Consultative Examination Study

Objective

As part of the Social Security Administration’s (SSA) process for determining eligibility for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits, state Disability Determination Services (DDS)—federally funded state agencies that support SSA in making disability determinations—may decide that more extensive information is needed concerning an applicant’s medical condition. One means of obtaining such information is to order a consultative examination (CE), which is a physical or mental health examination or test purchased on behalf of the claimant at SSA’s expense. The DDS must follow established federal regulations in ordering and reviewing CEs, though they have flexibility in managing the process and arranging CEs with providers. SSA is expected to oversee and assess the CE process and content in accordance with these regulations. After a series of reports conducted by the Government Accountability Office and the Institute of Medicine raised concerns about CE processes, content, and overall quality, SSA decided to conduct a study of the process in an effort to provide an empirical basis for comprehensively addressing these concerns. In particular, SSA sought to determine whether: (1) CEs are being requested in compliance with federal regulations; (2) medical sources are conducting CEs and including content in compliance with federal regulations; (3) CEs include sufficient information to make a disability determination and provide everything SSA paid for in the exam; and (4) there are specific process and content factors that contribute to the quality of CEs.

Status

The Consultative Examination Study was completed in November 2012 with the issuance of a final report.

To conduct this study, SSA awarded a contract to Comprehensive Occupational Medical Services (COMS), which subcontracted with Mathematica Policy Research, to obtain and analyze information from a sample of claims closed at two administrative levels (initial and hearings) in 2009 that contained CEs procured to assist in the claim determination or decision. In conjunction with SSA, the study team developed a template, or data collection instrument, to address the key research questions. A COMS review team, which included disability examiners and consultants with medical or psychological expertise, used the template to extract information from a sample of 327 CEs. This sample included CEs from the two largest physical health exam categories (internal medicine and musculoskeletal) and mental health exams. The CEs were generally split between the initial and hearings levels to facilitate comparisons by adjudication levels, though they were not selected in a way to generalize to the state or national population of CEs.

The CE study provided new information on CE processes and content unavailable in other data sources. Specific findings indicated that:

Most study CEs included at least partial information on most items required by federal regulations when conducting a basic exam. More specifically, at least 85 percent of sampled CEs had the necessary items noted in federal regulations, including a chief complaint, some history of the chief complaint, general exam items, lab tests ordered in accordance with the Listing of Impairments, a diagnosis, and the signature of a qualified medical source. In addition, most CEs contained sufficient information to make a disability determination.
Potential inefficiencies in the CE processes included: (1) a lack of documented consultation by the DDS examiner with medical consultants before ordering a CE; (2) medical evidence of record (MER) arriving after issuance of the CE order; and (3) treating sources not being utilized as CE providers. Furthermore, most CEs at both the initial and hearings levels did not include information on a prognosis. Some of these issues are potentially outside of SSA’s control (e.g., late arriving MER) or reflect differences in DDS review requirements.
Hearings level CEs included more detailed medical content relative to those at the initial level. In particular, hearings level CEs generally covered more exam items, were more likely to include a medical source statement, and were more likely to include an additional test. Also, relative to CEs conducted at the initial level, a higher proportion of CEs conducted at the hearings level contained all the information expected for an exam (e.g., expected findings, conclusions, and responses to specific questions). However, it is unclear whether these differences in CE content across adjudication levels substantially affected the overall quality of CEs. In particular, only a minority of CEs at both the initial and hearings level (approximately 10 percent) had deficient information in terms of being useful for a disability determination. In addition, more unnecessary tests were conducted at the hearings level, particularly for mental health CEs, pointing to a possible inefficiency in the CE ordering process at that adjudication level.

An Assessment of Consultative Examination (CE) Processes, Content, and Quality: Findings from the CE Review Data: Final Report

Inter–Rater Reliability Analysis of Data to Document the Consultative Examination Process Volume 1: Final Report

Inter–Rater Reliability Analysis of Data to Document the Consultative Examination Process Volume 1: Appendices

Not applicable.