Medical records and chart review play a major role in a disabled individual’s ability to receive SSDI or social security disability benefits. The treating physician will have to make available all relevant medical records to the Social Security Administration (SSA) along with a statement regarding any limitations the disabled person has that prevent him/her from working and earning wages. Also, the treating doctor can inform the SSA how the disabled person is responding to prescribed treatments, the nature of the disability and its severity, extent, and how long it is expected to last. The statements from the treating physician help the SSA determine whether the applicant is eligible to receive disability benefits.
When it comes to social security disability programs, certain questions arise in the minds of doctors and other health professionals treating disabled people who have applied for disability benefits. Following are some of the most frequently asked questions and their answers as explained by the SSA.
- How does the SSA define disability?
For adults, social security law defines disability as the incapacity to engage in substantial gainful activity or SGA because of any medically determinable physical or mental disability, which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. According to social security law, a child is considered disabled if he/she has any medically determinable physical or mental impairment or combination of impairments that causes significant and severe functional limitations, and that is expected to cause death or that has lasted or is expected to last for a continuous period of not less than twelve months.
- Who are eligible for disability benefits?
- Disabled workers below the age of 65 and their families.
- People who become disabled before the age of 22, if a parent or a grandparent who is covered under social security retires, becomes disabled, or dies.
- Blind workers.
- Disabled widows/widowers, age 50 or over, if the deceased spouse worked long enough under social security and paid taxes into the program.
- Why is SSA’s definition of disability so stringent?
Disability benefits are to be paid only to deserving individuals with the most severe form of disability. The disability determination will be carefully done so that no fraudulent claims are granted.
- Who is eligible for SSI or Supplemental Security Income benefits paid by the SSA?
- Disabled persons below the age of 65 who have very limited income and resources.
- Blind adults or children.
- Disabled children below 18 years.
- How does the SSA decide whether an applicant is disabled?
A team comprising a physician/psychologist, and a disability examiner employed by the DDS (Disability Determination Services) of the state in which the claimant lives, determines whether an applicant is disabled.
- Will the DDS team examine the disability applicant?
They don’t. The team relies on the medical evidence extracted from the medical records of the claimant, and the treating physicians’ statements. However, they may contact the applicant in case they need clarification of some points, or if they need some additional information.
- What about the medical criteria the state DDSs use?
All state DDSs use the same set of medical criteria. This will ensure consistent and uniform claim adjudication irrespective of where the claimant lives.
- Who develops Social Security’s disability evaluation criteria? Is it updated frequently?
Social Security’ disability evaluation criteria are developed by social security medical consultants along with other medical experts. It is updated when necessary. Any change in these criteria has to reflect the latest approved, established medical procedures and practices. These criteria are also known as Listings, or Listing of Impairments. You can access it online at Disability Evaluation under Social Security.
- What information should a treating physician include in the claimant’s medical report?
- History, and clinical and lab findings
- Diagnosis and treatment prescribed
- The patient’s response to the treatment
- A statement about what work activities the patient can still accomplish despite the impairment
- How significant is the treating doctor’s statement about what the claimant can still do?
It could be very important when it comes to the decision on whether the claimant is disabled as defined by the law. The SSA will give weight to the physician’s statement when it is well supported by the clinical and lab findings, and is consistent with other evidence in the patient’s medical chart. The state DDS may contact the treating doctor for any additional information they need.
- Does the SSA pay for the medical report prepared by the treating physician?
The SSA may pay a reasonable amount for reports of existing medical evidence it requests from physicians, psychologists, hospitals, or other non-government providers of medical services. The particular state DDS can be contacted for its payment information.
- What is meant by independent medical sources?
These are physicians and psychologists in private practice in all medical specialties who conduct consultative examinations or CEs for the DDS. Typically, if the treating physician does not have some requested information, the DDS may ask if he or she wishes to provide the information by carrying out tests or a medical exam for a fee that the DDS will pay. Alternately, the DDS may send the claimant to an independent medical source for an exam and the required information if the treating provider prefers not to do the exam or doesn’t have the equipment to perform the same.
- Can the physician provide the medical report over the phone instead of writing it up and sending it to the SSA?
Yes. Many state DDSs hire a tele-dictation service that enables the consultative physician to do that. This service can be used at any convenient time round the clock. The physician is sent a typed transcript of his/her telephoned report to review, sign and return to the DDS.
- What are continuing disability reviews (CDRs)?
All disability cases need to be reviewed periodically to ensure that the claimants are still disabled. The frequency of these reviews is based on the nature and severity of the disability, possibility of improvement and other factors. CDRs may range from 6 months for cases where medical improvement is expected, up to 7 years where medical improvement is not expected. Typically, if there is no sign of medical improvement, the benefits may continue. During a CDR, the physician may be asked to provide current medical evidence. In case any additional examination is needed, the DDS team may request the treating physician to perform the same or send the claimant to an independent medical source.
- What is the procedure if the claimant becomes disabled again after recovering from the disability?
If the person becomes disabled again within 5 years after an earlier period of disability, he/she need not observe a new 5-month waiting period before the benefits may resume. Any existing Medicare protection will resume immediately.
- What are the special provisions available for blind persons?
- An individual who has either a visual acuity of 20/200 or less, or a visual field restricted to 20 degrees or less, in the better eye, is eligible for disability benefits if he/she has worked long enough under social security.
- A blind person who is eligible for SSI needs no social security work credits.
- A blind person, even though working, is eligible for a disability “freeze” under social security. This means that future benefits that are figured on average earnings will not be cut because of low earnings or no earnings in some years due to blindness.
If a claimant’s application for SSDI is denied, the treating doctor may be able to help him or her with the disability appeal process. As a disability attorney would advise, more medical evidence needs to be collected to prove the disability or impairment. Since the SSA will perform a chart review of the claimant’s medical records, it is important that the doctor provides his/her opinion on the basis of the medical documentation.
The above FAQs would be useful for physicians treating disability claimants as well as attorneys handling social security disability cases.