmedical experts, who provide advice and assistance for complex case 
    adjudication, as well as with technical and other clerical personnel 
    who may handle more routine aspects of case development and payment 
    effectuation. 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 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. Team members will be knowledgeable but will also be 
    able to draw upon each other's expertise on complex issues. 
    Communication among team members will encourage consistent application 
    of disability policy. Improved automated systems will enable members of 
    the team to work together using a shared data base even when they are 
    not co-located. Handoffs, rework, and non-value steps will be 
    significantly reduced and fewer employees will be involved in 
    shepherding each claim through the process.
        Employees will perform multiple tasks instead of singular 
    activities, thus their roles will expand to encompass more of the 
    ``whole'' job. This will enable employees to experience the direct 
    relationship between their actions and the final product. Adequate 
    resources and sufficient training and mentoring will allow employees to 
    acquire the skills they need to process claims from intake through 
    adjudication. Employees will feel more of a sense of ownership for the 
    services they perform as a member of a team focused on serving 
    claimants.
        The new process will rely heavily on increased employee 
    empowerment, applying information technology and using 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: New Rules and Standards of Conduct
    
        The Social Security Act and 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 and others in the pursuit of their 
    claims. Representatives currently have the option for authorization of 
    fees through two procedures: 1) the fee petition method, whereby the 
    representative presents an itemization of services rendered and time 
    expended, and SSA determines a reasonable fee; and 2) the fee agreement 
    method, whereby the claimant and representative agree to a fee of 25 
    percent of the retroactive benefits due or $4,000, whichever is less.
        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. Although the 
    current regulations provide protection for claimants from fee abuses, 
    these rules fall short of assuring claimants that the representatives 
    they retain are qualified and will adequately represent their 
    interests.
        In the new process, SSA will continue to have a responsibility for 
    monitoring representational activity and for safeguarding the interests 
    of claimants. The new process will establish rules of representation 
    and standards of conduct to ensure that representatives fulfill their 
    responsibilities and serve the needs of the claimants they represent. 
    These new rules will, among other things, ensure that claimants receive 
    competent representation; establish a code of professional conduct for 
    representatives in all matters before SSA; and provide sanctions 
    against representatives, including suspension and disqualification from 
    appearing before the Agency in a representative capacity, for violating 
    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 a 
    claimant's personal choice. The new rules and standards of conduct 
    provide the framework for assuring that representatives claimants 
    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.
        SSA will also 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.
    
    Information Technology
    
        Information technology will be a vital element in the new 
    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. The new process will rely on seamless, electronic 
    processing of disability claims from the first contact with the 
    claimant to the final decision, including all levels of administrative 
    appeal. Existing Agency design plans for Intelligent Workstation/Local 
    Area Network (IWS/LAN) and a Modernized Disability System will provide 
    an integrated system and the electronic connectivity necessary to 
    support the new disability process.
        In a seamless electronic environment, all employees will use the 
    same hardware, the same claim assignment and scheduling software, the 
    same decision support 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. In this environment, data will need to be 
    input and validated once and multiple employees may access a single 
    claim record simultaneously.
        Information technology will be applied to enhance access to 
    services by claimants, their representatives, and other third parties. 
    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 
    conduct forums and produce video and computer-based training materials 
    for third parties who wish to participate in assisting claimants 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. Data will be transferred to SSA 
    using agreed upon methods. SSA will allow authorized representatives 
    appropriate access to electronic claim folders. Paper versions of 
    treating source forms will be designed so that the data can be read by 
    scanning equipment into SSA claim processing systems. A single vendor 
    payment system will be used to pay certain evidence providers for 
    information which they provide SSA. 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.
        The ability of decisionmakers to conduct thorough interviews and 
    evidence evaluation, and timely and accurate claim 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. Expert system software 
    will be included in SSA claim 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 rely on decision support features that ask 
    impairment-specific questions. The decision support system will use the 
    accumulated data of the electronic record to assist in the preparation 
    of the predecision notice, the statement of the claim, and decisions 
    rendered on appeal. Where disability decision team members cannot be 
    physically co-located, they can remain in communication by using two-
    way TV and other videoconferencing technologies. 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.
        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.
    
    Cost and Benefits
    
    Introduction
    
        SSA's strategy of coming to closure on an ideal, high-level 
    disability process design before undertaking detailed operational and 
    implementation planning has been consistent from the beginning of the 
    reengineering project. Although this project management approach served 
    SSA well, it has made the very necessary task of cost/benefit 
    projections unusually challenging. The following cost/benefit forecasts 
    will need to evolve as implementation details are developed. The 
    administrative cost numbers presented here cannot be applied to SSA's 
    administrative budget without further analysis.
        SSA will move forward on all aspects of the process redesign plan; 
    however, because of the extensive research and development required for 
    implementation of the simplified disability determination methodology, 
    we have not considered the effect of this redesign feature in our cost/
    benefit planning. In addition, because the ability of a single employee 
    to master the disability claim manager position is dependent on full 
    adoption of a simplified disability determination methodology, the 
    impact from that process redesign feature has also been separated out 
    from our cost/benefit planning at this time.
    
    Service Improvements
    
        Service to the public, as defined by average processing time, would 
    improve dramatically--from around 150 days to pay an initial disability 
    claim today to 60 days after implementation of the new process. Hearing 
    processing time would also improve from about 550 days to 225 days. 
    These figures were derived from running a computer simulation model of 
    the new process.
    
    Program Costs
    
        Under the supposition that SSA's current initial claim and 
    administrative appeal process leads to correct disability 
    determinations within the proper universe of people today, and because 
    SSA is not proposing any changes in the statutory definition of 
    disability, the redesigned process in and of itself would have no long-
    term effect on program outlays.
    
    Administrative Costs and Savings
    
        The project life period for implementing disability reengineering 
    is from October 1, 1994 to September 30, 2000. However, the full 
    benefits from the redesigned process will not be realized until 
    September 30, 2001.
        Cumulative administrative costs during the life of the project are 
    estimated at $148 million. The largest percentage of these costs will 
    be directed to special workforce training on the new process--a 
    critical enabler if the redesign plan is to work. The redesign will not 
    require additional investments in information technology spending over 
    current SSA plans.
        Cumulative administrative savings through FY 2001 are estimated at 
    $852 million. The bulk of these savings will come from more efficient 
    use of Federal and State workyears to process the anticipated 
    disability initial claim and appeal workloads during the project life 
    period. This savings estimate does not factor in Agency resource needs 
    for working existing backlogged disability cases.
        Subtracting cumulative administrative costs of $148 million from 
    cumulative savings of $852 million will result in a pay back to the 
    government of $704 million through FY 2001.
        Ongoing administrative cost savings will be over $305 million 
    annually, beginning in FY 2001. This figure includes spending increases 
    for enhanced employee education, better office security, and expanded 
    claimant services.
        The administrative cost savings associated with this project--$704 
    million during the implementation period, and $305 million annually, 
    thereafter--will allow the Agency to reallocate existing resources to 
    give more attention to other important workloads.
        SSA's workforce profile, with respect to disability process 
    workloads, would include at least the same number of professional 
    positions currently employed at the federal and state level. However, 
    the overall design, if fully implemented with all the process 
    enablers--especially enhanced automation--would require fewer clerical 
    and support positions to handle projected workloads.
    
    Conclusion
    
        SSA is committed to implementing a new disability determination 
    process that will deliver significantly improved service to the public, 
    remain neutral with respect to program dollar outlays, and will be more 
    efficient to administer.
        Administrative cost savings from the process will allow the Agency 
    to reallocate resources to give increased attention to other important 
    workloads.
        However, the redesigned process cannot be implemented without the 
    full funding, development, and installation of a new case processing 
    computer system. In addition, unless SSA invests substantially more 
    funds for research and development of the simplified disability 
    determination methodology, the full benefits of the redesigned 
    process--including better public service and the potential for even 
    greater long-term administrative efficiencies--will not be possible.
    
    Implementation Strategy
    
    Overview
    
        The disability process redesign is a high-level process description 
    that provides a broad vision of how a new process would work but leaves 
    operational, organizational, and other details for later development 
    and implementation. SSA must now begin to transition from the high-
    level analysis into this latter phase. As SSA implements the new 
    process, the five objectives of the redesign effort must continually be 
    kept in the forefront of implementation planning, execution and 
    assessment: the process will be user-friendly for claimants and those 
    who assist them; the right decision will be made the first time; 
    decisions will be made and effectuated quickly; the process will be 
    efficient; and the new process will provide employees with a satisfying 
    work environment. The success of the new process must be measured 
    against these objectives and emphasis must continually be on overall 
    measurement from the customer's perspective, and not individual 
    component results. Implementing a process of the magnitude of the new 
    disability claim process will require a strategy that is comprehensive, 
    creative, and inclusive. The following provides a general framework for 
    how implementation activity will proceed.
    
    Implementation Framework
    
        Planning for the implementation of the new process vision requires 
    a comprehensive approach that moves forward on multiple fronts 
    simultaneously. Although the new process will not be fully implemented 
    until FY 2001, SSA must start on October 1, 1994 (the beginning of FY 
    1995), to initiate activities, changes and improvements that will 
    establish the plan and pace for the long-term full implementation of 
    the new process. The goal is to make near-term, visible improvements 
    while at the same time building for long-term results.
    
    Multiple Track Approach
    
        Immediate or near-term implementation activities are those that can 
    begin in FY 1995 and will be fully implemented nationwide by the end of 
    FY 1996, or for which the research and development or site testing can 
    be initiated within the next two fiscal years. These activities include 
    streamlining and simplification initiatives or other procedural 
    elements of the new process that can be implemented using existing 
    administrative or regulatory discretion. They also include client-
    service activities associated with improving the claimant's access and 
    entry into the disability claim process; the development and site 
    testing of options for streamlining parts of the administrative appeals 
    process; the provision of consistent training and direction to 
    disability decisionmakers; and the establishment of new measures and 
    the testing of new quality assurance mechanisms. Additionally, because 
    the decision methodology associated with the new process depends on 
    significant amounts of research, consultation, development and 
    refinement, SSA must identify the specific research needs, develop the 
    appropriate scope of work and award research contracts as near-term 
    activities.
        Long-range implementation items are those requiring extensive 
    research and development that could not be tested fully before FY 1999 
    or could not be fully implemented nationwide before FY 2001. These 
    activities are those associated with the full development, testing and 
    refinement of a new decision methodology. They also include the 
    implementation of advanced technology enhancements that provide a 
    single, fully-integrated disability claim processing system which 
    supports paperless claim processing and provides interactive 
    capabilities for claimants and those who assist them, and for providers 
    of evidentiary information.
        The remaining mid-term items or activities are those elements of 
    the new process that can be developed and tested in FYs 1997 and 1998 
    and/or fully implemented nationwide by FY 1998. Mid-term activities 
    would include such items as the phased testing and implementation of 
    new service options; full development, testing and implementation of a 
    streamlined appeals process; the testing of more advanced technology 
    enhancements; and the activities associated with developing the 
    decision methodology based on the results of research efforts completed 
    by the end of the near term.
    
    Flexibility and Testing
    
        SSA recognizes that full implementation of the new process vision 
    is an iterative process that requires development, testing, additional 
    information gathering and possible modification of process changes as 
    they are implemented. Although SSA is committed to moving forward 
    quickly to begin implementing the new process, SSA has embraced an 
    equally strong commitment to rigorous testing and refinement of process 
    changes before they are fully or permanently implemented. Testing may 
    include, but is not limited to, geographic or time-limited site 
    testing, using ``laboratory'' settings, or relying on specific case 
    studies. Formalized testing is most appropriate for process changes 
    that depend on longer-term research and development, phased 
    implementation or major organizational change. In selecting sites for 
    initial implementation activity, SSA will take advantage of the 
    interest and capability of different offices, states, or regions to 
    demonstrate the viability of immediate improvements or identify early 
    successes in improved service or efficiency. Implementation sites will, 
    of course, be provided with the necessary resources to support their 
    efforts.
        Even with extensive testing, the nature of public policy 
    formulation, as well as sound management principles, dictate that SSA 
    remain flexible in developing, refining and implementing the specific 
    elements of the new process vision. Ultimately, if the results of the 
    iterative process necessitate modifications to the process vision, SSA 
    is prepared to make those modifications. SSA is committed to change, 
    not for its own sake, but because it is necessary to meet present and 
    future challenges as it strives to provide high-quality, responsive, 
    world-class service to its customers.
    
    BILLING CODE 4190-29-P
    
    TN19SE94.071
    
    
    BILLING CODE 4190-29-C
    
    Employees Will Make Change Happen
    
        Overall leadership, control, and coordination of all implementation 
    activities are vested in the Implementation Manager, who will report to 
    the Commissioner and Principal Deputy Commissioner. As part of these 
    responsibilities, the Implementation Manager, with the assistance of a 
    support team, will establish implementation priorities, develop 
    specific timelines, and provide oversight to ensure that implementation 
    decisions are consistent with the new process visions and the five 
    process objectives.
        Although the Implementation Manager will be the focal point for all 
    implementation activities, it is the employees and organizational 
    components in the SSA and DDS communities who will make the new 
    disability claim process a reality. Front-line employees will be asked 
    to directly participate in the development, testing and implementation 
    of process changes. They will also provide feedback on the 
    effectiveness of the these changes. Task management teams will be 
    chartered to address specific implementation issues and their duration 
    will depend on the nature of their issue. For example, task teams that 
    might be expected to require a longer-term existence are those dealing 
    with decision methodology or organizational readiness and change 
    management. The task teams will bring together staff from the affected 
    SSA and DDS components to provide the necessary guidance for actual 
    implementation action by organizational components. Central office 
    components, working with their Regional office counterparts, will be 
    responsible for ensuring that necessary implementation actions are 
    effectuated.
        SSA will rely on an internal Advisory Group, comprised of SSA 
    executives and union and association leaders to provide advice and 
    guidance on implementation activities and facilitate communication 
    about implementation plans.
    
    Non-SSA Experts and Interested Parties
    
        SSA will use an inclusive process that seeks input from a variety 
    of non-SSA communities including, but not limited to, disability 
    advocates, physicians, other health care and rehabilitation providers, 
    and the private disability and health insurers. The goal of this 
    inclusive process is to foster creative relationships with non-SSA 
    experts so that SSA can have access to specialized expertise and advice 
    as implementation activities progress.
    
    Open Lines of Communication
    
        SSA's unprecedented effort to establish new and beneficial 
    communication channels during the various phases of the disability 
    claim process redesign lays the groundwork for continued communication 
    during implementation. The internal and external contacts and the 
    avenues of communication established during the public dialogue period 
    will continue and will be an integral part of the implementation 
    process. SSA will continue open lines of communication about 
    implementation of the new process with individuals and organizations 
    who have a stake in the disability process, including front-line 
    employees, representatives from Federal and State employee unions and 
    associations, other Federal agencies, the Congress, the judiciary, and 
    disability advocates. SSA will use all appropriate avenues of 
    communication, including written materials, telecommunications, and 
    personal briefings, to ensure that necessary information about 
    implementation activities is regularly and widely disseminated and to 
    develop appropriate feedback channels. Additionally, SSA will explore 
    new opportunities and means of communicating with both internal and 
    external audiences to permit meaningful exchanges of information.
    
    Appendix I: 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
    
        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 following parameters and 
    expectations for the project which are driven by targets set forth in 
    the Agency Strategic Plan and 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 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 and State 
    Disability Determination Services (DDS) professional and management 
    associations recognized by SSA as having an interest in disability 
    issues. A list of Executive Steering Committee members appears at the 
    end of this appendix.
        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. A list of Team members 
    appears at the end of this chapter. 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 staff in all 
    SSA components that work with any aspect of the disability process 
    including experts in SSA policy, quality assurance, management 
    information, operational, and appellate processes. Dr. Frank S. Bloch, 
    Professor of Law and Director of the Clinical Education Center at 
    Vanderbilt, briefed the Team on 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's conducted extensive fact-finding 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 Team conducted an additional 111 interviews by telephone. The Team 
    also interviewed over 750 parties external to SSA for their views. 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.
        Individuals and groups both internal and external to the process 
    were interviewed for ideas about a new process. The Team solicited a 
    wide spectrum of opinions about problems with the current disability 
    process and directions for redesign. In addition to individuals in the 
    SSA and DDS communities, the team talked to a wide variety of externals 
    including physicians, health maintenance organizations and hospital 
    officials, disability advocates, attorneys, professional association 
    groups, Federal judges, other Federal agencies, and Congressional 
    staffs.
        Prior to site visits and contacts, Team members provided 
    individuals and organizations 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. The interviews provided useful insights into the problems 
    confronting the disability program and recommendations for solving 
    these problems.
    
    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. The following is a list of the 
    focus group sites and composition.
    
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    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 
    search 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. The table below identifies the 
    companies/organizations the Team used as benchmarking partners.
    
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    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 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.
    
    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 to build the models used to predict the operation of a 
    redesigned process. A model was built to represent both the current and 
    proposed processes. The model helped the Team assess 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. A summary of the model assumption and results appears in 
    Appendix II.
    
    Release of Initial Team Proposal
    
        The product of the Team's effort was a redesign proposal that was 
    presented to the Commissioner and Executive Steering Committee on March 
    31, 1994. The proposal provided the Team's view of the best process 
    improvement and process innovation ideas. The proposal is a high-level 
    concept that provides a broad understanding of how a redesigned process 
    would work but leaves operational, organizational, and other details 
    for later development.
        The Team distributed the proposal as widely as possible throughout 
    SSA, the State DDSs, and to interested public and private individuals 
    and organizations with the goal of seeking reactions, items of concern 
    and additional ideas for improvement. Copies of a shorter 25-page 
    version of the Proposal were distributed to all SSA and DDS employees 
    in early April 1994. Copies of the complete 132-page Proposal and 
    Background Report were also distributed to each SSA DDS facility in 
    sufficient numbers to make it easily available to staff. A 30-minute 
    videotape containing remarks by Commissioner Chater and a presentation 
    of the proposal by members of the Reengineering Team was distributed 
    for use in all SSA and DDS facilities. Group feedback discussions with 
    SSA and DDS employees were held in all ten regions and in SSA 
    headquarters components. A survey was distributed to each SSA and DDS 
    employee to assist employees in providing comments.
        The Proposal and Background Report was published in the Federal 
    Register on April 15, 1994 (59 FR 18188). A 60-day comment period was 
    established to invite public comment on the proposal. A public hearing 
    on the proposal was held in Washington, DC on May 16, 1994. Team 
    members conducted extensive briefings on the proposal with interested 
    parties, including employee unions, professional association groups, 
    disability advocates, the legal community, other Federal agencies, and 
    Congressional staffs.
        During the comment period that ended on June 14, 1994, the Team 
    received over 6,000 written responses from all interested parties. The 
    Team reviewed and analyzed each comment received. A summary of the 
    comments is included in Appendix III. In response to reactions received 
    during the comment period, the Team made changes to the original 
    proposal and submitted a revised proposal to the Commissioner and the 
    Executive Steering Committee on June 30, 1994.
        After extensive consultation with the members of the Executive 
    Steering Committee, SSA senior staff, representatives from employee 
    unions and associations, disability advocates and others, the 
    Commissioner accepted the Team's recommendations for a redesigned 
    disability process.
    
    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
    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
    Additional Support from:
    Dominic Fulgieri--Implementation Planning Staff, Baltimore, MD
    Rosanne Hanratty--Implementation Planning Staff, Baltimore, MD
    Kathleen Jones--Implementation Planning Staff, Baltimore, MD
    Linda Kaboolian--Kennedy School of Government, Harvard University, 
    Cambridge, MA
    Miriam Kahn--Process Reengineering Staff, Baltimore, MD
    Becky Klepper--Implementation Planning 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
    Carolyn Shearin-Jones--Implementation Planning Staff, Baltimore, MD
    Sandi Sweeney--Process Reengineering Staff, Baltimore, MD
    Wendy Tayback--Implementation Planning Staff, Baltimore, MD
    Latesha Taylor--Process Reengineering Staff, Baltimore, MD
    Linda Thibodeaux--Process Reengineering Staff, Baltimore, MD
    
    Appendix II: Model Results
    
    Summary Information
    
        The Team worked with modeling professionals in the SSA Office of 
    Workforce Analysis (OWA) to build computer representations of both the 
    current and the redesigned disability processes. The computer model was 
    built using FORTRAN programming language. Data based on assumptions, 
    task times and lapse times were input into the model. In making 
    assumptions, the team relied on historical data to the extent that such 
    information was available. The Team also relied on an April 1993 OWA 
    study that outlines the current disability claim process, including all 
    administrative appeals, and describes the tasks performed by line-
    employees in the seven operational components that are involved with 
    the disability claim process.
        Using a computer model allowed the Team to assess the impact of 
    changing from one process to another. Although the model did not 
    generate an actual visual simulation of either the current or the 
    redesigned process, the model did generate comparative data about the 
    relative impact of specific features and expected performance. The 
    sections that follow provide key comparative information regarding 
    overall processing times and employee work investment based on the 
    model results.
    
    Overall Processing Times
    
        Under the redesigned process, 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 the OWA study) to less 
    than 40 days. Available employees will be able to process a greater 
    number of claims and devote more time to each claimant, thus 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 the OWA study) to 
    approximately 5 months.
    
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    Employee Work Investment
    
        The table below provides a comparison of the number of different 
    employees that are likely to make some work investment in a claim at 
    each decisional level in the current and redesigned processes. The 
    following abbreviations were used in describing the types of employees 
    involved at each level.
    
    AAJ--Administrative Appeals Judge
    AC--Appeals Council
    ALJ--Administrative Law Judge
    AO--Adjudication Officer
    CA--Claims Authorizer
    CR--Claims Representative
    DCM--Disability Claim Manager
    DDS--Disability Determination Service
    DE--Disability Examiner
    DW--Decision Writer
    FO--Field Office
    HAA--Hearing and Appeals Analyst
    HO--Hearing Office
    MC--Medical Consultant
    MG--Management
    OPIR--Office of Program & Integrity Reviews
    PSC--Program Service Center
    QA--Quality Analyst
    SA--Staff Attorney
    Sup--Support Staff
    TA--Technical Assistant
    TECH--FO Technician
    TSC--Teleservice Center
    TSR--TCS Representative
    
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    Assumptions, Task Times and Lapse Times
    
        Listed below are key assumptions, task times and lapse times that 
    the Team used to model the redesigned process. The task times are shown 
    in minutes and represent the estimated time it will take an employee to 
    complete the described task. For each task time entry, three task time 
    numbers are shown. The middle number represents the most common task 
    time, while the first and last number represent the low and high 
    extremes for that task. The lapse times are shown in work days, rather 
    than calendar days, and represent the number of days between actions or 
    tasks.
    
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    Appendix III: Summary of Comments on Reengineering Proposal
    
    Overview
    
        During the comment period that began on April 1, 1994 and ended on 
    June 14, 1994, the Team received over 6,000 written responses from SSA 
    and DDS employees, employee unions, professional associations, members 
    of the public, claimant representatives, physicians, State governors, 
    claimant advocate groups, Federal components, and other interested 
    parties. Fifty-three percent of the written responses came from SSA 
    employees, 21% came from DDS employees, and 26% came from individuals 
    and organizations external to the SSA/DDS community. Members of the 
    Team read, analyzed, and collated every one of those 6,210 comments so 
    that no idea, reaction, or nuance would be overlooked.
        For the commenters who presented written reactions to the overall 
    proposal, 52% were favorable to the overall concept, 39% were 
    unfavorable, and 9% were neutral. Approximately 10% of these commenters 
    believed no reengineering was needed. Beyond the request for written 
    comments, additional means of gauging reaction to the proposal were 
    also employed: group employee feedback discussions were held in over 80 
    sites across the country with almost 2,000 SSA and DDS employees 
    participating; a public meeting was held in Washington, D.C.; and Team 
    members conducted briefings and spoke with more than 3,000 individuals 
    and organizations about the proposal during the comment period.
        There was a very mixed reaction to the proposal. Very few verbal or 
    written responses were totally favorable or unfavorable toward the 
    proposal--those liking it had concerns about some elements while those 
    generally disliking it found portions which they believed would be 
    improvements over the current process. Many commenters, regardless of 
    expressing praise or concern, addressed very limited aspects of the 
    proposal without providing a reaction to the overall proposal.
    
    Profile
    
        The comments expressed can be categorized as follows:
    
    --SSA received widespread praise for taking on the task of redesigning 
    the disability claim process. The prevalent belief was that dramatic 
    improvements are needed to provide better service and handle workloads 
    more effectively. Whether fully supporting the proposal or not, most 
    commenters expressed concern that the system is broken and that only 
    radical redesign will solve the problems that currently exist.
    --The most popular concepts were (listed from most to least frequently 
    mentioned):
    
         Elimination of the reconsideration step;
         The disability claim manager as single Agency point of 
    contact in the initial claim;
         A single presentation of substantive policies for all 
    decision makers;
         Encouragement of the claimant to be a partner in the 
    development of the claim;
         Elimination of the mandatory Appeals Council review step;
         Increased reliance on the use of information technology;
         Increased public awareness and education about program 
    requirements;
         Evidence development tailored to claimant circumstances;
         Disability claim managers empowered with full 
    decisionmaking authority; and
         The general aspects of the proposed disability 
    methodology.
    
    --The greatest concerns centered around (listed from most to least 
    frequently mentioned):
    
         Personal safety of disability claim managers;
         Ability of one person to fulfill the disability claim 
    manager role;
         Pre-denial personal interview with disability claim 
    manager;
         The general aspects of the proposed disability 
    methodology;
         Encouragement of the claimant to be a partner in the 
    development of the claim;
         The disability claim manager as single Agency point of 
    contact in the initial claim;
         Development and use of an Index of Disabling Impairments;
         Use of standardized forms to request evidence from 
    treating sources;
         Reliance on treating source certification of existing 
    evidence; and
         Potential bias of disability claim managers.
    
    --Many of the responses centered around how the proposal would be 
    implemented and what organizational changes would be needed to make the 
    new process work.
    --There were concerns about whether the proposal would meet the 
    objective of not increasing or decreasing program costs with fairly 
    divided opinions about whether the new disability methodology would 
    allow or deny more claims than the current methodology. Reliance on 
    treating sources as preferred sources of medical evidence and personal 
    bias resulting from disability claim manager face-to-face meetings with 
    claimants were often cited as the reason for the belief that there will 
    be an overall increase in allowed claims. The new four-step evaluation 
    process was cited as the most common reason for the belief that there 
    will be an overall increase in denied claims.
    
    [FR Doc. 94-22491 Filed 9-16-94; 8:45 am]
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Document Information

Published:
09/19/1994
Department:
Health and Human Services Department
Entry Type:
Uncategorized Document
Action:
Announcement of the plan for a new disability claim process.
Document Number:
94-22491
Pages:
0-0 (1 pages)
Docket Numbers:
Federal Register: September 19, 1994