What are Consultative Exams?

What are Consultative Exams?

The Social Security Administration (SSA) is responsible for developing a record and obtaining medical evidence for every disability claim. If you have filed a claim with SSA, it is likely that you will receive a notice from them, requesting that you attend a Consultative Evaluation, commonly referred to as a CE. SSA will usually ask a doctor or psychologist that they contract with to complete the CE. SSA often schedules a CE when there is not enough medical evidence in the claim file to determine whether or not you are disabled.

 Here is how the Consultative Exam process works.

SSA maintains a list of independent licensed physicians and psychologists, who have agreed to examine disability applicants for a small fee paid by SSA. A CE is not usually scheduled with your own doctor. You may have your own doctor perform the evaluation, and if (s)he is willing to do this, provide SSA with your doctor’s name, and ask them to make direct contact.

The primary purpose of a CE is to provide SSA with a summary and overview of your impairments and the functional limitations they may cause. A CE may be ordered to clear up any contradictory medical evidence or medical opinion in your file. It may be necessary to obtain up-to-date blood tests, x-rays or psychological testing. A CE is NOT a new treatment provider or source of medical advice for you.

It is common to feel that the CE was rushed and the doctor did not do a thorough job. This is because SSA pays the doctor the same flat fee, no matter how long the examination lasts. We have heard many reports of 10 minute CEs, which clearly is not long enough to gain an understanding of all the medical or mental health impairments. You should write notes immediately after your CE, memorializing the beginning and end times of your session with the doctor, what was said, and what precise testing was done.  Consider bringing a trusted friend or family member to the CE with you, and ask that they are allowed to remain in the room during the examination. If the doctor refuses this reasonable request, ask why and write down the answer. Provide your notes to your attorney, and also make your witness available if (s)he was allowed into the examination room. If the CE report is inconsistent with treatment records (and it often is), your attorney can use this information to file an objection with the Administrative Law Judge. Although most ALJs will not exclude an erroneous or incomplete CE report, this may be an important issue if an appeal becomes necessary.        

 

SSA can schedule a CE, but it cannot force you to attend one. If you do not show up, however, your claim will likely be denied due to lack of cooperation or insufficient medical evidence. The wisest action is to attend the CE, bring a witness, take notes, and let your attorney know about it. If your doctor is willing to perform a CE, let SSA know this as soon as possible and ask them to cancel the CE with the stranger and to let your doctor know what information they need.

For more information on Social Security Disability please feel free to browse our website or contact us anytime. We have been helping SSD and SSI applicants since 1980. We are here to help make the process of obtaining benefits as easy and stress free as possible for our clients.

 

Why You Should Care About the Plan to Repeal ACA

WHY YOU SHOULD CARE ABOUT THE PLAN TO REPEAL THE PATIENT PROTECTION & AFFORDABLE CARE ACT

WHY YOU SHOULD CARE ABOUT THE PLAN TO REPEAL THE PATIENT PROTECTION & AFFORDABLE CARE ACT

If you are reading this, you are probably seeking Social Security Disability or SSI benefits, or you are helping a disabled person. This is the population that saw the greatest benefit from the Patient Protection & Affordable Care Act (“ACA” or Obamacare), signed into law by President Obama on March 23, 2010.

Beginning in January 2014, when most of the ACA provisions took effect, we observed a significant change in the lives of our clients. Many were able to access health insurance for the first time, and no longer had to choose between going to the doctor or eating that week. Prior to the ACA, there was a healthcare gap which affected people who were not quite poor enough for welfare and Medicaid, but certainly not wealthy enough to pay health insurance premiums. Not only was this a humanitarian and ethical societal problem, it adversely affected the ability to prove disability to the Social Security Administration (SSA).

To establish disability, to the satisfaction of SSA, a claimant must provide medical evidence to establish a diagnosis and medical signs and symptoms. Without medical evidence, SSA usually disbelieves the claimant’s complaints and denies the claim. In more than one case, claimants died of their impairments, but their claims were still denied because there was not sufficient medical evidence. Medical evidence is very important. Without health insurance it is extremely difficult to access medical treatment … and without medical treatment, there is no medical evidence.

By providing health insurance to effectively fill this gap, the ACA made it possible for people who have been unable to work due to physical or mental impairments to prove disability. While federal disability benefits are certainly not going to make anyone wealthy (ranging from $735-$2,687 per month), this provides a level of financial security and dignity that every disabled American should be provided. This is a piece of our social contract, and something we should all be proud of and support.

The current Administration has promised to repeal the ACA. We anticipate that this will reopen the health care gap and result in the loss of health insurance for many people who can no longer work but are not yet poor enough for Medicaid. While our taxes pay for the Cadillac health insurance enjoyed by members of Congress, they are threatening to repeal the minimal healthcare benefits that have flowed from the ACA to millions of low-to-middle income people. To date, no replacement plan has been offered that will effectively protect these benefits.

And that is why you should care.   

2017 Numbers from the Social Security Administration (SSA)

Most years the cost of living increases, which results in slight changes in the numbers used by SSA in its disability programs, and it is important to use the correct numbers. The following is a chart of some of the changes between 2016 and 2017:

  2016   2017
 Substantial Gainful Activity (SGA) monthly earnings
 If you are not blind $1130  $1170
 If you are blind  $1820 $1950
 Trial Work Period (TWP) level of monthly earnings $810 $840
 Supplemental Security Income (SSI) monthly benefit amount
 For an individual  $733 $735
 For a couple living together who are both disabled $1100 $1103
 Quarter of Coverage earnings amount $1260 $1300

 

 

Substantial Gainful Activity (SGA)2017 Numbers from the Social Security Administration (SSA)

Step 1 of the disability determination process is whether or not you are “working.” SSA defines work as the ability to engage in SGA. Unless you are self-employed, this is simply measured as a dollar amount. So, in 2017, if you are working and able to earn $1170 (gross, before taxes are taken out of your paycheck), you are engaged in SGA and SSA will determine you are not disabled without analyzing your impairments. If you are working, but earning less than $1170, you are not earning SGA, and your case will proceed to Step 2.

If you are blind, you may earn up to $1950 before SSA determines that you are engaged in SGA.

Special rules apply to self-employed individuals. If you are self-employed but believe that you are disabled, you should bring your income information to your local SSA district office. They can determine if your self-employment is SGA, and advise you about the income rules that apply in your particular situation.

If you are able to work only because of special devices, medications and/or assistance that you pay for out-of-pocket, the cost of these IRWEs (impairment-related work expenses) will be deducted from your income when SGA is determined. For example, if you earn $1500 per month, but have to rent a wheelchair for $200 per month and pay $200 per month for medications to control your symptoms well enough to work, SSA will consider your monthly income to be $1100. Since this is less than $1170, you are not engaged in SGA.

Trial Work Period (TWP)

If you have been disabled for at least 12 months, and then return to work, you are eligible for a TWP. During a TWP, you can both receive your Social Security Disability benefits and keep your paycheck regardless of the amount. You can receive up to 9 TWP months. A TWP month is counted only when your income exceeds $840 (in 2017). If you earn less than this, the month is not counted in your 9-month TWP. After your ninth TWP month, your disability will cease in the next month you earn SGA ($1170).

If you start working while receiving Social Security Disability benefits, you should notify SSA of the dates and amount of your income, in writing, and get a receipt for the notice. SSA will let you know what your reporting requirements are, depending on the amount of your income, and will track your TWP. A receipt of the notice may be important down the road, if SSA loses the information and later assesses you with an overpayment. If you can prove that you notified SSA of the income, it will be easier to claim a waiver of overpayment.

If you start working while you are in the process of applying for Social Security Disability benefits, provide SSA with copies of your paystubs. If you are represented, be sure to notify your representative of your work activity. If you are able to earn at SGA levels within 12 months of your alleged onset date, your claim will be denied. If it has been longer than 12 months since you last worked, you may be eligible for a closed period of disability or a TWP.

TWP does not apply in SSI-only cases.

Supplemental Security Income (SSI)

SSI is a needs-based disability program, available for disabled people without significant income or liquid resources, and who do not have an adequate earnings record to qualify for Social Security Disability benefits. The SSI benefit amount is the same for everybody, and in 2017 it is $735/month. If you and your spouse live together and are both disabled and financially eligible for SSI, you can receive a total of $1103. This is because SSA assumes you share expenses and therefore need less than twice the single rate.

Quarters of Coverage

To qualify for Social Security Disability benefits, you must be “insured” for them. This means that during the 40 quarters prior to the onset date of disability, you worked and paid taxes for 20 quarters. A “quarter” of coverage is measured as a dollar amount, and you can earn four quarters per year. In 2017, a quarter of coverage is defined as $1300 in income. So, if you earn at least $5200, you get all four quarters for the year – regardless of how long it took you to earn that amount.

If you believe you are disabled and eligible for Social Security Disability or SSI benefits, please call Maddox & Laffoon for a free consultation.

SSA’s Disability Caseload In Fiscal Year 2015

It takes SSA several months, and sometimes years, to adjudicate a disability claim. While this can be very frustrating for a disabled person waiting for an individual decision, SSA is not delaying claims on purpose – there is simply a very large caseload. The following is a summary of the numbers of cases, approvals and denials, decided in Fiscal Year 2015, organized by appeal level.

Initial Applications: 2,756,319 claims were received by SSA nationally.
2,677,870 Initial decisions were made by SSA
Of these, 33% claims were approved and 67% were denied

Reconsideration: 704,341 Requests for Reconsideration were filed after Initial Denial
701,072 Reconsideration decisions were made by SSA
Of these, 12% were approvals and 88% were denials

Disability Hearings: 746,300 Requests for Hearing were filed nationally
507,883 Decisions were issued by Administrative Law Judges
Of these 18% were dismissals and 37% were denials
45% of the claims were approved after a hearing

Appeals Council: 149,437 Requests for Review of Hearing Decisions were filed
116,078 decisions were issued by the Appeals Council
Of these, 4% were dismissals and 83% were denials
1% of the appeals were allowed and 13% remanded for
another hearing

Federal Court: 18,078 cases were filed in Federal District Court after AC denial
18,348 decisions were issued by the Court
Of these 8% were dismissals and 45% were denials
2% of the cases were remanded for payment of benefits,
and 45% were remanded for another disability hearing

SSA’s Disability Caseload In Fiscal Year 2015If you are waiting for a decision at any level of the process, we feel your pain. Know that you are not alone, however, and that the delays are neither intentional nor unusual. Although the waiting times vary considerably at different offices across the country, expect the following in Western Washington:

3-8 months at the Initial Level
1-5 months for Reconsideration
10-18 months for a hearing to be scheduled
12-24 months at the Appeals Council
8-14 months in Federal District Court

For more information contact Maddox-Laffoon today. We can help answer questions you may have about SSA and Disability benefits.

 

Is Your Doctor Supportive of your Disability Case?

Is Your Doctor Supportive of Your Disability Case?

It’s not uncommon to hear a claimant for Social Security disability or SSI disability state that their personal physician is “completely behind getting my benefits for disability”, only to unfortunately find out down the road, that their physician isn’t being very helpful, or even worse, actually not supportive at all! The bummer part is that this often becomes the realization just as the disability lawyer is preparing a case for a hearing. When this happens, you and/or your lawyer need to try to gather recent medical records as well as a supportive statement/medical source statement or RFC form.

It is usually a pretty good clue that your doctor is not supportive of your disability case if you find their office is unresponsive to requests for medical records or that the doctor is unwilling to complete the rather lengthy RFC form. One would wonder, well if their doctor is not supportive to their case then why did they say they were? It may be because sometimes doctors say one thing to their patients, and another thing in their patient’s medical records. It may also be because they’ve changed their mind. Another reason may be that the doctor runs a pretty busy practice and does not wish to devote their time to a claimant’s disability case. If the last reason is the case, the doctor may charge to fill out the RFC form, which is money well spent.

However, if your doctor is not willing to fill out the form whether you pay a fee or not, you should consider switching doctors. If you do switch doctors, you’ll have to see them several times to establish that they are now your treating doctor.

Try to discern whether your doctor will support your claim, by having a simple conversation with them or by reviewing your own medical records.

When it’s all said and done, you have to realize that Social Security disability and SSI cases take too much time and energy to fight, only to realize that you don’t have the support of your doctor for your claim.

See Also:

Local Disability Attorneys Versus National Ones

ABLE Act of 2014