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Discrediting the Consultative Social Security Exam Before During and After the Exam

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How to discredit the consultative social security exam before, during and after the exam. Discredit the exam when it is: inaccurate; allows for bias of the examiner; where the claimant has difficulty getting to the exam; it costs the government money; it hurts the claimant; it scares the claimant.

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Discrediting the Consultative Social Security Exam Before During and After the Exam

  1. 1. Discrediting the Consultative Exam before during, and after the exam By Neil H. Good 1 Nosscr October 2014
  2. 2. Why Discredit The Exam  They are inaccurate  The allow for the bias of the Examiner  Our clients have difficulty getting there  They cost the government money  They hurt the clients  They scare the clients Nosscr October 2014 2
  3. 3. When Is SSA Supposed To Order Consultative Evaluation  20 CFR 404.1519a  They will purchase a CE when:  If SSA doesn’t get information from a Medical Source  To resolve inconsistencies in the medical evidence When the evidence is insufficient to decide  Highly technical evidence is not available  Current severity is not established Nosscr October 2014 3
  4. 4. Who Should Perform The CE  20 CFR 404.1519(H)  When in our judgment your treating source is qualified, equipped, and willing to perform the additional examination or tests for the fee schedule payment, and generally furnishes complete and timely reports, your treating source will be the preferred source to do the purchased examination. Even if only a supplemental test is required, your treating source is ordinarily the preferred source. Nosscr October 2014 4
  5. 5. Objecting To A CE  § 404.1519j. Objections to the medical source designated to perform the consultative examination.  If there is a good reason for the objection, we will schedule the examination with another medical source.  A good reason may be that the medical source we designated had previously represented an interest adverse to you  The presence of a language barrier, the medical source's office location (e.g., 2nd floor, no elevator), travel restrictions,  whether the medical source had examined you in connection with a previous disability determination or decision that was unfavorable to you.  If your objection is that a medical source allegedly “lacks objectivity” in general, but not in relation to you personally, we will review the allegations.  To avoid a delay in processing your claim, the consultative examination in your case will be changed to another medical source while a review is being conducted.  We will handle any objection to use of the substitute medical source in the same manner. Nosscr October 2014 5
  6. 6. How Do They Read The Report  (a) We will review the report of the consultative examination to determine whether the specific information requested has been furnished. We will consider the following factors in reviewing the report:  (1) Whether the report provides evidence which serves as an adequate basis for decision making in terms of the impairment it assesses;  (2) Whether the report is internally consistent; Whether all the diseases, impairments and complaints described in the history are adequately assessed and reported in the clinical findings; Whether the conclusions correlate the findings from your medical history, clinical examination and laboratory tests and explain all abnormalities;  (3) Whether the report is consistent with the other information available to us within the specialty of the examination requested; Whether the report fails to mention an important or relevant complaint within that specialty that is noted in other evidence in the file (e.g., your blindness in one eye, amputations, pain, alcoholism, depression);  (4) Whether this is an adequate report of examination as compared to standards set out in the course of a medical education; and  (5) Whether the report is properly signed..(20 CRF 404.1519p) Nosscr October 2014 6
  7. 7. What If SSA Can’t Read The Report  (b) If the report is inadequate or incomplete, we will contact the medical source who performed the consultative examination, give an explanation of our evidentiary needs, and ask that the medical source furnish the missing information or prepare a revised report.  (c)With your permission, or when the examination discloses new diagnostic information or test results that reveal a potentially life-threatening situation, we will refer the consultative examination report to your treating source. When we refer the consultative examination report to your treating source without your permission, we will notify you that we have done so.  (d)We will perform ongoing special management studies on the quality of consultative examinations purchased from major medical sources and the appropriateness of the examinations authorized. Nosscr October 2014 7
  8. 8. The Studies say 26% of CE’s are deficient.  An Assessment of Consultative Examination (CE) Processes, Content, and Quality: Findings from the CE Review Data  Final DATED November 12 2012 Report(http://www. socialsecurity.gov/ disabilityresearch/document /CE%20Report%202.pdf)  COMS Medical Consultants’ Assessment of CE Quality and Completeness  Minority of cases (11 percent) judged deficient for making disability determination  Minority of cases (16 percent) judged not to include all of the items expected (expected findings, conclusions, and responses to specific questions); more frequent occurrences of not including Nosscr October 2014 8
  9. 9. What Is The CE Report Required To Include  The Green Book explains : Consultative Exams: A Guide for Health Professionals  List A-K at a minimum  Then Specific types of exams-Musculoskeletal, Special Senses and Speech, Visual Impairments, Hearing Impairments, Respiratory System,  Cardiovascular System, Digestive System, Genitourinary Impairments, Hematological Disorders, Skin Disorders,  Endocrine Disorders, Neurological Disorders, Mental Disorders, Malignant Neoplastic Diseases, Immune System Disorders Nosscr October 2014 9
  10. 10. Minimum Requirements  A. Identity of Claimant with longitudinal Medical History  B. Current Medical History, onset date, current symptoms, treatment and results, typical daily activities, dates  C Past medical History  D. Current medications  E. Review systems-other symptoms and pertinent negatives Nosscr October 2014 10
  11. 11. Minimum Requirements  F. Social History – tobacco and DA&A  G. Family History  H. Physical Exam  I. Interpretation of Lab tests  Imagining tests  Medical Source Statement- opinion Nosscr October 2014 11
  12. 12. Minimum Requirements  Lifting/carrying/pushing/pulling  Sitting/standing/walking  Posture (for example, climbing/stooping/bending/balancing/cra wling/ kneeling/crouching)  Fine motor skills (that is, handling/fingering/gripping/feeling)  Overhead and forward reaching  Vision/hearing/speech  Environmental exposures (for example, heat/cold/humidity/noise/vibration) Nosscr October 2014 12
  13. 13. How Long Should The Exam Last  20 CFR § 404.1519n  (1) Comprehensive general medical examination—at least 30 minutes;  (2) Comprehensive musculoskeletal or neurological examination—at least 20 minutes; (3) Comprehensive psychiatric examination—at least 40 minutes;  (4) Psychological examination—at least 60 minutes (Additional time may be required depending on types of psychological tests administered); and  (5) All others—at least 30 minutes, or in accordance with accepted medical practices. Nosscr October 2014 13
  14. 14. What Is The Effect Of Not Going To The CE  HALLEX I-2-5-24 Claimant Fails or Refuses to Submit Evidence or Undergo a Consultative Examination or Test  It is never proper to dismiss a claimant's RH for failure to provide requested evidence or to undergo a requested CE. The ALJ should schedule the case for hearing and if after notice of hearing, the claimant fails to appear for the hearing, then dismissal may be proper under I-2-4-25. (20 CFR §§ 404.957 and416.1457.) Nosscr October 2014 14
  15. 15. Scheduling The Appointment  POMS DI 23007.010  Failure to attend a CE appointment means the claimant did not state orally or in writing that he or she would not attend the CE appointment, but the claimant fails to attend the CE appointment.  However, a claimant cannot fail to attend a CE appointment if: the claimant did not confirm the appointment, see DI 22510.019D; Nosscr October 2014 15
  16. 16. What Is Good Cause Not to Attend The CE  1. The claimant was seriously ill and unable to comply with the request.  2. There was a death or serious illness in the claimant's immediate family which prevented him or her from complying with the request.  3. The claimant did not receive the request to submit evidence or appear for a CE or test, or the claimant received the request untimely.  4. The request to submit evidence or appear for a CE or test contained incorrect or incomplete information about when and where to submit the evidence or appear for the CE or test.  5. The evidence requested is not available due to destruction or damage.  6. The claimant did not understand the requirement to provide the requested information.  7. The claimant lacked the financial ability/means to obtain the evidence requested. (20 CFR §§ 404.911) Nosscr October 2014 16
  17. 17. What Can Be Done Before The Consultative Exam  Send a letter asking why they need the CE  Object to the CE  Have a doctor write a letter explaining why the claimant cannot have the exam. (depression example)  Offer to pay for the difference between what SSA is willing pay and what the Dr. is going to charge Nosscr October 2014 17
  18. 18. What Can Be Done During The Consultative Exam  Advise the client to bring the records with  Advise the client to have somebody go with them(a nurse)  Have them ask if they can record the session blame it on the lawyer  Advise the client to explain if it is a bad day Nosscr October 2014 18
  19. 19. What Can Be Done After The Exam.  Have the client fill out the questionnaire  Submit the Questionnaire  Have the client’s doctor fill out the range of motion questionnaire  Submit the Range of Motion for to DDS Nosscr October 2014 19
  20. 20. What do you do at the hearing  In court Compare the ROM Form to that of the Treating physician or PT  Have the client testify about what he disagrees in the CE  Have the witness come to court to testify Nosscr October 2014 20

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