Section 6 Recommendations (and Benchmarking)
The findings (“best practices”) from this Study in conjunction with practices of the
specialty of Occupational Medicine, and certain procedures of other Federal Agencies
who purchase CE-type examinations, collectively suggest that several improvements to
the CE process are feasible. However, attempts at standardizing - or “benchmarking” -
CE’s will have to be compatible with SSA and State resources, (i.e., dependent on CE
budgetary, personnel, and management constraints).
Medical Consultants should review all CE requests
The decision to purchase a CE should involve the DDS Medical Consultant (MC). Such
involvement should include a documented process whereby the MC considers whether
any specific issues or questions should be posed to the CE provider. (For example, how many severe asthmatic episodes or seizure episodes occurred within the past year; or
what specific daily activities aggravate or ease back pain and how much; or are
medications taken as directed and are there any side effects? These types of questions
were rarely posed, or addressed in the CE’s reviewed). All relevant MER should be
forwarded to the CE provider, and – to avoid wasteful activity - irrelevant MER not
forwarded. Here, again, the MC can be helpful in “sorting” the MER. (Of note, DI
22510.26B1a and b, e.g. for neurological allegations, requires that MER be forwarded.)
SSA should require that the items of MER reviewed by the CE provider be listed in the
CE Report. Any time devoted to review of MER should be included in the time duration
SSA expects the CE provider to devote to the claimant, and it should be considered in
setting the CE provider’s fee. For childhood claims, e.g., relevant MER could include
Teacher Questionnaires, as well as the SSA 3820.
The CE provider should clarify ADL’s with the claimant
Input obtained by SSA related to the claimant’s ADL’s should be a regular component of
the CE provider’s packet. Such information lessens the time the CE provider has to
devote to this issue, and more importantly, also informs the CE provider about the
claimant’s alleged functional limitations. However, whether or not the CE provider
obtains previously collected ADL data from the DDS, the CE provider should discuss
ADL issues directly with the claimant, especially since ADL data collected by SSA might
be 30 to 60 days old.. The review of ADL’s with the claimant should be described in the
CE Report. The CE provider should also routinely clarify whether the claimant’s
diagnosis and severity level are consistent with his/her allegations.
Greater use of specialist CE providers, including generalists who can become
“specialists” for CE purposes The data collected in this Study strongly suggest that claimants with musculoskeletal
complaints are often referred to CE providers who do not have specific expertise with the
types of impairments that the claimants allege. This issue can be addressed in one of two
ways. A concerted effort could be made to recruit more orthopedic surgeons, physiatrists,
occupational medicine specialists, etc. for CE panels. It is not clear if this would require
fee adjustments, given California’s experience. However, even in California., some
claimants with these allegations are referred to generalists. This implies there is a
recruitment obstacle for specialists here, too. This approach might also require more CE’s,
since many claimants have additional impairments also requiring a CE. The Department
of Labor’s Office of Workers Compensation Programs (OWCP) appears to take this
On the other hand, the Veterans Administration’s approach might be more practical. Here,
the Agency simply stipulates through the use of Templates (as some DDS’s also
apparently do occasionally) the minimum data inputs (clinical findings) it expects from
the CE provider concerning a particular impairment. Generalist providers, as licensed,
often residency-trained physicians, should be capable of obtaining specifically requested
data, especially if SSA adopts an intensive approach to training providers regarding the
specific types of observations it is seeking, and attempts to refer similar types of
impairments to the same providers.
Treating Sources as CE Providers
A significant difference between the standard IME and the CE is that SSA allows
claimants – in many, but not all instances – to have a CE performed by their treating
physician (TS). Based on the E-Files reviewed by COMS, TS’s appear very reluctant to
perform this service for their patient/claimants, or even to simply provide an MSS.
Furthermore, this reluctance appears to hold true as much for claimants with qualifying
impairments as it does for less severely afflicted ones. The basis for this behavior was not
evident in the E-Files and probably should be explored by SSA. One possible
contributing factor is the format DDS’s use to request a CE from a TS. More direct
(phone, E-Mail) contacts with TS’s, especially by MC’s, and especially if the MC personally is acquainted with the TS, might improve the frequency of TS CE’s. However,
many treating sources, especially if they are not confident that their patient/claimants will
receive a favorable decision from SSA, will simply be reluctant to be placed in an
adversarial relationship with their patients. SSA should further explore the reasons why
TS’s are reluctant to perform CE’s for their patient/claimants.
Standardized Templates It should be noted that several States (DDS’s) have made some efforts to standardize CE
findings for some body systems. These include chest pain and neurological
questionnaires, and ROM, hand function, and back-related Charts. Other States have a set
of “boilerplate” physical finding requests, i.e., “one size fits all,” whenever the
musculoskeletal or neurological body systems are implicated. But none of these
approaches are consistent throughout SSA, and they also do not reach the level of disease
specificity expressed in VA clinical worksheets, especially regarding Medical History
items. Instituting such worksheets in SSA, however, will likely improve CE quality only
modestly, unless CE providers are “oriented” to acquire the data sought, e.g., a detailed
pain history or confirmed straight leg raising test or completely examined knee or
shoulder (for stability, anatomically specific tender sites, and specific muscle group and
dermatomal findings, etc.). It should also be noted that for mental health-related
impairments, a Template approach alone might not adequately capture (i.e., be too
superficial) all relevant and valid clinical findings.
If a claimant alleging a chronic respiratory impairment, e.g., COPD, is referred to a
pulmonologist for a CE, or to an internist for a “Respiratory” CE per Greenbook, SSA
expects that, in addition to addressing the requirements for an Internal Medicine CE, the
CE provider should ask the claimant about cough, dyspnea, etc., and note any use of
accessory muscles of respiration, the presence or absence of adventitious breath sounds, etc. However, under the same guidelines, if the same claimant is referred to an internist
for an “Internal Medicine” CE because s/he also suffers from potentially disabling
rheumatoid arthritis, the requirements per Greenbook are expressed only in “general
terms,” such as “factors” which increase the “problem or impairment” and pertinent physical “aspects of the examination dealing with ... the complaints,” though in
“particular detail” to be sure. Similar comparisons can be drawn between rheumatology
CE’s and IM CE’s or even orthopedic CE’s and IM CE’s regarding osteoarthritis for example. Even without adopting the VA’s approach using disease-specific Templates, the Greenbook should be modified so that specific allegations are addressed similarly
regarding the HPI and physical examination irrespective of the examining CE provider’s specialty. COMS is aware that SSA occasionally orders orthopedic CE’s, e.g., from
generalists. However, this did not appear to be a common approach in the CE’s reviewed
as part of this Study. Differences in requirements between POMS directives and the
Greenbook for CE Report contents should also be reconciled.
Deficient CE Reports
SSA should standardize criteria for review and approval/rejection of CE Reports prior to their use in claim adjudication. This step is needed so that deficiencies can be “corrected” while the findings are still “fresh” in the CE provider’s mind or – in very rare circumstances – the claimant can be recalled, if necessary, and also so that the
additional/corrected information can contribute to a correct claim decision. Despite DI
22510.020 B.2. ([CE] Report Inadequate), correction of deficiencies – other than obtaining signatures – was rare in the CE Reports reviewed by COMS.
Standardized review of CE Reports for quality
DDS policies regarding review of CE Reports for quality per se vary, although essentially the quality of each CE Report is obviously noted by the actual user of the Report. All CE
Reports should receive a Quality Rating, and Ratings (and the types of deficiencies noted)
should be tracked. However, given the IT resources available to SSA, and the availability
of CE Reports in electronic format, it would be prudent to utilize IT-based procedures to
evaluate and expedite CE Report processing, as well as to develop Program oversight
tools for senior management.
One approach might be to follow the VA’s lead and develop quality indicators linked to
specific items/responses in disease specific, impairment specific, or body system specific
Templates. A “quality score” would be assigned to a CE Report based on the presence or absence of the quality indicators, with cumulative scores maintained for each provider.
Some quality indicators would be generic (e.g., providing all vital signs), while others
would depend on the specific diagnosis/impairment at issue (e.g., a longitudinal history of symptomatic episodes of a recurring disorder (e.g., asthma, epilepsy) or verifying a
“positive” Straight Leg Raising test by various additional maneuvers). (See Appendix K
for examples of potential quality indicators for two types of allegations: Obstructive Lung
Disease and Diabetes Mellitus). A review tool could also be developed that linked
authorization for payment to a satisfactory CE Report score. Finally, in the era of pay-for-
performance healthcare reimbursements, payment amounts might even be linked to
cumulative “quality scores.” A need for “remedial” training – or other appropriate
administrative action - could also thereby be identified.
MC review of all requested ancillary studies
Another component of management of the CE process that should be standardized is the
ordering of ancillary studies, particularly X-Rays. Based on MER, a DDS could
reasonably conclude that a particular ancillary study is indicated. However, whenever a
clinical CE is indicated to assess properly a claimant’s allegation(s), the need for
ancillary studies should be confirmed based on the findings obtained from the medical
history and physical examination, as occurs in non-emergent medical practice in the
community. Even if studies appear indicated based on MER alone, it would usually be
prudent to defer ordering them until the claimant has been evaluated by the CE provider,
assuming of course that the CE provider is assessing the same clinical issue for which the
ancillary study is indicated. Appropriate views to obtain in an X-Ray study, e.g., could
easily change as a result of the clinical CE findings. Furthermore, DDS MC’s should be
involved in all decisions to purchase ancillary studies so that performance of unnecessary
studies is minimized. However, if ancillary studies are deferred to a greater extent than
currently i.e., until after the clinical evaluation, a procedure (communication with the CE
provider) is needed to maximize the likelihood that indicated studies, and only indicated
studies, are performed.
Improve the timeliness of CE requests and durations of CE Exams
It is not clear from the E-Files reviewed or the DDS questionnaires how much of the
delays across the country in obtaining CE’s are due to internal DDS issues as opposed to
CE provider availability. Given that E-Files record the dates at which the various steps in
the CE procurement process are completed, it might be reasonable for Regional Offices
to monitor the timeliness of CE procurements and offer assistance as appropriate when
indicated. Regional Office medical consultant staffs represent a broad spectrum of
medical specialties, and such consultants might be able to help DDS’s recruit hard to
obtain CE specialists.
COMS reviewed SSA CE policy guidelines provided in DI 22510 – Development of
Consultative Examination and DI 39545 – Purchased Medical Services. These Sections
provide guidance to the DDS’s and FO’s on the overall administration and execution of
the CE process. However, when COMS analyzed these policy areas for guidance on the
duration of CE’s (DI 22510.015A3 and DI 39545), we identified multiple areas
discussing “scheduling intervals.” Clarification is needed in DI 39545.020 which notes
“the purpose of … minimum scheduling timeframes is to ensure that CEs are complete
and sufficient time is made available to obtain the information needed to make an
accurate determination.” In this Section, timeframes are provided for various types of
exams (i.e. general medical, psychological, etc.), however, it is unclear if these
timeframes are intended as scheduling intervals between CE’s or the actual time the provider is expected to devote to the claimant.
The expected exam intervals defined in current policy are fairly short, e.g., “comprehensive” musculoskeletal or neurological exams can be scheduled at 20 minute
intervals. But if a provider schedules “comprehensive general medical examinations” every 90 minutes, but only “sees” the claimant for 20 minutes, the guidelines are satisfied. To be sure, there is an admonition in DI 39545.250A that the guidelines are not meant to limit the “actual duration” of the CE. Thus, a provider is perfectly free to take 45 minutes to perform each examination and simply let claimants scheduled at shorter intervals, but later in the day progressively “wait” longer times for their CE’s (unless there are “no-
The POMS directives regarding the expected durations of various types of CE’s should be changed to clearly emphasize expected (actual) CE durations in addition to guidelines for scheduling intervals. In this regard, the wider use of body system Templates will help to standardize further exam times (including the “interview” phases), and also to forego collecting unnecessary data. A rational “no-show” policy, however, should also be
All stakeholders understand that a prognosis is only an estimate or prediction, subject to unexpected change. CE providers, as physicians who have voluntarily agreed to examine claimants for SSA, should possess sufficient expertise in the types of impairments they are willing to address to be able to - and be expected to - offer a prognosis, when appropriate. When not possible or appropriate, the basis for not providing a prognosis should be clearly stated in the CE Report.
Inclusion of Medical Source Statements (MSS’s)
DDS’s should ensure that Medical Sources Statements are included in CE Reports and that these Statements are completed in accordance to current policy guidance. When formulating an MSS, it is reasonable to request that all elements of the standard MSS be addressed, noting, when appropriate, those that are not applicable or relevant. CE providers should also address items outside the standard MSS, but relevant to an RFC, if they possess the expertise for doing so. An example of the latter would be a pulmonologist CE provider who should describe appropriate environmental and work exposure restrictions for a claimant with asthma.
An inadequate or inappropriate MSS, however, poses a dilemma for SSA. In 1997, the GAO reported that the seminal explanation for the relatively high rate of claim allowances at the ALJ level was that ALJ’s frequently estimated claimant functional capacities as being more restricted than did initial adjudicators. This conclusion allowed for any interim progressions in impairment severity levels (50). In a follow-up Report in 2004, GAO continued to hold that SSA had not adequately addressed this situation (51). Thus, for a disability claim at Step 4 or 5 of the sequential process, an accurate and well
documented RFC “as is possible” is an indispensable requirement for a correct and
supportable claim decision not only initially, but also, if necessary, on appeal.
The initial RFC is formulated at the DDS based on the totality of evidence in the
claimant’s file. The findings from a CE, however, including any judgments in the form of an MSS should – if reasonable – materially influence the RFC subsequently developed.
On the other hand, an inappropriate MSS, given that it has been produced by a clinician who has actually examined the claimant, creates a dilemma for the DDS. An RFC
incompatible with the MSS will now have to be produced by a DDS MC who, though
s/he might possess more expertise in the type of impairment at issue, will not have
directly evaluated the claimant. Any functional capacity estimate produced at the ALJ level, by contrast, will also have been based in part on a face-to-face claimant interview. Thus, MSS’s formulated by CE providers who have discussed symptoms and ADL’s with
the claimant directly, have personally physically examined the claimant, and who also have significant experience and expertise in the impairment posed by the claimant would seem to add value to the CE process and thereby provide an important service to the DDS and SSA.
Enhancement of CE provider recruiting
The recruitment of appropriate CE providers poses one of the greatest barriers to CE quality. Current efforts at recruitment are obviously not satisfying SSA’s needs. A more structured approach to the CE process – along the lines of the VA’s approach - might
help to alleviate this problem somewhat. However, more effective provider recruitment is also needed. SSA should consider involving its current medical consultant staff (at all levels) in recruitment efforts (specialist to same specialist). Every effort should be made to maximize the participation of Board Certified providers, specialist or generalist, in the CE process. Also, Medical Consultants can be helpful with respect to contacting treating sources to request their participation in the CE process (to perform CE’s or just provide MSS’s).
Training for CE providers
There needs to be more intensive training of CE providers, and this training should recur as necessary to keep providers informed of Disability Program changes. But because CE providers are independent vendors, and not government employees, such training has to be mindful of the sensitivities in this relationship. Some approaches to consider are case banks, video demonstration materials, and in some instances, one-on-one encounters
utilizing established experts as trainers. SSA’s Office of Training should partner with the Regions and States to develop a more formal CE provider training methodology as well as a defined schedule for regular follow-up training. The emphasis must be on obtaining the specific types of observations SSA requires, especially regarding supportable MSS’s. Some degree of training should be mandatory. If CE provider performance is substandard, the amount of mandatory training should be increased.
Conduct an outreach panel to explore “best practices” in CE-type examination procedures and identify workable improvements to the CE process SSA should consider convening a Conference with invitations given – at a minimum - to the Compensation and Pension Service of the VA, OWCP (in DOL), a sample of DDS’s,
the AMA (Disability Guides experts), several private insurers who underwrite disability
policies, and clinician scholars with expertise in the clinical assessment of disability
applicants and beneficiaries. The aim of such a Conference would be to identify “best
practices” regarding the performance of CE-type medical examinations (including those
involving mental health), and determine which ones would be appropriate for adoption by
SSA. SSA might want to extend this outreach to claimants and advocates to obtain their
perspectives on improvements to the CE process. At a minimum, SSA should request a
briefing from the VA on the details of its Compensation and Pension Exam Program.
Conduct a review of claims at the ODAR level for CE quality Finally, the inability of COMS to review ODAR claims represents a shortfall in achieving
the goals of this Solicitation. COMS was thus unable to assess the quality of CE’s
purchased by ALJ’s, and also the influence of any CE’s purchased earlier in the
adjudicative process on subsequent ALJ decisions. Such research is recommended. Given
the rates at which ALJ’s order CE’s, it would be appropriate to assess whether
improvements in the quality of CE’s performed during initial adjudications might lessen
these rates. It would also be reasonable to assess how CE’s, ordered both initially and at
the ODAR level, influence the setting of RFC’s by ALJ’s.