DISABILITY EXAMINER POSITION PAPER
Throughout the almost 50 year history of the Social Security Administration’s Disability Insurance Program, the disability claims adjudication process has been a Federal-State venture, with the State Agency (Disability Determination Services) disability examiner * making the initial medical-legal-vocational determination, following complex and frequently changing Federal rules and regulations. The Social Security Administration’s disability programs are unique among disability programs. It follows, then, that those individuals who evaluate claims for Social Security (SSDI) and Supplemental Security Income (SSI) disability benefits must possess unique knowledge, skills, and abilities.
The Social Security and SSI definitions of disability differ markedly from any other public or private industry definitions of disability. While other disability programs focus exclusively or primarily on the degree of impairment, the Social Security and SSI adult disability programs are work and function oriented. The SSI child disability program is function oriented. The Social Security Advisory Board offers a specific explanation of this difference in one of its recent reports: “The concept of disability has both medical and functional components …a given medical condition may or may not be ‘disabling’ depending on the specific functional capacities and how they interact with the educational and vocational profile of the affected individual” (The Social Security Definition of Disability, Social Security Advisory Board, October 2003, page 17). What this means is that an impairment is disabling only if it prevents an adult individual from working or a child from functioning in normal age-appropriate activities. As a result, those who adjudicate Social Security disability claims are required, as a matter of routine, to deal with the interplay of abstract medical, legal, functional and vocational concepts. It takes years before an individual becomes adept at this complex task.
The task is monumental. The SSDI and SSI programs are the two largest federal programs providing cash assistance to people with disabilities (and their dependents and survivors). The SSDI program, established in 1956 by the Social Security Act, provides monthly cash benefits to workers with disabilities. In 2003, SSA paid about $60.7 billion in DI benefits to 5.8 million workers with disabilities (age 18 to 64), $316 million to 151,000 spouses of disabled workers and $4.7 billion to 1.5 million dependent children of disabled workers.
SSI is a means-tested income assistance program created in 1972 that provides a financial safety net for individuals who are aged or blind or have other disabilities and who have low income and limited resources. SSI has no prior work requirement. In 2003, SSA paid about $22.6 billion in SSI federal benefits to about 3.9 million people with disabilities (age 18 to 64) and an additional $6 billion to about 959,000 children with disabilities.
In 2003, the DDSs made 2.5 million initial disability determinations, over 484,000 reconsideration determinations and approximately one million continuing disability review determinations.
The ability of the disability examiner to adjudicate these cases accurately and in a timely manner carries enormous consequences for the Social Security Administration and the citizens who call upon the Agency for assistance. Therefore, it is extremely critical that the individual performing the job of Disability Examiner be highly trained and able to perform their job duties in a highly professional environment.
Every job has a logic – a way of thinking that is unique to that particular job. For example, the purpose of a legal education is not to learn how to be a lawyer or a judge, but to learn how to reason like one. The ability to understand and to be understood in a legal setting does not depend as much on the knowledge of legal proceedings (these vary from jurisdiction to jurisdiction anyway) as it does on the ability to apply the appropriate legal concept in a given situation. The Social Security disability examiner is neither a physician, an attorney or a vocational rehabilitation counselor. Nevertheless, he or she must extract and employ major concepts that are fundamental to each of these professions. The U.S. General Accounting Office has reported that, “Our prior work has found that the examiner’s job – which involves working with medical consultants to determine impairment severity, ability to function and disability benefit eligibility – requires considerable expertise and knowledge of complex regulations and policies. And according to the Social Security Advisory Board, changes in agency rules and in the type of disability claims received by the DDSs have made disability decision-making more subjective and difficult.” (Strategic Workforce Planning Needed to Address Human Capital Challenges Facing the Disability Determination Services, GAO-04-121 Social Security Administration, page 10).
The Social Security Advisory Board offers further clarification of the complexity of the job of the Disability Examiner: “In the early years of the program, over 90 percent of the cases were decided on the basis that the claimant’s medical condition was specifically included in the listings or was of equal medical severity…but the degree of subjectivity clearly is more substantial where the decision moves from entirely medical standards to an assessment of the individual’s vocational capacity.” (The Social Security Definition of Disability, Social Security Advisory Board, October 2003, page 4). “The proportion of initial allowances based strictly on medical factors has declined from around 93 percent in the early years of the program to 82 percent in 1983 and to a 2000 level of 58 percent.” (The Social Security Definition of Disability, Social Security Advisory Board, October 2003, page 7). In essence, the disability examiner must appropriately and interchangeably, during the course of adjudication, apply the “logic” of a doctor, a lawyer and a rehabilitation counselor.
The disability examiner performs a comprehensive review of the disability claims folder; determines appropriate jurisdiction; and develops the case through contact with the applicant, medical sources, schools, employers, governmental agencies, etc., deciding the most effective way to procure such information. The disability examiner analyzes and evaluates data in medical, educational, vocational and legal reports, physician’s statements, laboratory test results, psychological evaluations, school records and governmental applications and forms and determines adequacy and sufficiency of information available for adjudication. Social Security disability examiners are required by law to follow a complex sequential evaluation process, performing at each step, an analysis of the evidence and a determination of eligibility or continuing eligibility for benefits before proceeding to the next step. Adjudication of claims for Social Security and/or SSI disability benefits requires that disability examiners be conversant (reading, writing, and speaking) in the principles of medicine, law and vocational rehabilitation.
A disability examiner is not a physician but he/she must be able, on the basis of signs, symptoms and laboratory findings, to make judgments about the presence, onset, clinical severity, and prognosis of any physical or mental impairment alleged by the applicant. This includes the ability
to recognize a symptom complex that has been neither alleged by the applicant or diagnosed by a treating source and then to determine the need for and to identify and order the appropriate physical or mental examination required and/or any necessary laboratory studies, x-rays or other tests needed to independently evaluate the alleged or un-alleged condition. Disability case adjudication also requires the ability of the disability examiner, when appropriate, to exchange ideas, information, and opinions with a program physician, psychologist, speech and language pathologist or vocational consultant so as to arrive jointly at conclusions regarding impairment severity and functional restrictions and limitations as a result of the impairment(s). Disability examiners are experts in the accumulation of medical information bearing on disability decision-making processes –knowing what kind of evidence to secure; when this evidence is sufficient and of requisite quality; how to secure this evidence while avoiding the dangers of exposing disability claimants to unnecessary or dangerous testing, and while respecting their human dignity; and how to accomplish disability decision making in a fiscally responsible manner. Although other disability programs may accept statements from treating or examining physicians as proof of disability, in the Social Security and SSI disability programs, the statement of a physician has no probative value. The disability examiner must review, analyze and weigh all opinion evidence and determine appropriate weight to give to each piece of evidence, applying complex rules of evidence.
The disability examiner is not an attorney but he/she must be able to apply legal concepts of rules of evidence, weighing of evidence, evidentiary sufficiency, administrative finality, Collateral Estoppel, due process, Res Judicata, and disclosure of evidence under the federal Privacy and Freedom of Information Acts. He/ she must also be aware of relevant Circuit Court decisions which impact on case development and adjudication in that circuit, or in that DDS, and apply those legal concepts and provisions to each individual case adjudicated. The disability examiner must be able to translate the medical concept of clinical severity into the legal concept of Social Security disability program severity and the resultant functional restrictions into vocational and/or age-appropriate assessments. This includes the ability to explain extemporaneously to an applicant, treating physician, attorney, advocate or Congressional staff how a physician’s opinion was weighed in the disability evaluation decision and, if appropriate, why that opinion about the patient’s “disability” is being rejected. It also includes the ability to write an analysis, in a quasi-legal decision rationale, the weighing of opinion evidence and the decision arrived at that is sound enough to explain to an audience of claimants, attorneys, judges, and justices the basis for that decision.
The disability examiner is not a rehabilitation counselor. Nevertheless, disability examiners must be able to determine the vocational potential of applicants. This includes the ability to evaluate the impact of physical and/or mental impairments on an applicant’s ability to perform work related functions to determine whether (based on such factors as age, education and previous work history) an individual can return to his or her former occupation, or, if not, whether the individual retains the functional ability to engage in any other occupation that exists in the national economy.
A disability examiner is not a school psychologist, counselor or speech & language pathologist. Yet when adjudicating SSI childhood claims he/she must assess not only the severity of the child’s impairment(s) but the impact of those impairments, both singly and in combination, on the child’s level of functioning compared to normal children his/her age in multiple domains: acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for him/her self, as well as the cumulative effects of the physical or mental impairment(s) and their associated treatments or therapies on the child’s ability to function in an age-appropriate manner.
A disability examiner must be proficient with a wide range of technological tools. He/she must be familiar with, and able to use effectively, a number of computer applications and software packages including, but not limited to, Word, Excel and Outlook; Web based applications such as Policy Net and Web page navigation; computer generated reference materials and case processing systems such as Levy, Versa, MIDAS, as well as the federal Social Security Administration query system. Many of these programs are in a continuing state of change. As a result, the disability examiner must continuously learn and relearn the programs in order to use these tools effectively and efficiently.
The Social Security Administration’s disability programs are unique. As a result, disability examiners require unique competencies. A disability examiner must have knowledge of the total disability program as well as proficiency in adult and child physical and mental impairment evaluation, knowledge of vocational and job bank information and the legal issues which impact on case development and adjudication. A disability examiner must be familiar with technical eligibility requirements such as earnings records, insured status and income and resources. A disability examiner must have complete and extensive knowledge of the Social Security Act and amendments and all provisions, opinions, precedents, decisions and disability letters and guidelines issued. He/she must have the ability to communicate verbally and in writing; write analyses of medical, opinion and other evidence; write non-technical reports describing these issues to lay persons; and be proficient with a wide range of technological tools. A disability examiner analyzes complex medical, vocational, functional and programmatic data and determines appropriate course of action. The disability examiner discusses medical requirements with staff physicians and vocational issues with vocational consultants as needed. The disability examiner evaluates the resultant functional restrictions on the ability to work and/or perform normal daily activities. In addition to all this, the disability examiner must ensure a timely, quality decision regarding initial or continuing eligibility for disability benefits is made.
The U.S. General Accounting Office declared in one of their reports to Congress that: “The critical task of making disability decisions is complex, requiring strong analytical skills and considerable expertise, and it will become even more demanding with the implementation of the Commissioner’s new long-term improvement strategy and the projected growth in workload.” (Strategic Workforce Planning Needed to Address Human Capital Challenges Facing the Disability Determination Services, GAO-04-121 Social Security Administration, page 41). NADE concurs with the opinion expressed by the U.S. General Accounting Office. We believe that the Social Security Administration’s goal of achieving an electronic disability claims process represents an important, positive direction toward more efficient delivery of disability payments. However, while technology can be expected to reduce hand-offs, eliminate mail time and provide other efficiencies, technology is merely a tool. It cannot replace the highly skilled and trained disability examiner who evaluates the claim and determines an individual’s eligibility for disability benefits in accordance with Social Security federal rules and regulations.
* Disability examiner is a generic title and reflects the responsibilities and duties of disability adjudication under the Social Security Administration’s disability programs but does not necessarily reflect the actual titles of specific positions in individual states.
Approved by NADE Board 2-13-04