[Federal Register Volume 59, Number 180 (Monday, September 19, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-22491]
[[Page Unknown]]
[Federal Register: September 19, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Process Reengineering Program; Disability Reengineering Project
Plan
Agency: Social Security Administration, HHS.
Action: Announcement of the plan for a new disability claim process.
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SUMMARY: The Social Security Administration (SSA) announces a plan to
redesign the claim process for Social Security Disability Insurance and
Supplemental Security Income (SSI) disability benefits. This notice
contains the plan, as well as background information. The aim of the
plan is to achieve dramatic improvements in service to claimants filing
for disability benefits and restore public confidence in SSA's
disability programs.
FOR ADDITIONAL COPIES CONTACT: Social Security Administration, PO Box
17052, Baltimore, MD 21235, (410) 966-8255. The plan is available in
alternative formats for visually impaired individuals. Please use this
same telephone number to request a copy of the plan in an alternative
format.
SUPPLEMENTARY INFORMATION:
Background--What is the Process Reengineering Program?
SSA began an Agency-wide program of Process Reengineering in the
summer of 1993. The Process Reengineering Program is one way that SSA
is seeking to improve its overall delivery of service to the public.
The Process Reengineering Program essentially asks the question,
``If SSA had the opportunity today to design its processes, what would
they look like?'' In other words, ``how would we design a process if we
were starting over?'' The Programs objective is to fundamentally
rethink and radically redesign SSA's processes to achieve dramatic
improvements in critical measures of performance such as quality of
service, speed and efficiency. The ultimate goal is to achieve
dramatically improved levels of service from the customer's perspective
while enriching and improving the work lives of employees.
The Process Reengineering Program is the culmination of an
investigation by SSA of the reengineering efforts conducted by private
companies, public organizations, academic institutions, and consulting
firms with ``hands on'' experience. The positive findings from that
investigation, combined with concerns about the impact of current and
projected workloads, led SSA to conclude that a disability claims
process reengineering effort was critical to its objectives of
providing world-class service to the public and restoring public
confidence in its disability programs.
Based on analysis of what has worked best in other organizations,
SSA developed a customized reengineering methodology. This methodology
used a team approach (composed of SSA and State Disability
Determination Service (DDS) employees) and combined a strong customer
focus with classic management analysis techniques to intensely review a
single business process. While the reengineering team was comprised of
employees who were knowledgeable about the current disability process,
the methodology focused heavily on obtaining the views of a broad
segment of individuals, groups and organizations involved both
internally and externally to the process.
What Does the Disability Reengineering Project Address?
Despite the outstanding efforts of SSA and State DDS employees
throughout the country, the Agency continues to have difficulty
providing a satisfactory level of service to claimants filing for
disability benefits. The steps in the current disability process have
not changed in any important way since the beginning of the Disability
Insurance program in the 1950s. Yet, case loads, types of disabilities,
and the demographic characteristics of individuals with disabilities
who are potentially eligible for benefits have changed radically.
The State DDSs make the initial decisions about whether an
applicant for Disability Insurance or SSI benefits is disabled. In
Fiscal Year (FY) 1995, it is estimated that SSA will forward 2.9
million initial disability claims to the DDSs for disability
determinations--a 69 percent increase over FY 1990 levels. Similarly,
the number of requests for an administrative law judge hearing on
denied claims is expected to increase to 542,000, a 75 percent increase
over FY 1990 levels. Recent management initiatives to improve service
through resource reallocations and productivity enhancements have not
been sufficient to deal successfully with the workload demands and it
is expected that disability processing times and backlogs will continue
to grow under the present process.
The result is that many claimants have to wait much too long at
each stage of the process. SSA and State DDS employees are working
longer and harder, while becoming increasingly frustrated about their
inability to provide the type of service the public deserves.
For these reasons, the first SSA reengineering project focused on
the process of filing for benefits--beginning with the initial claim
and continuing through the payment of benefits or the final
administrative appeal--under both the Disability Insurance program and
the disability portion of the SSI program.
The parameters set for this first project restricted the team from
proposing any changes to the statutory definition of disability or the
amount of benefits for which individuals are eligible. The project also
did not address vocational rehabilitation, work incentives or
continuing disability reviews as these issues are being addressed by
SSA in other ways.
How Was the Disability Process Reengineering Project Accomplished?
The Disability Process Reengineering Project began in October 1993
when a team of 18 Federal and State employees came together for the
purpose of reengineering the initial and administrative appeals system
for determining an individual's entitlement to Disability Insurance and
SSI disability payments. After completing their initial tasks of
analyzing the current process, obtaining process improvement
recommendations from over 3,600 individuals and groups internal and
external to the disability claim process, benchmarking with public and
private sector organizations to identify ``best practices,'' and
modeling theoretical processes via computer, the team presented an
initial proposal on March 31, 1994. (A copy of this proposal was
published in the Federal Register, Vol. 59, No. 73, on Friday, April
15, 1994.) The team distributed the proposal widely throughout SSA, the
State DDSs, and to interested public and private individuals and
organizations and asked the audience for reactions to the proposal,
items of concern, and additional ideas for improvement.
During the comment period that began on April 1, 1994, and ended on
June 14, 1994, the team received over 6,000 written responses from SSA
and DDS employees, employee unions, professional associations, members
of the public, claimant representatives, physicians, State governors,
claimant advocacy groups, Federal entities, and other interested
parties. Members of the team read and analyzed every one of the
comments so that no idea, reaction or nuance would be overlooked. Group
employee feedback discussions were held in over 80 sites across the
country to facilitate dialogue with almost 2,000 SSA and DDS employees.
In addition, team members conducted briefings and spoke with more than
3,000 individuals about their reactions to the proposal during this
period. A public forum was also held in Washington, D.C. A summary of
the comments received is provided in Appendix III of the attached plan.
After considering all comments, the team reviewed the breadth of
the initial proposal to determine concepts that needed to be revised,
language that needed to be clarified, and details that needed to be
added. On June 30, 1994, the team submitted its revised proposal to the
Commissioner of Social Security. Subsequently, after careful
consideration, on September 7, 1994, the Commissioner released SSA's
Plan for a New Disability Claim Process. Accepting all of the concepts
contained in the team's June 30 revised proposal as SSA's plan, the
Commissioner released the redesign plan with the understanding that
certain concepts (primarily aspects of the simplified disability
methodology) would require extensive research and testing before
determining how quickly they could be implemented.
What Service Improvements Does the Plan for a New Disability Claim
Process Offer?
The Commissioner established five primary objectives against which
SSA will measure the success of a redesigned disability claim process:
-- The process is user friendly for claimants and those who assist
them;
-- The right decision is made the first time;
-- Decisions are made and effectuated quickly;
-- The process is efficient; and
-- Employees find the work satisfying.
By focusing on these objectives, the redesigned process replaces an
existing process that is slow, labor-intensive, and paper reliant with
a seamless claim process that makes better use of technology,
eliminates fragmentation and duplication, promotes more flexible use of
resources, and results in dramatic improvements in public service. With
the redesign plan, SSA has embarked on an era of change that will
revitalize and streamline the way it delivers disability claim service
to the public to achieve greater quality, speed and efficiency.
Specific customer focused improvements that the plan will offer
include a process that will:
Be a user-friendly, more accessible and customer focused
process, that ensures benefits are paid to all eligible individuals as
quickly as possible. Case processing times will be cut in half once the
new process is fully implemented;
Provide complete and accurate consumer-oriented
information to applicants throughout the process and allow individuals
who are able to be full partners in the processing of their claim;
Utilize modern technology and highly skilled and trained
employees to deliver high-quality service in an accountable, cost-
efficient manner;
Implement a comprehensive quality assurance program that
continually strives to improve operational excellence and the level of
service that disability applicants receive; and
Use education and training opportunities to enrich
employees jobs, increase their job satisfaction and quality of work
life.
A detailed description of the redesigned disability claim process
is included in the attached plan.
What Happens Next?
SSA will move quickly to begin implementing the redesigned
disability claim process. Some new process features, involving research
and changes to regulations and computer systems, necessitate a phased-
in approach. Other new process features can be implemented in the near-
term and, when combined with special short-term initiatives to address
case backlogs, will result in better service for individuals currently
filing for disability benefits. The goal is to make near-term, visible
improvements while at the same time building for long-term results.
SSA will make an unprecedented effort to conduct a full and open
dialogue with both SSA and non-SSA audiences as the Agency moves
through the implementation phase. The Agency will use all appropriate
modes of communication to ensure that necessary information about
implementation activities is regularly and widely disseminated and will
develop appropriate feedback channels to permit the meaningful exchange
of information.
Dated: September 7, 1994.
Rhoda M. G. Davis,
Director, Process Reengineering Program.
Message From the Commissioner
Social Security Administration's Plan for a New Disability Claim
Process
It was 10 months ago that I challenged this Agency to restore
public confidence in its programs, provide world-class service to its
customers, and ensure a nurturing environment for its employees. While
there is much left to be done to meet these goals, I am proud to say
that with the release of this document we have reached a major
milestone toward meeting the challenges I set forth.
This document lays the foundation for the new disability claim
process. It is a solid foundation upon which to build--it provides a
broad description of the new process, with the detailed elements of the
process to be developed.
The new design gives us the opportunity to develop relationships
with the public and our employees that are based on open communication,
partnership, and the belief that our customers need to be provided as
much information as possible about the process and the program. I
believe this new design holds the potential to provide the world-class
service I pledged to furnish the American people--it will be user-
friendly, it will ensure the right decision is made the first time, it
will allow decisions to be made and effectuated quickly, and it will be
an efficient process. Just as importantly, the new design will also
provide our employees with a nurturing environment through empowerment,
education, challenge, career opportunity, and professionalism.
As the discussions about our reengineering effort and the future of
the disability claim process evolved, I listened to the issues and
opinions and the hopes and fears that have been expressed. I heard from
SSA and State employees, the public, members of Congress,
representatives of other Federal agencies, State officials, union
representatives, and various experts in the disability field. I believe
that everyone wants something better for the American people. I am
convinced that we must be bold in our efforts. Therefore, I have chosen
to accept the recommendations of the Agency's Disability Process
Reengineering Team which were presented to me on June 30, 1994, with
the full understanding that certain aspects of the decisional
methodology will require extensive research and testing to determine
whether they can be implemented. Because those aspects of decisional
methodology that deal with functional assessment, baseline of work, and
the evaluation of age require much study and deliberation with experts
and consumers, we are making no conclusions about their ultimate place
in the disability process. Our implementation plans include the
research needed to begin in this area. As more is known, we will
reevaluate our planning assumptions. Until then, the concept of a
single person as the disability claim manager for all cases cannot be
fully implemented. Instead, we will seek ways of working in teams to
provide claimants with the level of service they seek.
The cost of redesigning our disability claim process will not be
inexpensive; however, the tangible savings will be worth the
investment. The workyear savings will allow us to use current staff to
accomplish other pressing workloads and activities of the Agency while
avoiding new hiring to replace all those who retire or otherwise leave
on their own accord. Thus, we will be able to do our part to reduce the
Federal workforce overall. Additionally, with these savings will come
such intangibles as improved customer service, an empowered and better
trained workforce, and increased public confidence in the process.
It is now time for us to move forward with concrete actions to
begin the actual redesign of the way we do business in our disability
programs. On July 12, 1994, I announced that Charles A. (Chuck) Jones,
the Director of the Michigan Disability Determination Service, had
accepted the challenge of managing the implementation of SSA's plan to
reengineer the disability process. In that role, he will be responsible
for the overall leadership and coordination of the redesign
implementation. He will establish timelines and priorities and will
provide direction to component efforts as well as to task management
teams. As Implementation Manager, Chuck will report directly to me and
the Principal Deputy Commissioner.
During the discussions of the Team's proposal, I heard several
consistent underlying themes about how our new design should be
implemented: we must unify the process; we need enabling information
technology; we need to ensure the safety of employees; we must
continuously deliver effective training; we must retain the existing
Federal/State relationship; and we must develop a simpler methodology
for making disability decisions. I am absolutely committed to turning
these needs into realities as we move ahead. Some will not be easy, and
all will take time and money; however, all will need to be addressed if
we are to achieve the successful outcome of the redesign.
As implementation plans are developed and task teams are brought
together, we will continue to assess all related activities against the
five primary objectives of our redesigned process:
--making the process ``user friendly'' for claimants and those who
assist them;
--making the right decision the first time;
--making the decision as quickly as possible;
--making the process efficient; and
--making the work satisfying for employees.
However, this work will not be done in isolation-- internally, we
will continue to seek advice on these issues from our Advisory Group,
comprised of SSA and DDS executives and union and association leaders.
Externally, we will continue to publicly inform all who are interested
and create opportunities for dialogue and consultation.
Special thanks are extended to the Disability Process Reengineering
Team whose recommendations are the result of an unprecedented endeavor
for this Agency, and I dare say for most Federal agencies. The Team's
thousands of hours of interviews, research, analysis, computer
modeling, feedback sessions, and revisions have created a daring image
for us of what can be if we truly seek to provide world-class service.
We must accept their challenge and begin the arduous task of bringing
to reality what is now only a concept.
The next few years will be challenging for all of us as we build
our redesigned process, but that will not be a new experience for those
of you who are employees of SSA and the State DDSs. You have been
called upon in the past to rise to the occasion and have always more
than met the challenge; your flexibility, resourcefulness,
professionalism, and just plain hard work are legendary. Now more than
ever, I will need you to be bold and help build a better future for
those who seek our services.
Shirley S. Chater,
Commissioner of Social Security.
Case for Action
Overview
SSA and the State Disability Determination Services (DDSs) have
always striven to provide high-quality, responsive service to the
public. In recent years, the disability insurance (DI) and Supplemental
Security Income (SSI) claims workload has been the Agency's most
challenging problem. SSA has been faced with unprecedented workload
increases in both the DI and SSI programs which have severely strained
its resources. Despite improvements in productivity by employees in
field offices, DDSs, hearing offices, the Appeals Council and the
processing centers over the last several years, SSA has had difficulty
providing a satisfactory level of service to claimants for disability
benefits. SSA recognizes that, in an era of spending limitations and
competing social spending priorities, placing more and more resources
into the current process is not a viable alternative.
Additionally, demographic changes in the general population and in
the SSA claimant population present challenges as well as opportunities
as SSA strives to provide world-class service to its customers. Despite
the workload and demographic changes, however, the procedures for
processing disability claims have not changed in any important way
since the beginning of the DI program in the 1950's and many of the
Agency's current practices are based, in large part, on procedures
begun 40 years ago. Disability process changes that have evolved over
time tend to reflect small, incremental improvements designed to
address various pieces of the overall process. It has become
increasingly clear that incremental improvements are no longer
sufficient to achieve the level of service that will make a substantial
difference to disability claimants. Thus, SSA needs a longer-term
strategy for addressing service delivery problems in the disability
claim process.
Workload and Operations Trends
Over the last several years, as workloads have increased
dramatically, the disability process has been placed under increasing
stress. The upward trend in the number of claims and the number of
beneficiaries awarded is reflected as follows:
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The increase in workload has occurred concurrently with significant
downsizing activity in SSA and staffing fluctuations in the State DDSs.
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Even with the downsizing, the total costs for processing initial
disability and appeals determinations (excluding the costs for
processing the Sullivan v. Zebley court case) remain enormous--more
than half of the total administrative costs (including DDS costs) for
SSA in Fiscal Year (FY) 1993 were devoted to this task.
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Despite these funds, and despite directing a larger percentage of
the SSA resources toward disability initial claims and appeals
processing in recent years, average processing times for initial
claims, as well as appeals, have escalated dramatically since 1988.
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The high workload level is expected to continue and will adversely
affect SSA's ability to timely process initial disability claims and
appeals. Recent management initiatives to improve service through
resource reallocations and productivity enhancements have not been
sufficient to deal successfully with the workload demands and it is
expected that disability processing times and backlogs will continue to
grow under the present process. In FY 1995, it is estimated that 2.9
million initial disability claims will be forwarded to DDSs for
disability determinations--a 69 percent increase over FY 1990 levels.
Similarly, in FY 1995, annual requests for administrative law judge
(ALJ) hearings will rise to 542,000, a 75 percent increase over FY 1990
levels. The average time to process an initial disability claim (the
combined average for both DI and SSI claims) is expected to rise to 154
days in FY 1995; the average time from ALJ hearing request to decision
is expected to rise to 342 days in the same period.
Demographic Trends
American society has changed dramatically since the DI program
began in the 1950s. This is reflected in an increased demand for SSA's
services, changes in the characteristics of claimants seeking benefits,
and new complexities in claim-related workloads and processes.
The demographic character of the SSA disability claimant population
has changed as well. The enactment of the SSI program in the 1970's
added individuals who have limited or no work histories, increased the
number of individuals filing based on disabilities such as mental
impairments, and provided for eligibility of disabled children.
Additionally, the requirements of the SSI program added complex and
time consuming development of non-disability eligibility factors such
as income, resources and living arrangements. The 1990 U.S. Supreme
Court decision, Sullivan v. Zebley, resulted in increased claims for
children; children comprised 21 percent of all SSI claims in 1992, up
from 11 percent in 1988. Homeless individuals and others with special
needs have strained the delivery system. These claimants require
significant intervention and assistance to navigate the disability
claim process.
A trend in the general population which is reflected in SSA's
disability claimant population is the increased number of people in the
United States for whom English is not the native language. Recent
national Census data indicate that 1 in 7 people speak a language other
than English in the home; this is an increase of almost 38 percent in
the last 10 years. SSA will need to accommodate the special
communication needs of these claimants in its ongoing claimant contacts
and in public information vehicles.
Forty percent of claimants filing for disability benefits and
polled in a recent SSA survey had filed for or received benefits from
Aid to Families with Dependent Children, welfare or social services
within the past year. Approximately three-fourths of them were granted
this assistance and three-fourths of those grantees were still
receiving assistance when they applied for disability benefits. SSA has
the opportunity to develop productive relationships with these social
service entities to improve the processing of disability claims for
mutual customers.
Technological advances such as personal computers, facsimile
machines, electronic mail, and videoconferencing are increasingly
available to our claimants, their representatives, medical providers
and other third parties involved in the disability process. SSA can
take advantage of these capabilities to offer expanded service options
and to modernize the ways it interacts with providers of claims-related
information and evidence.
The Current Process
The procedures in the current process have not changed in any
significant way since the DI program began in the 1950s, a time when
caseloads, demographic characteristics of claimants, types of
disabilities, and available technology were radically different. In the
1970s, Congress federalized State programs of cash assistance to the
aged, blind and disabled into the SSI program and added this to the
responsibilities of SSA. SSA adopted the DI disability determination
procedures for SSI blind and disabled claims.
Slow, Manual Process
In the current process, a disability claim passes through from 1 to
4 decisional paths to receive a favorable decision. The initial claim,
reconsideration, ALJ hearing and Appeals Council review levels all
involve multi-step uniform procedures for evidence collection, review,
and decisionmaking.
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The process starts at the initial level when an individual first
applies for DI and/or SSI benefits on the basis of a disabling physical
or mental condition. An individual calls the national toll-free
telephone number and is referred to a local SSA field office or visits
or calls one of 1,300 local field offices to apply for benefits. Field
office personnel assist with application completion, obtain detailed
medical and vocational history and screen nonmedical eligibility
factors. Field office personnel forward the claim to 1 of 54 State DDSs
where medical evidence is developed and a final decision is made
regarding the existence of a medically determinable impairment which
meets the definition of disability. The decision is made by an
adjudicative team consisting of a disability specialist and a program
physician.
After possible quality assurance review in the DDS or in the SSA
regional Disability Quality Branch, the claim is returned to the field
office; denials are retained pending possible appeal. In FY 1993, 39
percent of initial claims were allowed and sent to 1 of 7 processing
centers (which include the Office of Disability and International
Operations and the 6 Program Service Centers) for final processing and
storage, as well as adjudication of claims for dependents. Allowed SSI
claims remain in the field office for payment effectuation and folder
retention. A sample of these are reviewed after payment for
nondisability quality assurance. According to SSA's computer-based
processing time measurements, an initial claim currently takes an
average of about 100 days to process from the time of filing until a
decision is made. However, from the claimant's perspective, a better
understanding of how long the process takes comes from a 1993 study
conducted by SSAs Office of Workforce Analysis, which showed that an
average claimant waits up to 155 days from the initial contact with SSA
until receiving an initial claim decision notice. During this period,
16 to 26 employees will handle the claim.
The claimant may request reconsideration of the initial decision
within 60 days of receiving the denial notice. In FY 1993, claimants
requested reconsideration in 48 percent of denied claims. Local field
office personnel receive the reconsideration request, update necessary
information, and forward the claim file to the DDS for review, possible
medical development, and a medical decision. The reconsideration
decision is made by a different adjudicative team than the one that
made the initial determination.
After possible quality assurance review in the DDS or in the
regional Disability Quality Branch, about 14 percent of these claims
are returned to the field office for payment and forwarding to a
processing center; the remaining denials are forwarded to the field
office for retention, pending possible further appeal. According to
SSAs computer-based processing time reports, the average
reconsideration takes about 50 days--however, according to the Office
of Workforce Analysis study, a claimant has now been involved with the
disability process for roughly 8 months from the initial contact with
SSA, and up to 36 different employees could have handled the claim.
A claimant can request a hearing before an ALJ within 60 days of
receiving an unfavorable reconsideration decision. In FY 1993,
claimants requested an ALJ hearing in about 75 percent of all
reconsideration denials. By this time, a claimant has usually retained
an attorney or other representative to assist in pursuing the claim for
benefits. About 75 percent of all claimants retain a representative at
the hearing level. Local field office personnel receive the request for
hearing and forward it with the claim file to one of 132 local SSA
hearings offices. Hearing office personnel review the file for possible
additional development, conduct a hearing, and render a decision.
DI claims allowed at the hearing level are sent to a processing
center for payment effectuation and adjudication of claims for
dependents, and storage. Allowed SSI claims are returned to the local
field office for income and resource development, and payment. Denied
claims are forwarded to the Appeals Council for retention pending a
possible request for review. According to computer-based reports, the
hearing process takes about 265 days. However, according to the Office
of Workforce Analysis study, a claimant has been dealing with SSA for
over a year and a half at this point in the process.
If dissatisfied with the hearing decision, a claimant (or
representative) may request Appeals Council review within 60 days of
receiving the ALJ decision. In FY 1993, about 23 percent of hearing
decisions were unfavorable. The Appeals Council considers about 18
percent of all ALJ dispositions, including cases it reviews on its own
motion. Requests for Appeals Council review are typically received
directly from the claimant's representative. The Appeals Council may
deny or dismiss a request for review, issue a decision, or remand the
claim to an ALJ. The Appeals Council remands claims to the ALJ level
about 27 percent of the time for subsequent development and decision.
Denied claims, representing about 70 percent of the Appeals Council
dispositions, are held in the Appeals Council for possible appeal to
Federal District court. Allowed claims are sent to a processing center
or field office for further action as in hearing cases. According to
processing time reports, this part of the process takes on average
about 100 days; however, according to the Office of Workforce Analysis
study, a claimant has spent almost 2 years dealing with SSA since
initially contacting the Agency.
At least part of the processing time results from the time added as
the claim moves from one employee or facility to another (handoffs),
and waits at each employee's workstation to be handled (queues). As
workloads increase, the amount of time a claim waits at each processing
point grows.
``Task time'' is the time employees actually devote to working
directly on a claim, rather than the total amount of time it takes for
a claimant to receive a final decision. Based on the Office of
Workforce Analysis study, a claimant can wait as long as 155 days from
the first contact with SSA until receiving an initial claim decision
notice--of which only 13 hours of this is actual task time. The same
study reveals a claimant can wait as long as 550 days from that initial
contact through receipt of the hearing decision notice--of which only
32 hours is actual task time.
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Complex, Confusing Process
Many applicants enter the SSA disability process uninformed about
the process itself and the definition of disability. They are unaware
of the criteria for establishing disability and the evidence they will
be required to submit. Even third parties and advocate organizations,
often more knowledgeable than the general public about SSA procedures,
experience difficulty obtaining meaningful information about the status
of their clients claims, finding that they often are transferred from
one employee to another.
Disability claimants face a ``one size fits all'' approach to the
intake and processing of their claim, finding themselves answering
questions they believe are intrusive and irrelevant to their claim.
Front-line employees currently devote hours to completing forms and
obtaining information which may not be necessary for a finding of
disability. Claimants often do not understand what happens to the claim
after initial contact with SSA and view multiple requests for medical
information with annoyance. Often claimants do not understand how the
decision was made and, therefore, believe that it was reached
arbitrarily. If the claim is approved, whether at the initial or
appellate level, claimants and their representatives, as well as front-
line employees, are concerned about the complicated procedures and
length of time it takes to effectuate payment and entitle eligible
dependents.
SSA employees, claimants, and other interested parties all agree
that the current process takes too long to provide applicants a
decision, and leaves them confused about who has responsibility for
their claim, and puzzled about the status of their claim during various
points in the process. Additionally, nearly all believe that many
claimants can and should assume more responsibility for submitting
evidence and pursuing their claim.
Most view the reconsideration step as little more than a rubber
stamp of the initial determination, creating additional work for
employees and yet another bureaucratic obstacle for claimants and their
representatives. Some believe a face-to-face interview with the
decisionmaker is vital to reaching a fair, accurate determination;
others believe just as strongly that the decision should be reached on
the basis of a paper review, and that a face-to-face interview can lead
to subjective decisions that are not based on objective criteria.
Quality reviews and Appeals Council reviews are often mentioned as
areas where opportunities exist for streamlining and improving the
current process.
Claimants and their representatives have learned their chances for
a favorable decision improve if they appeal their claim to an ALJ. The
public, in particular, believes that it is necessary to hire an
attorney to maneuver through the appeals process, and voices resentment
at having to do so. Higher allowance rates at the ALJ level lead to the
perception that different adjudicative standards apply at the initial
and appeals levels. A variety of factors may be contributing to this.
The facts of many cases change over time as a claimants condition
changes. ALJs often have access to information not considered at lower
levels in the process because earlier decisionmakers are not as likely
to have face-to-face interaction with the claimant.
Contributors to Complexity
The collection of medical evidence presents problems as the case is
developed, accounting for a considerable portion of the total time
involved in disability claim processing. Health care providers who are
a claimants treating source often do not understand the requirements
for establishing disability, and find medical evidence request forms
confusing and repetitive. They believe that evidence requests burden
them with far too much paperwork and offer far too little in the way of
compensation for the time invested. Adjudicators often find that
evidence is primarily treatment-oriented and fails to provide either
the highly specialized clinical findings or the functional information
that is required by the regulations. To compensate for poor or missing
medical evidence, DDSs purchase consultative examinations, devoting
substantial resources to scheduling, purchasing, and processing these
examinations.
Once the medical evidence has been collected, the methodology used
by disability decisionmakers is complex and controversial. The current
sequential evaluation process, which was originally designed to
identify and evaluate cases in a simple, rapid and consistent fashion
has grown increasingly complex as the result of court decisions and
changes in medical technology. This complexity has, in turn,
contributed to the increasing difficulty and fragmentation in other
portions of the disability process, including intake, evidence
collection, and appeals.
For example, the Listings of Impairments was originally designed to
highlight readily identifiable disabling impairments. Many of the
Listings have since evolved into complex and highly detailed diagnostic
requirements, demanding specialized medical evidence that may not be
readily available from treating sources. Some, but not all, of the
Listings consider the functional consequences of an impairment; however
functional considerations vary significantly among the Listings.
Additionally, in assessing an individuals functional abilities at the
later steps in the sequential evaluation, adjudicators collect and
analyze evidence from a multitude of different, and often conflicting,
sources including: objective clinical and laboratory findings; treating
source opinions and other third-party statements considered to be
consistent with the objective evidence; and the individuals description
of his or her limitations. The development of extensive medical
evidence in every case impedes timely and efficient decisionmaking. The
varying approaches to assessing a claimants functional ability that are
required at different steps in the sequential evaluation, along with
the nature and types of evidence that adjudicators may rely on to
assess function often lead to different interpretations of the same
evidence by different adjudicators. Vocational rules originally
designed to provide a structured approach to decisionmaking have grown
increasingly complex, leading to varying interpretations and
inconsistent decisions.
Fragmented Process
The fragmented nature of the disability process is driven by and
exacerbated by the fragmentation in SSA's policy making and policy
issuance mechanisms. Policy making authority rests in several
organizations with few effective tools for ensuring consistent guidance
to all disability decisionmakers. Different vehicles exist for
conveying policy and procedural guidance to decisionmakers at different
levels in the process. While the standards for disability
decisionmaking are uniform, they are expressed in different wording in
the various policy vehicles.
Training on disability is not delivered in a consistent manner, nor
is it provided simultaneously to disability decisionmakers across or
among levels in the process. Mechanisms for reviewing application of
policy among levels of the process are fragmented and inconsistent.
Review of DDS decisions is heavily weighted toward allowances; no
systematic quality assurance program is in place for hearing decisions
although the opportunity for feedback from the Appeals Council or from
the courts is heavily weighted toward denials.
The organizational fragmentation of the disability process creates
the perception that no one is in charge of it. SSA measures the process
from the perspective of the component organizations involved, rather
than the perspective of the claimant. Multiple organizations (field
offices, DDSs, hearings offices, Appeals Council operations, and
processing centers) have jurisdiction over the claim at various points
in time, with each line of authority managing toward its own goals
without responsibility to the overall outcome of the process.
Additionally, the impact of one components work product on other
components is not measured, further contributing to the fragmentation
of the process. Each component's narrow responsibilities reinforce a
lack of understanding among component employees of the roles and
responsibilities of other employees in different components.
The Need for a Redesigned Disability Claim Process
Concerns about the Agency's business processes generally, and the
quality of service in the disability claim process in particular, led
SSA leadership to the conclusion that a disability process
reengineering effort was critical to the SSA goal of providing world-
class service to its customers. The National Performance Review, headed
by the Vice President, directed improvement of the SSA disability
process as a key service initiative for the Federal government.
Leading private sector organizations have used process
reengineering to identify and quickly put in place dramatic
improvements in their operations. The objective of a reengineering
review is to fundamentally rethink and radically redesign a business
process from start to finish, so that it becomes many times more
efficient and, as a result, significantly improves service to the
organization's customers. By focusing on the disability claim process
as a single business process, SSA hoped to cut across the
organizational lines and multiple components that handle the many
pieces of the disability process.
Redesign Technique
A project team composed of 18 Federal and State employees, under
the direction of an SSA senior executive, assembled at SSA Headquarters
in October 1993 to conduct the disability claim process reengineering
review. With the guidance of an Executive Steering Committee the Team
was challenged to fundamentally rethink the way SSA processes
disability claims. The Team's initial findings and proposal, issued in
March 1994, for a redesigned disability claim process were widely
shared during a 60-day public comment period. Based on the comments
received, the Team presented a revised proposal to the Commissioner of
Social Security on June 30, 1994. After extensive consultation with
individuals and organizations in the internal and external disability
community, the Commissioner accepted the Team's recommendations for a
redesigned disability process. A summary of the methodology used to
redesign the disability claim process is included in Appendix I.
New Process Goals and Expectations
The Commissioner established five primary objectives against which
SSA will measure the success of a redesigned disability claim process:
--The process is user friendly for claimants and those who assist them;
--The right decision is made the first time;
--Decisions are made and effectuated quickly;
--The process is efficient; and
--Employees find the work satisfying.
By focusing on these objectives, the redesigned process replaces an
existing process that is slow, labor-intensive, and paper reliant with
a seamless claim process that makes better use of technology,
eliminates fragmentation and duplication, promotes more flexible use of
resources, and results in dramatic improvements in public service. With
the redesigned process, SSA has embarked on an era of change that will
revitalize and streamline the way it delivers disability claim services
to the public to achieve greater quality, accuracy, speed and
efficiency. A detailed description of the redesigned disability claim
process is presented in the following section.
Description of the New Process
Overview
Claimants for disability benefits under the new process will be
provided a full explanation of SSA's programs and processes at the
initial contact with SSA. Claimants will be offered a range of options
for filing a claim and conferring with decisionmakers, using various
modes of technology to interact with SSA. Claimants, who are able to do
so, along with third parties and representatives who act on their
behalf, will assist in the development of their claims, deal with a
single contact point in the Agency, and have the right to a personal
interview with decisionmakers at each level of the process. The number
of steps will be consolidated and the issues on appeal will be focused.
If the claim is approved, the effectuation of payment to the claimant,
eligible dependents and the representative will be streamlined.
BILLING CODE 4190-29-P
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The new process will result in correct decisions at the earliest
possible point in the process. A correct disability decision is one
that appropriately considers whether an individual does or does not
meet the factors of entitlement for disability as defined by SSA's
statute, regulations, rulings and policies. Correct decisions in the
new process depend on: a simplified decision methodology that provides
a common frame of reference for deciding disability at all levels of
the process; consistent direction and training to all adjudicators;
enhanced and targeted collection and development of medical evidence;
an automated and integrated claim processing system that will assist
adjudicators in evidence gathering, analysis and decisionmaking; and a
single, comprehensive quality review process across all levels. The
goal of the new process is to guide all adjudicators at all levels of
the process, who will be using the same standards for decisionmaking,
to making correct decisions in an easier, faster, and more cost-
effective manner.
A disability claim manager will handle most aspects of the
disability claim at the initial level, thus eliminating many steps
caused by numerous employees handling discrete parts of the claim
(handoffs) and the time lost as the claim waits at each employee's
workstation to be handled (queues). This will reduce the time needed to
rework files and redevelop information from the same evidentiary
sources. Levels of appeal will be combined and improved, reducing the
need to redevelop nonmedical eligibility factors after a favorable
decision because less time will have elapsed since initial filing.
The new process will enable the current work force to handle an
increased number of claims, freeing the most highly specialized staff
(physicians and ALJs) to work on those cases and tasks that make the
best use of their talents, and targeting expenditures for medical
evidence to those areas most useful in determining disability.
Employees will perform a wider range of functions, using their
skills to their full potential, enabling them to meet the needs of
claimants and minimize unnecessary rework. The new process will
facilitate employees' ability to do the total job by providing
technology and the training and support to use that technology. [For
ease of reference, references in this plan to ``SSA'' or ``employees''
include both Federal and State employees who participate in the
disability process.]
Process Entry and Intake
Customized Intake and Entry
The disability claim entry and intake processes will reflect the
SSA commitment to providing world-class service to the public. The
hallmarks of the process will be accessible, personal service that
ensures timely and accurate decisions. SSA will work to make potential
claimants better informed about the disability process and fully
prepare them to participate in it. Every effort will be made to provide
services to meet the needs of culturally diverse, non-English speaking
claimants. SSA will also be flexible in providing modes of access to
the claim process that best meet the needs of claimants and the third
parties and representatives who act on their behalf. SSA will provide
claimants with a single point of contact for all disability claim-
related business. Finally, SSA will ensure that the disability
decisionmaking process promotes timely and accurate decisions.
Making Program Information Available
SSA will make available to the general public comprehensive
information packets about the DI and SSI disability programs. [For ease
of reference, references in this plan to the SSI Disability Program
include the Program for those who are blind.] The packets will include
information about the purpose of the disability programs; the
definition of disability; the basic requirements of the programs; a
description of the adjudication process; the types of evidence needed
to establish disability; and the claimant's role in pursuing a claim.
The packets may be customized locally to include referral information
about other programs and resources for legal representation. The goal
is to target the information to likely beneficiaries and to ensure that
potential claimants and other groups involved in the disability process
have a better understanding of SSA disability programs, their medical
and nonmedical requirements, and the nature of the decisionmaking
process. This should result in reduction of general inquiries from
members of the public unfamiliar with SSA disability programs and
increase the number of claimants who enter the disability process
knowledgeable and prepared to assume responsibility for pursuing their
claims.
SSA will make disability information packets commonly available in
the community, both at facilities frequented by the general public
(libraries, neighborhood resource centers, post offices, the Department
of Veterans Affairs offices, and other Federal government
installations) and at facilities frequented by potential claimants
(hospitals, clinics, other health care providers, schools, employer
personnel offices, State public assistance offices, insurance
companies, and advocacy groups or third-party organizations that assist
individuals in pursuing disability claims). SSA studies have shown that
claimants frequently rely on advice from their physicians and from
State public assistance personnel in deciding whether to file a claim
for disability benefits. Therefore, SSA will make a special effort to
target its public information activities at these and other known
sources of referrals for claims. SSA will also make the disability
information packets available electronically.
In addition to comprehensive program information, the packets will
describe the types of information that a claimant will need to have
readily available when the individual files a claim. It will also
contain two basic forms: The first, designed for completion by the
claimant, will include general identifying information and will serve
as the claimant's starter application for benefits; the second,
designed for completion by the treating source(s), will request
specific medical information about a claimant's alleged impairments.
SSA will encourage claimants who are able to do so to review the
information in the packet and have the basic forms completed prior to
telephoning or visiting an SSA office to apply for disability benefits.
Claimants will be encouraged to immediately submit starter applications
to protect the filing dates for benefits. The starter application will
serve as a claim for both programs, but it will include a disclaimer
should the claimant want to preclude filing for benefits based on need
(i.e., SSI).
Claimants Will Choose Mode of Entry
The disability claim entry process will be multi-faceted, allowing
claimants and third parties and representatives who assist them the
maximum flexibility in deciding how they will participate in the
process. Claimants may choose to enter the disability claim process by
telephoning the SSA toll-free number, electronically, by mail, or by
telephoning or visiting a local office. Claimants may also rely on
third parties to provide them assistance in dealing with SSA. Finally,
claimants may formally appoint representatives to act on their behalf
in dealing with SSA. SSA field managers will also have the flexibility
to tailor the various service options to their local conditions,
considering the needs of client populations, individual claimants, and
the availability of third parties who are capable of contributing to
the application process.
If an individual submits a starter application by mail or
electronically, SSA will contact the claimant to schedule an
appointment for a claim intake interview or, at the claimant's option,
conduct an immediate intake interview by telephone.
If an individual telephones SSA to inquire about disability
benefits, the SSA contact will explain the requirements of the
disability program, including the SSA definition of disability, and
provide a general explanation of evidence requirements. The SSA contact
will determine whether the individual has the disability information
packet, and mail it or advise the claimant regarding possible means of
electronic access. If an individual indicates a desire to file a claim
at that time, the SSA contact will complete the starter application
available on-line as part of the automated claim processing system to
protect the claimant's filing date and schedule an appointment for a
claim intake interview. The interview may be in person or by telephone
at the claimant's option. If the individual has no medical treating
sources, the SSA contact will annotate this information within the on-
line claim record.
If a claimant visits an SSA office, the SSA contact will refer the
claimant for an immediate claim intake interview or, at the claimant's
option, complete the starter application and schedule a future
appointment for an intake interview.
In all cases, appointments for claim intake interviews will be made
available within a reasonable time period, generally 3 to 5 working
days, but no later than two weeks.
Local management will determine how to best accommodate claimants'
needs in learning about the disability process and completing a claim
intake interview. Depending on an individual's circumstances, such
accommodation may involve: Referral to the nearest location for
obtaining a disability information packet which can then be mailed in;
an immediate telephone or in-person interview; arranging for an on-site
visit from an SSA representative; or referral to appropriate third
parties who can provide assistance. Additionally, depending on the
nature of the individual's disability, SSA may encourage the individual
to file in person when it appears that a face-to-face interview will
assist in the proper claim intake and development; however, face- to-
face interviews will not be required in every claim. Face-to-face
interviews, when considered necessary by either the claimant or SSA,
can also be accomplished via videoconferencing. In any case, SSA will
make every reasonable effort to meet the needs of the claimant in
completing the application process. Every effort will be made to
provide services to members of the public who have limited knowledge of
English.
Similarly, local managers will modify the claim entry and intake
process to provide maximum flexibility for representatives who act on
behalf of claimants or third parties who can assist claimants in
completing the application process. Such accommodations may include,
but are not limited to: (1) Using automated means to interact with SSA
to protect a claimant's date of filing (e.g., telephone, fax, or E-
mail); (2) providing appointment slots for third parties to accompany
claimants to interviews or to provide assistance during telephone
claims on a claimant's behalf; (3) out-stationing SSA personnel at a
third-party location to obtain applications and/or medical evidence,
when appropriate; and (4) providing ``open appointment'' scheduling to
permit claimants to contact SSA within a flexible band of time.
Interested third parties will be encouraged to participate in the
development of claims.
Local managers will also conduct outreach efforts that are designed
to meet the needs of hard-to-reach populations or assist those
individuals unable to access the SSA claim process without considerable
intervention. As appropriate, outreach efforts may be facilitated
through videoconferencing, teleconferencing or other electronic methods
of obtaining and processing claim information to provide timely service
despite claimants' geographic or social isolation.
Disability Claim Manager
A disability claim manager will have responsibility for the
complete processing of an initial disability claim. The disability
claim manager will be a highly-trained individual who is well-versed in
both the medical and nonmedical aspects of the disability programs and
has the necessary knowledge, skills, and abilities to conduct personal
interviews, develop evidentiary records, and adjudicate disability
claims to payment. However, the disability claim manager will also be
able to call on other SSA resources, including medical and technical
support personnel, to provide advice and assistance in the claim
process.
Disability claim managers will rely on an automated claim
processing system that will permit them to: Gather and store claim
information; develop both medical and nonmedical evidence; share
necessary facts in a claim with medical consultants and specialists in
nonmedical or technical issues; analyze evidence and prepare well-
rationalized decisions on both medical and nonmedical issues; and
produce clear and understandable notices that accurately convey all
necessary information to claimants. In making decisions, disability
claim managers will use a simplified decision methodology that
effectively streamlines evidence collection, and will rely on standards
for decisionmaking that are used at all levels of the process.
The disability claim manager will be the focal point for claimant
contacts throughout the claim intake and adjudication process. The
disability claim manager will explain the disability programs to the
claimant, including the definition of disability and how SSA determines
if a claimant meets disability requirements. The disability claim
manager will also convey what the claimant will be asked to do
throughout the process; what the claimant may expect from SSA during
this process, including anticipated timeframes for decision; and how
the claimant can interact with the disability claim manager to obtain
more information or assistance. The disability claim manager will
advise the claimant regarding the right to representation and provide
the appropriate referral sources for representation. The disability
claim manager will also advise the claimant regarding community
resources, including the names of organizations that could help the
claimant pursue the claim. The goal will be to give the claimant access
to the decisionmaker and allow for ongoing, meaningful dialogue between
the claimant and the disability claim manager.
Scope of Duties
The broad scope of the disability claim manager's duties and
responsibilities, as outlined above and discussed in more detail in the
following sections, presupposes a well-trained, skilled, and highly
motivated workforce that has the program tools and technological
support to issue quality decisions. Although disability claim managers
will work exclusively within the disability programs, they will perform
multiple tasks instead of singular activities, enabling them to
experience the direct relationship between their actions and the final
product. Varying levels of job complexity provide the opportunity for
personal development, growth, and learning.
In carrying out their duties and responsibilities, disability claim
managers will work in a team environment with internal medical and
nonmedical experts, who provide advice and assistance for complex case
adjudication, as well as technical and other clerical personnel who may
handle more routine aspects of case development and payment
effectuation. Where disability team members cannot be physically co-
located, they can share information via the automated claim processing
system and remain in communication using telephones or
videoconferencing. Each disability team member will have at least a
basic familiarity with all the steps in the process and an
understanding of how he or she complements another's efforts; team
members will be able to draw upon each other's expertise on complex
issues.
In this team environment, and with the proper training, program
tools (a simplified decision methodology and one set of standards for
decisionmaking) and technological support, one individual should be
able to handle the duties and responsibilities of the disability claim
manager. An individual employee as the disability claim manager is
basic to the objective of a single point of Agency contact for
claimants.
However, in the near term, it may be necessary to consider whether
the duties of a disability claim manager may be more appropriately
carried out by more than one individual and, therefore, whether it is
necessary to expand the ``disability team'' described above to include
additional employees. Claim complexity, customer service needs, and
service area location may dictate a need for flexibility in delineating
the specific duties of the individuals who comprise the members of the
disability team. In the near term, apprentice positions will be
developed in which employees perform one or more duties of the
disability claim manager while gaining experience and qualifying for
greater responsibility. As the program tools and technological support,
which are the underpinnings of the new process, are fully implemented,
it is envisioned that team duties and positions will be modified and
consolidated as necessary to fully realize the goal of an individual
employee as disability claim manager.
Process Flexibility
The disability claim manager will conduct a thorough screening of
the claimant's medical and nonmedical eligibility factors. If the
claimant appears ineligible for either disability program based on the
claimant's allegations and evidence presented or available at the time
of the claim intake interview, the disability claim manager will
explain this to the claimant. However, the decision regarding whether
to file an application will be the claimant's alone and the disability
claim manager will not discourage a claimant from filing an
application. If the claimant decides not to file a claim, the
disability claim manager will follow existing procedures for closing
out an oral inquiry.
If the claimant decides to file, the disability claim manager will
complete appropriate application screens from the automated and fully
integrated (DI and SSI) claim processing and decision support system.
Impairment-specific questions will assist the disability claim manager
in obtaining information that is relevant and necessary to a disability
decision. Based on the claimant's statements and the evidence that is
available at the interview, the disability claim manager will determine
the most effective way to process the claim. If the evidence is
sufficient to decide the claim, the disability claim manager will take
necessary action to issue a decision and, if necessary, effectuate
payment. The disability claim manager will determine what additional
evidence is required to adjudicate the claim and will take steps to
obtain that evidence. Such steps may include asking the claimant to
obtain further medical or nonmedical evidence if the claimant is able
to do so, requesting medical evidence directly from treating sources,
or ordering further medical evaluations. As in the current process, SSA
will pay for the reasonable cost of providing existing medical
evidence. If the claimant has a formal representative, the
representative will have the responsibility to develop medical and
nonmedical evidence.
The disability claim manager will decide whether to defer
nonmedical development (e.g., requesting SSI income and resource
information, or developing DI dependents' claims) or do it
simultaneously with development of the medical aspects of the claim. In
making this decision, the disability claim manager will take into
account the type of disability alleged, evidence and other information
presented by the claimant, and other relevant circumstances, e.g.,
terminal illness, homelessness or difficulty in recontacting the
claimant. Because the disability claim manager maintains ownership of
the claim throughout the initial decision-making process, the
disability claim manager will be in the best position to choose the
most efficient and effective manner of providing claimants with timely
and accurate decisions while meeting claimants' individual service
needs.
Although the disability claim manager will be responsible for the
adjudication of an initial claim, the disability claim manager will
call in other staff resources, as necessary. With respect to disability
decisionmaking, the disability claim manager will, in appropriate
circumstances, refer claims to medical consultants to obtain expert
advice and opinion. SSA will develop guidelines to assist the
disability claim manager in determining when expert medical advice is
appropriate. Similarly, other staff resources will be called upon for
technical support in terms of certain claimant contacts and status
reports; development of nondisability issues including auxiliary claims
or representative payee issues; and payment effectuation. However, the
disability claim manager will make final decisions on both the medical
and nonmedical aspects of the disability claim.
Claimant Partnership
Throughout the disability claim process, SSA will encourage
claimants to be full partners in the processing of their claims. Many
claimants are able to obtain the documentation necessary to develop
their record, either on their own or with the assistance of a third
party. Others have substantial difficulty doing so, and may have no
third party to assist them. Given the range of claimant capabilities,
SSA will retain ultimate responsibility for development of claims when
claimants are not formally represented.
To the extent that they are able, claimants and their families and
other personal support networks will actively participate in the
development of evidence to substantiate their claim for disability
benefits. SSA will provide assistance and/or engage third-party
resources, when necessary and appropriate. SSA will keep claimants
informed of the status of their claims, advise claimants regarding what
additional evidence may be necessary, and inform claimants what, if
anything, they can do to facilitate the process.
At the completion of the claim intake interview, the disability
claim manager will issue a receipt to the claimant that will identify
what to expect from SSA and the anticipated timeframes. It will also
identify what further evidence or information the claimant has agreed
to obtain. Finally, it will provide the name and telephone number of
the disability claim manager for any questions or comments which the
claimant may have, including any difficulty in obtaining the
information the claimant agreed to obtain.
Third Parties
Certain third-party organizations may be willing to provide a
complete disability application package to SSA. Based on local
managements assessment of service area needs and the availability of
qualified organizations, SSA will recognize third-party organizations
who are capable of providing a complete application package, including
appropriate application forms and medical evidence necessary to
adjudicate a disability claim. In such claims, SSA will permit the
third party to identify potential claimants, screen for medical and
nonmedical criteria, and contact SSA to protect the filing date. The
third party will interview the claimant; complete all applications and
related forms; obtain completed treating source statements; and obtain
additional medical evaluations, when appropriate. Using procedures
agreed on with local management, the third party will submit claims for
adjudication by a disability claim manager. SSA will monitor such third
parties to ensure that quality service is provided to claimants and to
prevent fraud. SSA may establish rules, standards, and procedures for
third-party interaction with claimants and SSA. Third parties may be
required to undergo periodic program, procedural or software training,
and may be required to meet standards for staffing and automation
support. In individual cases, disability claim managers may elect to
contact the claimant for the purpose of verifying identity or other
claim-related issues, as appropriate. SSA will also perform ongoing
document verification on a sample basis to assure the integrity of
claims submitted by third parties. The automated claim processing
system will facilitate effective monitoring of the claim-taking and
evidence submission practices of third parties by permitting random
and/or targeted selection of claim files involving specific third
parties or specific types of evidence.
Personal Interview With Claimant
When the evidence does not support an allowance, the disability
claim manager will issue a predecision notice advising the claimant of
what evidence has been considered and providing the opportunity to
submit further evidence, if any, and/or the opportunity for a personal
interview within 10 calendar days. The predecision notice will further
advise the claimant that if he or she does not submit evidence or
request a personal interview within the 10 days, the claim will be
decided based on the evidence of record. If the claimant requests a
personal interview, the disability claim manager will conduct the
interview in person, by videoconference, or by telephone, as the
disability claim manager determines is appropriate under the
circumstances. In appropriate circumstances, this predecision interview
may be held concurrently with the initial intake interview. If the
claimant identifies further available evidence, the disability claim
manager will advise the claimant to obtain the evidence if the claimant
is able to do so or, as necessary, assist the claimant in obtaining it.
The claimant will be advised of the specified timeframes for submitting
additional evidence.
In preparing the predecision notice, the disability claim manager
will rely on existing information available on-line as part of the
automated claim processing and decision support system. As part of the
evidence gathering process, the disability claim manager will have
previously analyzed all the medical and non-medical information
gathered, and entered the pertinent data into the electronic claim
record. The decision support system will use the accumulated data in
the electronic record to assist the disability claim manager in
producing the predecision notice.
``Statement of the Claim''
The initial disability determination will use a statement of the
claim'' approach. The statement of the claim will set forth the issues
in the claim, the relevant facts, the evidence considered, including
any evidence or information obtained as a result of the predecision
notice, and the rationale in support of the determination. The
statement of the claim not only reflects SSAs commitment to fully
explaining the basis for its action but also recognizes that claimants
need clear information about the basis for the determination to make an
informed decision regarding further appeal.
As with the predecision notice, much of the information that will
provide the basis for the statement of the claim will be available on-
line as part of the automated claim processing and decision support
system. Adjudicators will create the statement of the claim and
whatever supplementary information is necessary for a legally
sufficient notice to the claimant based on the information in the
decision support system. For allowance decisions, the statement of the
claim will be more abbreviated than for denial decisions; however, it
will contain sufficient information to facilitate quality assurance
reviews and/or continuing disability reviews. The statement of the
claim will be part of the on-line claim record and will be available to
other adjudicators as the basis and rationale for the Agencys action,
if the claimant seeks further administrative review.
In making initial disability determinations, disability claim
managers will rely on standards for decisionmaking that are used at all
levels of the process. SSA will develop a single presentation of all
substantive policies used in the determination of eligibility for
benefits and all decisionmakers will be bound by these same policies.
These policies will be published in accordance with the Administrative
Procedure Act. Expert systems will be developed to facilitate the
development and delivery of disability policy as an integrated part of
the automated claim processing system.
Disability Decision Methodology
Promoting Consistent, Equitable, and Timely Decisions
SSA must have a structured approach to disability decisionmaking
that takes into consideration the large number of claims (2.7 million
initial disability decisions in FY 1994) and still provides a basis for
consistent, equitable decisionmaking by adjudicators at each level. The
approach must be simple to administer, facilitate consistent
application of the rules at each level, and provide accurate results.
It must also be perceived by the public as straightforward,
understandable and fair. Finally, the approach must facilitate the
issuance of timely decisions.
As described further below, the goal of the new decisionmaking
approach is to focus decisionmaking on the functional consequences of
an individual's medically determinable impairment(s). The new process
will assess an individual's functional ability, assess it once in the
process, do it directly rather than indirectly, and rely on
standardized functional assessment instruments to do so. By focusing on
function, the new approach will permit both providers of medical
evidence and adjudicators at all levels of the process to use a
consistent frame of reference for deciding disability, regardless of
the diagnosis. It will also facilitate evidence collection by lessening
the need for voluminous medical records and, instead, look at the
consequences of medical findings, i.e., function. Ultimately,
adjudicators will make correct decisions in an easier, faster, and more
cost-effective manner.
The cornerstone of the new approach is, of course, the statutory
definition of disability. Under the statute, disability (for adults)
means the:
``. . .inability to engage in any substantial gainful activity
by reason of any medically determinable physical or mental
impairment 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. . .An individual shall be determined to be
under a disability only if his physical or mental impairment or
impairments are of such severity that he is not only unable to do
his previous work but cannot, considering his age, education, and
work experience, engage in any other kind of substantial gainful
work which exists in the national economy. . .'' (Sec. 223(d) of the
Social Security Act).
Four-Step Evaluation Process for Adults
The new decisionmaking approach is the foundation on which SSA will
base the claim intake process and evidence collection. The focus will
be, first, to document the medical basis for concluding that an
individual has a medically determinable physical or mental impairment.
Second, once the evidence establishes a medically determinable
impairment(s), decisionmakers will, in most cases, use additional
medical findings to determine the link between the disease or
impairment and the loss of function.
The disability decision methodology will consist of four steps that
flow from the statutory definition of disability. They are:
Step 1--Is the individual engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2--Does the individual have a medically determinable physical
or mental impairment?
If no, deny.
If yes, continue to Step 3.*
Step 3--Does the individual have an impairment included in the
Index of Disabling Impairments i.e., an impairment that clearly
restricts functional ability to a degree that the individual is unable
to engage in substantial gainful activity without measuring the
individual's functional ability?
If yes, allow.*
If no, continue to Step 4.
Step 4--Does the individual have the functional ability to perform
substantial gainful activity?
If yes, deny.
If no, allow.*
*An impairment must meet the duration requirement of the
statute; a denial is appropriate for any impairment that will not be
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
Any individual who is engaging in substantial gainful activity will
not be found disabled regardless of the severity of the individual's
physical or mental impairments. Under the new approach, SSA will
simplify the monetary guidelines for determining whether an individual
who is an employee (except those filing for benefits based on
blindness) is engaging in substantial gainful activity. In making this
determination, SSA will evaluate the work activity based on the
earnings level that is comparable to the upper earnings limit in the
current process (i.e., $500). A single earnings level will simplify the
evidentiary development necessary to evaluate work activity and
establish the appropriate onset date of disability. Additionally, SSA
will continue to exclude impairment-related work expenses in evaluating
whether an individual's earnings constitute substantial gainful
activity. SSA will continue to evaluate whether work activity is done
under special conditions and/or is subsidized. Finally, SSA will
continue to use separate earnings criteria to evaluate the work
activity of blind individuals in the DI program as in the current
process.
Step 2--Medically Determinable Impairment
Because the statute requires that disability be the result of a
medically determinable physical or mental impairment, the absence of a
medically determinable impairment will justify a finding that the
individual is not disabled. Under the new approach, decisionmakers will
consider whether an individual has a medically determinable impairment
or combination of impairments, but will no longer impose a threshold
``severity'' requirement. Rather, the threshold inquiry will be whether
the individual has a medically determinable physical or mental
impairment or combination of impairments. To establish the presence of
a medically determinable impairment, evidence must show an impairment
that results from anatomical, physiological, or psychological
abnormalities which are demonstrable by medically acceptable clinical
and laboratory diagnostic techniques.
Decisionmakers will continue to evaluate the existence of a
medically determinable impairment based on a weighing of all evidence
that is collected, recognizing that neither symptoms nor opinions of
treating physicians alone will support a finding that the individual
has a medically determinable impairment or combination of impairments.
There must be medical signs and findings established by medically
acceptable clinical or laboratory diagnostic techniques which show the
existence of a physical or mental impairment or combination of
impairments. Depending on the nature of an individual's alleged
impairment(s), SSA will consider the extent to which medical personnel
other than physicians can provide evidence of a medically determinable
impairment.
There will be an exception to the requirement that evidence include
medically acceptable clinical and/or laboratory diagnostic techniques.
This will occur when, even if SSA accepted all of the individual's
allegations as true, SSA still could not establish a period of
disability; under these circumstances, SSA will not require evidence to
establish the existence of a medically determinable impairment. For
instance, if an individual describes a condition as one that will
clearly not meet the 12-month duration requirement, (e.g., a simple
fracture), SSA will deny the claim on the basis that even if the
allegations were medically documented, SSA could not establish a period
of disability.
Step 3--Index of Disabling Impairments
If an individual has a medically determinable physical or mental
impairment documented by medically acceptable clinical and laboratory
techniques, and the impairment will meet the duration requirement, the
decisionmaker will compare the individual's impairment(s) against an
index of severely disabling impairments. The index will describe
impairments so severely debilitating that, when documented, can be
presumed to equal a loss of functional ability to perform substantial
gainful activity without assessing the individual's functional ability.
The index will be consistent with the statutory definition of
disability by limiting the presumption of inability to perform
substantial gainful activity, without considering age, education and
previous work, to a relatively small number of claims with the most
severe disabilities. Individual functional ability will be assessed in
all other cases in a consistent manner at Step 4 in the process.
Because the index will permit severely disabling impairments to be
identified quickly and easily, it will only consist of descriptions of
specific impairments and the medical findings that are used to
substantiate the existence and severity of the particular disease
entity. The medical findings in the index will be as nontechnical as
possible and will exclude such things as calibration or standardization
requirements for specific tests and/or detailed test results (e.g.,
pulmonary function studies or electrocardiogram tracings). The index
will be easy to understand and simple enough so that laypersons will be
able to understand what is required to demonstrate a disabling
impairment in the index. Additionally, SSA will draw no conclusions
about the effect of an individual's impairments on his or her ability
to function merely because an individual's impairment(s) does not meet
the criteria in the index. Finally, SSA will no longer need the concept
of ``medical equivalence'' in relation to the index. Because
impairments included in the index are presumed to limit functional
ability so as to preclude substantial gainful activity without
reference to an individual's age, education and previous work, a
combination of impairments, or an impairment closely related to one
that is in the index, would be found disabling when an individual's
functional ability is assessed. Therefore, rules for determining
equivalence for impairments in the index will not be necessary.
Step 4--Ability to Engage in Any Substantial Gainful Activity
The majority of disability claims will be evaluated using a
standardized approach to measuring functional ability to perform
substantial gainful activity. This standardized approach will
realistically measure an individual's functional ability to do the
principal dimensions of work and task performance. The approach will be
known and accepted in the medical community. It will be universally
used by public and private disability programs in which benefits are
based on the ability to perform work-related duties. Standardizing the
approach to assessing individual functional ability will facilitate
consistent decisions regardless of the professional training of the
decisionmakers in the disability process.
In using a standardized approach to measuring functional ability,
SSA will be assessing the individual's physical and mental abilities to
perform work-related activities. Individualized assessments of
functional ability will also consider the effects of the individual's
education. Once the individualized assessment of functional ability is
made, the individual's age will determine whether his or her functional
ability is compared against the demands of the individual's previous
work or against a ``baseline'' of occupational demands. The baseline
will describe a range of work-related functions that represent work
that exists in significant numbers in the national economy that does
not require prior skills or formal job training.
Standardized Measure of Functional Ability
SSA will develop, with the assistance of the medical and advocacy
community and other outside experts from public and private disability
programs, standardized instruments or protocols which can be used to
measure an individual's functional ability. These standardized measures
of functional ability will be linked to clinical and laboratory
findings to the extent that SSA needs to document the existence of a
medically determinable impairment or combination of impairments.
However, extensive development of all available clinical and laboratory
findings will not always be necessary in evaluating an individual's
functional ability to perform basic work activities.
Functional assessment instruments will be designed to measure, as
objectively as possible, an individuals abilities to perform a baseline
of occupational demands that includes the principal dimensions of work
and task performance, including primary physical, psychological, and
cognitive processes. Examples of task performance include, but are not
limited to: physical capabilities, such as sitting, standing, walking,
lifting, pushing, pulling; mental capabilities, such as understanding,
carrying out, and remembering simple instructions; using judgment;
responding appropriately to supervisors and co-workers in usual work
situations; and responding appropriately to changes in the routine work
setting; and postural and environmental limitations. To the extent that
current regulations already set forth guidelines for evaluating an
individual's ability to perform certain of these tasks, they will be
utilized in the new process.
Functional assessment instruments will be designed to realistically
assess an individuals abilities to perform a baseline of occupational
demands. To the extent possible, objective measures of function will be
developed. However, a realistic and individualized assessment of
function may require, in addition to objective measures of function, a
standardized means or standardized tools for collecting information
regarding an individuals perceptions of his or her functioning, the
effect of symptoms, including pain, and the individuals activities of
daily living. Functional assessment instruments may also require
impairment-specific measures to account for the episodic nature of
certain impairments or to meet a more general need for longitudinal
information.
SSA will be primarily responsible for documenting functional
ability using the standardized functional assessments. In the near
term, SSA will solicit information on which to base a functional
assessment from treating medical sources, other nonmedical sources, and
from claimants in a manner that is similar to the current process. In
the future, the standardized functional assessments will be widely
available and accepted so that functional assessments may be performed
by a variety of medical sources, including treating sources. The SSA
goal will be to develop functional assessment instruments that are
standardized, that accurately measure an individuals functional
abilities and that are universally accepted by the public, the advocacy
community, and health care professionals. Ultimately, documenting
functional ability will become the routine practice of physicians and
other health care professionals, such that a functional assessment with
history and descriptive medical findings will become an accepted
component of a standard medical report.
Disability insurance payers have incentives to participate in the
research necessary to develop standardized functional assessments and
some private insurers have already expressed interest in working with
SSA in this effort. Standardized functional assessments will not only
provide SSA with the functional information necessary to make
disability decisions; functional measurements will also assist in
developing provider reimbursement levels relating to rehabilitation and
in assuring quality in rehabilitation programs by permitting assessment
of the relationship between rehabilitative interventions and outcomes.
Ultimately, the use of the same functional assessment measurements by
both SSA and medical insurance payers will facilitate the cooperation
and participation of the medical community in developing, refining, and
implementing them.
Baseline Occupational Demands
SSA will use the results of the standardized functional assessment
in conjunction with a new standard that SSA will develop to describe
basic physical and mental demands of a baseline of work that represents
substantial gainful activity and that exists in significant numbers in
the national economy.
To develop the new approach, SSA will conduct research and will
work in conjunction with outside experts and consumers to specifically
identify the activities that comprise a baseline of occupational
demands needed to perform substantial gainful activity. The baseline
will describe a range of work-related functions that represent work
that exists in significant numbers in the national economy. In
establishing the work-related functions that comprise an appropriate
baseline of occupational demands, SSA will ensure that: 1) the
functional activities are a realistic reflection of the demands of
occupations that exist in significant numbers in the national economy;
and 2) the occupations are those that can be performed in the absence
of prior skills or formal job training.
The Department of Labors Advisory Panel for the Dictionary of
Occupational Titles (DOT) has made recommendations for developing a new
DOT by 1996 which will be a data base system that collects, produces,
and maintains accurate, reliable, and valid information on all
occupations in the national economy. This new system will provide
comprehensive occupational data that includes, but is not limited to:
physical demands of work; sensory/perceptual requirements; cognitive
job demands; physical working conditions; and job characteristics such
as pace or intensity of work, and the scope of interactions with
others. The development of a national data base with detailed
occupational information should assist SSA in conducting the initial
research necessary to identify a baseline of occupational demands that
represents work existing in significant numbers in the national
economy. It should also provide a mechanism to ensure that the baseline
of occupational demands remains current and reflects changes in the
national economy over time.
Effect of Education
The statute recognizes that education may play a role in an
individual's ability to perform substantial gainful activity.
Experience demonstrates that educational level alone, i.e., the
numerical grade level that an individual has attained, may not be a
good indicator of ability to function. For example, completion of a
certain educational level in the remote past, without any practical
application of that education in recent work activity, has no positive
effect on an individual's ability to perform substantial gainful
activity. Similarly, completion of a certain grade level does not
necessarily represent mastery of the subject matter.
In relying on standardized functional assessments, SSA will be
measuring an individual's ability to perform the principal dimensions
of work and task performance, including primary physical,
psychological, and cognitive processes, and the positive effects of
education will be appropriately reflected in the assessment of an
individual's cognitive abilities. Thus, evaluation of a claimant's
educational level will be done as an integral part of establishing the
functional ability of that individual. The baseline of occupational
demands will not reference prior skills or significant formal job
training.
The issue of whether literacy and/or specific communication or
language skills will be a factor in disability evaluation depends on
the extent to which such skills are occupational demands of work
existing in significant numbers in the national economy. In conducting
the necessary research to identify the occupational demands of baseline
work that represents work existing in significant numbers in the
national economy, SSA will need to consider whether literacy or
specific communication and language skills are required as occupational
demands.
Effect of Age
The effect of aging on the ability to perform substantial gainful
work is very difficult to measure, especially in the context of today's
world when individuals are living longer than preceding generations.
Despite this change, the demographic characteristics of those preceding
generations continue to provide the framework for disability
decisionmaking because SSA's approach for deciding disability has
changed little since the inception of the DI program.
The statute recognizes that age should be considered in assessing
disability on the assumption that the ability to make a vocational
adjustment to work other than work an individual has previously done
may become more difficult with age. In determining the impact of age,
recognition should be given to the changes that occur with each
succeeding generation. Accordingly, in the new process, SSA will
establish an age criterion in relation to the full retirement age. The
full retirement age will gradually increase over time, based on the
recognition that succeeding generations can expect to remain in the
workforce for longer periods than the preceding generation.
In applying age criterion under the new process, an individual who
falls within the prescribed number of years preceding the full
retirement age will be considered as nearing full retirement age.'' In
establishing what the prescribed number of years should be, SSA will
conduct research and consult with outside experts on the relationship
between age and an individual's ability to make vocational adjustments
to work other than work the individual has done in the recent past.
SSA will rely on the age of the individual in relation to the full
retirement age to decide which of two decision paths to follow as
described in the next two sections.
Individuals Not Nearing Full Retirement Age
For an individual who is not nearing full retirement age, SSA will
compare the individual's functional abilities against the functional
demands of the baseline work. The ability to perform the baseline work
will represent a realistic opportunity to perform substantial gainful
activity that exists in significant numbers in the national economy and
a finding of disability will not be appropriate.
However, anyone who cannot perform the baseline work will be
considered unable to engage in substantial gainful activity, and a
finding of disability will be justified. The range of work represented
by less than the baseline will be considered so narrow that despite any
other favorable factors, such as young age or higher education or
training, an individual would not be expected to have a realistic
opportunity to perform substantial gainful work in the national
economy.
For individuals who are not nearing full retirement age, the
ability or inability to perform previous work is not a significant
factor. These individuals should be capable of making a vocational
adjustment to other work, as long as they are functionally capable of
performing the baseline work.
Individuals Nearing Full Retirement Age
For individuals who are nearing full retirement age, SSA will
compare the individuals functional abilities against the functional
demands of the individuals previous work. Individuals nearing full
retirement age can not be expected to make a vocational adjustment to
work other than work they have performed in the recent past. However,
consistent with the statute, if an individual, even one nearing full
retirement age, is capable of performing his or her previous work, SSA
will find that the individual is not disabled.
For those individuals who have no previous work, SSA will compare
the individuals functional ability to the range of work-related
functions that represent work that exists in significant numbers in the
national economy, i.e., baseline work, and a finding of not disabled
will be appropriate if the individual is capable of performing the
baseline work. In such claims, when the fact that the individual has no
previous work is not related to the existence of his or her
impairment(s), a finding of disability will not be appropriate if the
individual retains the functional ability to perform a range of work-
related functions that represent work that exists in significant
numbers in the national economy. In contrast, those individuals who
have significant functional limitations caused by a medically
determinable impairment and lack of education would not be able to
perform a range of work-related functions that represent work existing
in significant numbers in the economy. Such individuals would be found
disabled, as they are today.
Medical Consultant Expertise
SSA will continue to rely on medical consultants to provide expert
advice and opinion regarding medical questions and issues that will
arise in deciding disability claims. Disability adjudicators at all
levels of the administrative review process will call on the services
of medical consultants to interpret medical evidence, analyze specific
medical questions, and provide expert opinions on existence, severity
and functional consequences of medically determinable impairments.
Additionally, on a national basis, SSA may identify specific types of
issues that may require a medical opinion. If a medical consultant is
called on to offer expert advice and opinion, the medical consultant
will provide a written analysis of the issues and rationale in support
of his or her opinion. The written analysis will be included in the
record and will be considered with the other medical evidence of record
by disability adjudicators at all levels of administrative review.
Additionally, medical consultants will assist in the training of other
consultants and disability adjudicators; contact other health care
professionals to resolve medical questions on specific claims; carry
out public relations and training with the medical community; and
participate in the quality assurance program.
Childhood Disability Methodology
As with adults, SSA must have a structured approach to disability
decisionmaking in childhood claims that takes into consideration the
relatively large number of claims and still provides a basis for
consistent, equitable decisionmaking by adjudicators at all levels of
administrative review. The approach for childhood claims must also
derive from the statute. Under the statute, ``an individual will be
considered to be disabled for purposes of this title if he is unable to
engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment 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 (or in the case of a child
under the age of 18, if he suffers from any medically determinable
physical or mental impairment of comparable severity).''
Sec. 1614(a)(3)(A) of the Social Security Act)
Of course, any decision approach for childhood claims must be
consistent with the Supreme Courts interpretation of this statutory
language in Sullivan v. Zebley, 493 U.S. 521 (1990).
Four-Step Evaluation Process for Children
The disability decision methodology for childhood claims will
consist of four steps that are based on the statutory definition of
disability. As with adults, the approach is one that provides accurate
decisions that can be achieved efficiently and cost-effectively,
primarily by ensuring that documentation requirements are directed
toward the ultimate finding of disability. To the extent possible, the
approach for childhood claims should mirror the adult approach. The
four steps are:
Step 1--Is the child engaging in substantial gainful activity?
If yes, deny.
If no, continue to Step 2.
Step 2--Does the child have a medically determinable physical or
mental impairment?
If no, deny.
If yes, continue to Step 3.*
Step 3--Does the child have an impairment that is included in the
Index of Disabling Impairments?
If yes, allow.*
If no, continue to Step 4.
Step 4--Does the child have an impairment(s) of comparable severity
to an impairment(s) that would prevent an adult from engaging in
substantial gainful activity?
If yes, allow.*
If no, deny.
*An impairment must meet the duration requirement of the
statute; a denial is appropriate for any impairment that will not be
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
Any child who is engaging in substantial gainful activity will not
be found disabled regardless of the severity of his or her physical or
mental impairments. The guidelines for determining whether a child is
engaging in substantial gainful activity will be identical to the
guidelines for adults. Although the issue of work activity will arise
infrequently in childhood claims, the step is warranted for two
reasons: 1) the approach for adults and children should be as similar
as possible; and 2) as a child approaches age 18, it is increasingly
likely that work activity may be an issue.
Step 2--Medically Determinable Impairment
Because the statute requires that disability be the result of a
medically determinable physical or mental impairment or combination of
impairments, the absence of a medically determinable impairment will
justify a finding that a child is not disabled. To establish the
presence of a medically determinable impairment or combination of
impairments, evidence must show an impairment that results from
anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
The same guidelines and rules that apply for adults will apply
equally for children. SSA will continue to evaluate the existence of a
medically determinable impairment based on a weighing of all evidence
that is collected, recognizing that neither symptoms nor opinions of
treating physicians alone will support a finding of disability.
SSA will use the same exception for evidence collection in
childhood claims that will be applied in adult claims. If a child has a
medically determinable physical or mental impairment that is not an
exception to further development, SSA will then evaluate whether the
impairment(s) is included in the index of disabling impairments.
Step 3--Index of Disabling Impairments
If a child has a medically determinable physical or mental
impairment or combination of impairments documented by medically
acceptable clinical and laboratory techniques and the impairment(s)
will meet the duration requirement, SSA will compare the child's
impairment(s) against an index of disabling impairments.
As with adults, the index for childhood claims will function to
quickly identify severely disabling impairments. The index will
describe impairments so severely debilitating that the impairment is of
comparable severity to an impairment that would prevent an adult from
engaging in substantial gainful activity without assessing the child's
functional ability. As with adults, individual functional ability in
childhood claims will be assessed in a consistent manner at Step 4 in
the process.
The index for childhood claims will consist of descriptions of
specific impairments and the medical findings that are used to
substantiate the existence and severity of the particular disease
entity. The medical findings in the index will be as nontechnical as
possible and will be simple enough so that laypersons will be able to
understand what is required to substantiate a disabling impairment in
the index. As with adults, SSA will draw no conclusions about the
effect of a child's impairments on his or her ability to function
merely because a child's impairment(s) is not included in the index.
Additionally, SSA will no longer use the concept of ``medical
equivalence'' or functional equivalence in relation to the childhood
index.
Step 4--Comparable Severity to an Impairment(s) That Would Prevent an
Adult From Engaging in Substantial Gainful Activity
Consistent with the approach for adult claims, SSA will develop,
with the assistance of the medical community and educational experts,
standardized instruments which can be used to measure a child's
functional ability. These standardized measures of functional ability
will be linked to clinical and laboratory findings to the extent that
SSA needs to document the existence of a medically determinable
impairment or combination of impairments. The functional assessment
instruments will be designed to measure, as objectively as possible, a
child's ability to function independently, appropriately, and
effectively in an age-appropriate manner. Ultimately, the course of
documenting and developing for functional abilities in childhood claims
will, to the extent possible, mirror the adult approach. However, SSA
will consider whether it is appropriate to defer the development of
standardized functional assessment instruments for use in childhood
claims until it gains experience in the development, refinement and use
of such instruments for adults.
SSA will use the results of the standardized functional assessments
to determine whether a child has impairment(s) of comparable severity
to an impairment(s) that would prevent an adult from engaging in
substantial gainful activity, as in the current process.
Medical Evidence Development
Timely and Accurate Decisions
SSA's ability to provide timely and accurate disability decisions
depends to a significant degree on the quality of medical evidence it
can obtain and the speed with which it can obtain it. The medical
evidence collection process accounts for a considerable portion of the
total time involved in processing disability claims.
The new process will eliminate multiple, repetitive requests for
information from health care providers. Health care providers will be
relieved of requests for information that burden them with far too much
paperwork and will be compensated for the time invested in providing
information.
Core Diagnostic and Functional Information Focus
The goals of the evidence collection process will be to focus
requests for evidence on the critical diagnostic and functional
assessment information necessary for a disability decision and to form
a new partnership with the sources of this information so that it can
be obtained in the most efficient, cost-effective manner. Medical
evidence development will be driven by the four-step approach used to
decide disability. Two of the core elements of that approach are: (1)
identifying an individual's medically determinable impairments
(including those that meet the Index of Disabling Impairments
criteria); and (2) assessing the functional consequences of those
impairments. The decisionmaker will develop medical evidence that is
sufficient to satisfy the core elements but target evidentiary
development to obtain only the evidence necessary to reach an accurate
decision on the ultimate question of disability.
Treating Source Preference
SSA will give primary emphasis to obtaining medical information
from treating sources that provides brief, but specific, diagnostic
information regarding an individual's medically determinable
impairments and the functional consequences of those impairments.
Treating source statements will include diagnostic information about a
claimant's impairments, the clinical and laboratory findings which
provide the basis for the diagnosis, onset and duration, response to
treatment, and the functional limitations that can reasonably be linked
to the clinical and laboratory findings. Depending on the nature and
extent of an individual's impairments and treating sources, statements
from multiple medical sources may be appropriate. Once the standardized
measurement criteria described earlier are widely available, a
standardized functional assessment available from a treating source
will be accepted as probative evidence. Treating sources or another
examining source may perform the standardized functional assessment at
SSA's expense.
Standardized Request Form
SSA will develop a standardized form which effectively tailors a
request for evidence to the specific diagnostic and functional
assessment information necessary to make a disability decision. Such
information includes but is not limited to diagnostic information about
a claimant's impairments, the clinical and laboratory findings which
provide the basis for the diagnosis, onset and duration, response to
treatment, and the functional limitations that can reasonably be linked
to the clinical and laboratory findings. Treating sources will be
encouraged to submit such information electronically. Standardizing
requests for evidence in this manner will facilitate the participation
of claimants, representatives and third parties in the evidence
collection process.
The form will permit treating sources to provide necessary
diagnostic and functional assessment information in summary form on a
single document. In appropriate circumstances, SSA will accept a
treating source's statements on the standardized form as to history and
diagnosis, the clinical and laboratory findings which provide the basis
for the diagnosis, onset and duration, response to treatment, and the
functional limitations that can reasonably be linked to the clinical
and laboratory findings, without resorting to the traditional,
wholesale procurement of actual medical records. In completing
standardized forms, treating sources will certify that they have in
their possession the medical documentation referred to in the statement
and that said documentation will be promptly submitted at the request
of SSA. The certification approach does not relieve treating sources
from providing objective evidence in support of their diagnoses and
opinions; rather it is designed to streamline the collection of
necessary evidence. The approach is also consistent with evidence
collection methods used by private disability insurance carriers, which
request specific medical records in individual claims, when necessary
and appropriate to the individual circumstances, or at random as part
of a quality assurance program.
Treating source completion of the standardized forms will be
monitored to prevent fraud. Decisionmakers will verify treating source
statements by obtaining underlying medical records when appropriate.
The automated claim processing system will facilitate effective
monitoring of the evidence submission practices of individual treating
sources by permitting random and/or targeted selection of claim files
involving that treating source for quality assurance and program
integrity reviews.
Treating Source Incentives
As in the current process, SSA will pay for the reasonable cost of
providing existing medical evidence. SSA will acknowledge the value of
treating source information by establishing a national fee
reimbursement schedule for medical evidence. The fee reimbursement
schedule will utilize a sliding-scale mechanism to reward the early
submission of medical information; additionally, the sliding scale will
be adjusted to reflect the quality of the evidence received. A
national, sliding-scale fee schedule will provide incentives for
treating sources to cooperate in the evidentiary development process
and invest quality time to provide medical certifications on behalf of
their patients.
SSA will provide resources to focus professional educational
efforts and medical relations outreach at the local and/or regional
level to ensure that treating sources are given up-to-date information
on program requirements and made aware of specific evidentiary needs or
problems as they arise in the adjudication process. SSA will conduct
educational outreach on the national level on an ongoing basis with the
medical community to provide a better understanding of the SSA
disability programs, the medical and functional requirements for
eligibility, and the best ways to provide medical information needed
for decisionmaking.
Consultative Examination
If a claimant has no treating source, or a treating source is
unable or unwilling to provide the necessary evidence, or there is
conflict in the evidence that can not be resolved through evidence from
treating sources, the decisionmaker will refer the claimant for an
appropriate consultative examination. Because the standardized
measurement criteria for assessing function will be widely available,
consulting sources will be able to perform functional assessments that,
in the absence of adequate treating source information or where there
are unresolved conflicts in the evidence, will be considered probative
evidence. Depending on the service area, SSA will consider contracting
with large health care providers to furnish consultative examinations
for a specified geographic location.
As part of an ongoing training and medical relations program, SSA
will ensure that providers of consultative examinations are provided
adequate training on disability requirements. Those medical providers
who conduct consultative examinations for SSA will also need ongoing
training regarding changes in the disability program. SSA will prepare
training programs for this audience which will utilize written,
audiotape, videotape, and computerized training methods.
Administrative Appeals Process
Simple, Accessible Process
To eliminate the public perception that multiple, mandatory appeal
steps are obstacles to receiving timely, fair, and accurate decisions,
SSA will reduce the number of mandatory appeals steps in the
administrative process. Streamlining the appeals process will not only
promote more timely decisions but also ensure that claimants do not
inappropriately withdraw from the claim process based on a perception
that it is too difficult or time-consuming to pursue their appeal
rights.
Claimants will be able to fully participate in the administrative
appeals process with or without a representative. SSA will ensure that
claimants are fully advised of their right to representation and SSA
will routinely provide the appropriate referral sources for
representation. SSA will also encourage the early participation of a
representative when the claimant has appointed one and will give the
representative responsibility for developing evidence necessary to
decide a claim. However, the decision whether to appoint a
representative must remain with the claimant and SSA will neither
encourage nor discourage claimants in seeking representation.
The administrative appeals process will instill public confidence
in the integrity of the system. To instill such confidence, SSA will
provide an initial decisionmaking process that is thorough and results
in fully developed records with fair and accurate decisions.
Additionally, the claimant will be given the basis of a decision in
clear and understandable language. Finally, SSA will ensure that its
policies have been consistently applied at all levels of administrative
review.
As noted previously, the initial disability determination will use
a ``statement of the claim'' approach which will set forth the issues
in the claim, the relevant facts, the evidence considered, including
any evidence or information obtained as a result of the predecision
notice, and the rationale in support of the determination. The
statement of the claim will be part of the on-line claim record and
will stand as the basis and rationale for the Agency's action, if the
claimant seeks further administrative review. SSA will standardize
claim file preparation and assembly, including the use of appropriate
electronic records, at all levels of administrative process until such
time as the claims record is fully electronic.
First Appeal Level
Because the initial determination will be the result of a process
that ensures fully developed evidentiary records and ample opportunity
for the claimant to personally present additional evidence prior to an
adverse determination, there will be no need for any intermediate
appeal (e.g., reconsideration) prior to the ALJ hearing. If the
claimant disagrees with the initial determination, the claimant may,
within 60 days of receiving notice, request an ALJ hearing.
Adjudication Officer
When a claimant requests an ALJ hearing, an adjudication officer
will conduct an interview in person, by telephone, or by
videoconference, and become the primary point of contact for the
claimant. The adjudication officer will have the same knowledge, skills
and abilities as the adjudicators who decide claims initially. The
adjudication officer will also have specialized knowledge regarding
hearings procedures. The adjudication officer will be the focal point
for all prehearing activities but will work closely with the ALJ,
medical consultants and the disability claim manager, when appropriate.
The adjudication officer will provide the claimant an in-depth
understanding of the hearing process, with particular focus on the
right to representation. To prevent delays caused by a lack of
understanding of this right, the adjudication officer will again
provide the appropriate referral sources for representation; give the
claimant, where appropriate, copies of necessary claim file documents
to facilitate the appointment of a representative; and encourage the
claimant to decide about the need for and choice of a representative as
soon as is practical. The adjudication officer will be available to
answer the claimant's questions and concerns regarding the hearing
process.
The adjudication officer will also identify the issues in dispute
and whether there is a need for additional evidence. If the claimant
has a representative, the representative will have the responsibility
to develop evidence. If the claimant has a representative, the
adjudication officer will also conduct informal conferences with the
representative, in person or by telephone, to identify the issues in
dispute and prepare written stipulations as to those issues not in
dispute. If the claimant submits additional evidence, the adjudication
officer may refer the claim for further medical consultation and
opinion, as appropriate.
The adjudication officer will have full authority to issue a
revised favorable decision if the evidence so warrants. This will
ensure that allowance decisions are expedited and not delayed until a
formal hearing before an ALJ. If the adjudication officer issues a
favorable decision, the adjudication officer will refer the claim to a
disability claim manager to effectuate payment.
The adjudication officer will consult with the ALJ during the
course of prehearing activities, as necessary and appropriate to the
circumstances in the claim. As a preliminary matter, the adjudication
officer will also routinely schedule a date for the hearing that is a
standard number of days after the hearing request. Standardizing the
hearing date process will facilitate claimant understanding and reduce
the possibility of non-appearance at the hearing. It will also enable
representatives to plan their schedules when taking on a case. The
adjudication officer may exercise discretion in establishing an earlier
or later hearing date depending on the individual circumstances and the
ALJ's calendar. Electronic access to ALJs' calendars, as established by
individual ALJs, will facilitate timely and appropriate scheduling of
hearings. The adjudication officer will refer the prepared record to an
ALJ only after all evidentiary development is complete and the claimant
or a representative agrees that the claim is ready to be heard.
The ALJ will retain the authority and ability to develop the
record. However, use of an adjudication officer realigns most, if not
all, prehearing activities so that the burden of ensuring their
completion rests with other members of the adjudicative team. With
completely developed claims before them, ALJs will be able to
concentrate their efforts on conducting more hearings and rendering
decisions faster.
Hearing Proceedings
The ALJ hearing will be a de novo proceeding in which the ALJ
considers and weighs the evidence and reaches a new decision. A de novo
hearing is consistent with the role of an ALJ envisioned under the
Administrative Procedure Act. Under that scheme, the ALJ is an
independent decisionmaker who must apply an agency's governing statute,
regulations and policies, but who is not subject to advance direction
and control by the agency with respect to the decisional outcome in any
individual claim. ALJs are independent triers of fact who perform their
evidentiary factfinding function free from agency influence. At the
same time, the Administrative Procedure Act ensures that an ALJ's
decision is subject to later review by the agency, thus giving the
agency full authority over policy. Policy responsibility remains
exclusively with the agency while the public has assurance that the
facts are found by an official who is not subject to agency influence.
A hearing before an ALJ will remain an informal adjudicatory
proceeding as it is under the current process. The claimant will have
the right to be represented by an attorney or a non-attorney with the
decision regarding representation made by the claimant alone. An
informal, nonadversarial proceeding is consistent with the public's
strong preference for a simple, accessible hearing process that
permits, but does not require, a representative. An informal process
facilitates the earlier and faster resolution of the issues in dispute,
thus promoting more timely decisions.
As an independent factfinder in a nonadversarial proceeding, the
ALJ will still have a role in protecting both SSA interests and the
claimants interests, particularly when the claimant is unrepresented.
However, an improved initial determination process with its focus on
early and comprehensive evidentiary development, predecision notices
and opportunity for personal interviews, fully rationalized initial
decisions, and prehearing analysis of contested issues should ensure
that the Agency position is fully explored and presented to the ALJ.
Moreover, the primary burden of compiling an evidentiary record will be
shifted to the representative--if one is appointed--or to the claimant
(when able to do so), with assistance (when necessary) from SSA
personnel. This will permit the ALJ, in most circumstances, to close
the record at the conclusion of the oral hearing, deliberate on the
issues, and render prompt decisions.
In making disability decisions, ALJs will rely on the same
standards for decisionmaking that are used by the disability claim
managers and adjudication officers. Adjudication officers and other
decision writers will assist ALJs in preparing hearing decisions, using
the same decision support system that supports the preparation of
initial disability determinations. A simplified disability decisional
methodology, in conjunction with the use of prehearing stipulations
that frame the issues in dispute, will result in shorter, more focused
hearing decisions. If the ALJ issues a favorable decision, he or she
will refer the claim to a disability claim manager to effectuate
payment.
Final Decision of the Secretary
Under the new process, if a claimant is dissatisfied with the ALJ's
decision, the claimant's next level of appeal will be to Federal
district court. A claimant's request for Appeals Council review will no
longer be a prerequisite to seeking judicial review.
As under the current process, the Appeals Council will continue to
have a role in ensuring that claims subject to judicial review have
properly prepared records and that the Federal courts only consider
claims where appellate review is warranted. Accordingly, the Appeals
Council, working with Agency counsel, will evaluate all claims in which
a civil action has been filed and decide, within a fixed time limit
whether it wishes to defend the ALJ's decision as the final decision of
the Secretary. If the Appeals Council reviews a claim on its own
motion, it will seek voluntary remand from the court for the purpose of
affirming, reversing or remanding the ALJ's decision. The Secretary's
authority for seeking voluntary remand prior to the Secretary's filing
of an answer to the civil action is currently provided for in
Sec. 205(g) of the Act. Favorable Appeals Council decisions will be
returned to the disability claim manager to effectuate payment. The
number of civil actions requiring substantive action by the Appeals
Council will be relatively small because, in the new process, ALJ
decisions will be the result of a fully developed evidentiary record
where the factual and legal issues have been focused for final
resolution.
Additionally, the Appeals Council will have a role in a
comprehensive quality assurance system. As part of the in-line review
component of this system, which is described in greater detail below,
the Appeals Council will conduct its own motion reviews of ALJ
decisions (both allowances and denials) and dismissals prior to
effectuation. If the Appeals Council decides to review a claim on its
own motion, the Appeals Council may affirm, reverse or remand the ALJ's
decision, or vacate the dismissal. The Appeals Council's review will be
limited to the record that was before the ALJ.
The Agency will establish appropriate mechanisms to respond to
claimant allegations of ALJ misconduct or bias. To the extent that the
allegations of ALJ misconduct may affect the final decision in a claim,
the Agency will consider whether an appropriate mechanism includes some
form of final Agency review at the claimant's request.
Quality Assurance
System of Agency Accountability
SSA will be accountable to the public, the ultimate judge of the
quality of SSA service, and will strive to consistently meet or exceed
the public's expectations. SSA will have a comprehensive quality
assurance program that defines its quality standards, continually
communicates them to employees in a clear and consistent manner, and
provides employees with the means to achieve them.
The quality assurance program will have three primary components:
1) substantial resources to ensure that the right decision is made the
first time; 2) comprehensive and systematic reviews of the quality of
the decisionmaking process at all levels; and 3) measures of customer
satisfaction against the SSA standards for service.
Investment in Employees
SSA's ability to ensure that the right decision is made the first
time depends on a well-trained, skilled, and highly motivated workforce
that has the program tools and technological support to issue quality
decisions.
SSA will make an investment in comprehensive employee training to
ensure that all employees have the necessary knowledge and skills to
perform the duties of their positions. SSA will develop national
training programs for initial job training and orientation as well as
continuing education to maintain job knowledge and skills. Such
training will include general communication skills and how to deal
effectively with the public generally, and disability claimants in
particular. National training programs will also address changes to
program policy. Consistent program policy training will be provided to
disability decisionmakers at all levels of the process.
In addition to initial program training, continuing education
opportunities will be made available to employees to enhance current
performance or career development. These opportunities may be in the
form of self-help instruction packages, videotapes, satellite
broadcasts, or non-SSA training or educational opportunities. SSA will
ensure that employees are given sufficient time and opportunity to
complete the required continuing education. Employee feedback on the
value of these continuing education opportunities, including the
quality of training materials, methods, and instructors, will be used
to continually improve training programs.
In addition to formal program training, SSA will rely on a targeted
system of in-line quality reviews and monitoring of adjudicative
practices for all employees. The elements include a mentoring process
for new employees, peer review for experienced employees and management
oversight at key points in the adjudicative process. SSA will create
mechanisms that facilitate peer discussions of difficult claims or
issues. Quality reviewers and policy makers will participate in these
types of discussions. Peer reviews and mentoring will not only promote
timely and accurate development of disability claims, but will also
foster a spirit of teamwork. They will also promote earlier
identification and resolution of problems with policy or procedures.
Managers will be expected to oversee the adjudication process. They
will conduct spot checks at key points in the adjudication process or
perform special reviews based on profiles of error-prone claims. The
goal of these reviews is to provide immediate, constructive feedback on
identified errors to reduce or eliminate their possible recurrence.
Payment errors on claims detected during in-line reviews will be
corrected before a claimant is notified of the decision.
As noted previously, under the Administrative Procedure Act, the
ALJ is an independent decisionmaker who must apply an agency's
governing statute, regulations and policies, but who is not subject to
advance direction and control by the agency with respect to the
decisional outcome in any individual claim. Accordingly, a system of
peer review, mentoring and management oversight in advance of the ALJ's
decisionmaking is inappropriate. However, the ALJ decision may be
subject to final agency review. Therefore, as part of the in-line
quality assurance process, ALJ decisions (both allowances and denials)
and dismissals will be subject to review by the Appeals Council on its
own motion prior to effectuation of the ALJ's decision or dismissal.
Several key features previously described in this plan are critical
to ensuring that adjudicators have the necessary program tools to issue
accurate decisions. A single presentation of all substantive policies
used in determining eligibility for benefits must be in place.
Additionally, an automated and integrated claim processing system will
provide the necessary technological support for adjudicators at all
levels of the administrative process. Expert systems will be developed
to integrate disability policy into the claim processing system. Among
other things, the claim processing system will facilitate claims
taking, evidence development, and the preparation of accurate notices
and decisions by providing on-line editing capacity to identify errors
in advance and decision support software to assist in analysis and
decisionmaking. The processing system will help to identify errors of
both procedure and substance, and also support routine analysis to aid
in avoiding future similar errors. An on-line technical review will
occur each time information is added to the electronic record.
Comprehensive employee education and an in-line review system will
build quality into the system of adjudication with the goal of error
prevention. SSA must monitor that quality on a systematic, national
basis. Accordingly, all employees (including ALJs) will be subject to
and receive continuous feedback from comprehensive end-of-line reviews
as described in the following section.
End-of-Line Reviews
A second necessary component of quality assurance is an integrated
system of national postadjudicative monitoring to ensure the integrity
of the administrative process and to promote national uniformity in the
adjudication of disability claims at all levels of the process. This
system of quality measurement will include comprehensive reviews of the
whole adjudicatory process. At a minimum, a comprehensive end-of-line
quality measurement system must: be statistically valid; review both
allowances and denials in equal proportion; review the entire
disability claim process, both the medical and nonmedical aspects; and
review claims decided at all levels of the adjudicatory process.
These end-of-line reviews will focus on whether correct decisions
were made at the earliest possible point in the process. This type of
review will not be aimed at correcting errors in individual claims but,
rather, will be the means to oversee, monitor and provide feedback on
the application of Agency policies at all levels of decisionmaking.
However, erroneous decisions detected during end-of-line reviews will
be subject to existing reopening regulations. Reliance on an integrated
claim processing system will facilitate the selection of a
statistically valid sample of claims at all levels of the process for
this review.
An integrated claim processing system will permit the selection of
other postadjudicative samples of claims as SSA deems necessary to
effectively test new operational procedures or monitor specific
procedures in the administrative process; oversee the implementation of
new program policy regulations and initiatives; and monitor both
internal and external claims development practices to prevent fraud.
SSA will use the results from these end-of-line reviews to identify
areas for improvement in policies, processes or employee education and
training. SSA will also use the results to profile error-prone claims
with the goal of preventing errors at the front end.
Customer Satisfaction Surveys
A final component of quality assurance is measuring customer
satisfaction. To measure whether SSA has met or exceeded the public's
service expectations, SSA must measure the public's level of
satisfaction with the level of service SSA provides. Customer surveys
(including feedback cards) and periodic focus groups will be the most
frequently used methods of determining the public's views on the
quality of SSA service. SSA will also survey representatives and third
parties who provide assistance or act on claimants' behalf in dealing
with SSA. Survey results will be communicated to staff on a timely
basis, both as Agency feedback and individual feedback, along with any
plans to address identified problems.
SSA will also seek employee feedback on how well SSA has met their
expectations. Employee feedback will be sought on a wide array of
issues including Agency goals and performance indicators, training and
mentoring needs, and the quality of operating instructions. Although
formal mechanisms will be used to obtain feedback periodically, each
employee will be encouraged to provide continuous feedback on how to
make improvements in the process.
Measurements and Management Information
Service Perspective
SSA's measures of performances will be revised to assess the
performance of the Agency as a whole in providing service to claimants
for disability benefits. Management information regarding the
contributions at each step in the process to the final product, as well
as to the work product passed on to other steps will be available. For
example, current component processing time measures will be replaced by
a measure of time from the first point of contact with SSA until final
claimant notification. Meaningful, timely management information will
be facilitated by a seamless claim processing system with a common
database that is used by all individuals who contribute to each step in
the process.
Other measures, such as cost, productivity, pending workload, and
accuracy will be developed or revised to assess the performance of the
Agency as a whole and the participants in the process who contribute to
this performance. Measurements for public awareness, as well as
claimant and employee satisfaction, will add to this assessment.
Management information will be current and accessible from an
intelligent workstation. In addition to routine, published national
reports generated from the management information system, other reports
needed by national or local entities, or individual employees will be
preformatted and system-generated on demand. Managers and employees
will have the flexibility to change parameters and to access the full
data base, permitting comparisons of performance and trends analysis.
The management information system will also permit customized, ad hoc
reports for special studies or immediate special purpose activities
with access to the full data base. Tools including user-friendly report
generator software and statistical forecasting and modeling
applications will be available on the intelligent workstation to assist
users in the data analysis.
New Process Enablers
Reengineering is dependent on a number of key factors that provide
the framework for the new process design. Each of these ``enablers'' is
an essential element in the new disability process.
Process Unification
Under the Social Security Act, the Secretary is granted broad
authority to promulgate regulations to govern the disability
determination process. In addition to regulations, SSA publishes: 1)
Social Security Rulings, which are precedential court decisions and
policy statements or interpretations that SSA has adopted as binding
policy, and 2) Acquiescence Rulings, which explain how a decision by a
U.S. Court of Appeals will be applied when the court's holding is at
variance with the Agency's interpretation of a provision of the statute
or regulations. ALJs and the Appeals Council rely on the regulations
and rulings in making disability decisions. However, guidance for
decisionmakers at the initial and reconsideration levels is provided in
a series of administrative publications, including: 1) the Program
Operations Manual System instructions which provide the substance of
the statute, regulations, and rulings in a structured format and 2)
other administrative issuances which clarify or elaborate specific
policy issues. The use of different source documents by adjudicators
fosters the perception that different policy standards are being
applied at different levels of decisionmaking in the disability claim
process.
To ensure that SSA provides consistent direction to all
adjudicators regarding the standards for decisionmaking, SSA will
develop a single presentation of all substantive policies used in the
determination of eligibility for benefits. These policies will be
published in accordance with the Administrative Procedures Act and all
decisionmakers will be bound by these same policies.
Public and Professional Education
Public and professional education is essential to ensure that
individuals and other groups involved in the disability process have a
proper understanding of SSA disability programs, their medical and
nonmedical requirements, and the nature of the decisionmaking process.
SSA will make information widely available for the general
population with the goal of reducing general inquiries from members of
the public unfamiliar with SSA disability programs and increasing the
number of claimants who enter the disability process knowledgeable and
prepared to assume responsibility for pursuing their claims. Pamphlets,
factsheets, posters, videos, information on diskettes and on computer
bulletin board systems will be developed and presented in a simple,
straightforward and understandable manner. Information will be
available in many languages and dialects and will accommodate vision
and hearing impaired individuals.
SSA will work with national and local groups involved in the
disability programs to develop direct lines of communications. These
efforts will be aimed not only at providing information but also at
creating ongoing organizational relationships to maintain a dialogue
about the disability process.
SSA will also conduct educational outreach with the medical
community to provide them with a better understanding of the SSA
disability programs, the medical and functional requirements for
eligibility, and the best ways to provide medical information needed
for decisionmaking. In addition to the use of printed materials, SSA
will arrange briefings and training sessions in association with
medical organizations and societies at the local, State and national
levels, as well as through hospital staff meetings. Those medical
providers who conduct consultative examinations for SSA will need
ongoing training regarding changes in the disability program. SSA will
prepare training programs for this audience which will utilize written,
audiotape, videotape, and computerized training methods.
SSA will conduct outreach efforts with the legal community, to
ensure that information about the disability programs is widely
available to the organized bar and the Federal judiciary. Policy
documents, regularly updated electronically, and rules of
representation will be available at forums sponsored by the organized
bar and in initial orientation and continuing legal education programs
designed for Federal judges.
Claimant Partnership
SSA's interaction with claimants will focus on enabling their
participation in the process. SSA will also work with third parties,
such as family members and community-based organizations, to provide
additional claimant support.
Understandable public information materials and comprehensive
information packets will be widely available. Explanations of the
programs, the decisionmaking process, and claimant responsibilities
will be widely available and furnished at the point individuals first
make contact with SSA. Claimants, who are able to do so, will be asked
to do more to facilitate development of supporting information,
particularly with respect to medical evidence. To encourage the release
of evidence by treating medical sources, SSA will network with the
treating source community to overcome the lack of understanding and
possible resistance to providing patient information. SSA will
encourage private insurers and public agencies that refer claimants to
SSA as a condition of receiving other benefits to provide medical
evidence for these individuals.
SSA will develop ongoing relationships with community organizations
to ensure that competent third-party resources are available to assist
the claimants. Examples of resources that SSA will help develop
include: transportation and escort services for indigent claimants and
those who experience difficulty in getting to consultative
examinations; enhancement of medical provider capacity to identify
potentially eligible patients, secure claims and provide medical
evidence; and software with compatible format design which will allow
direct input of claim-related information to SSA. SSA will have an
ongoing demonstration program that provides funds for truly innovative
projects that test models for national implementation.
In order to expedite the referral of potentially eligible
individuals, SSA will develop productive working relationships with
Federal, State and local programs that serve individuals with
disabilities. Other programs will be able to use SSA-developed
decisional support systems to evaluate potentially eligible persons
prior to referral and to transfer information to SSA through compatible
databases. Local managers will be encouraged to develop and maintain
appropriate working relationships with local Federal, State and third-
party resources.
Active participation by claimants, supported by SSA's efforts and
the contributions of third parties will result in a fundamental shift
in claimant expectations and satisfaction with the SSA disability
process. From the SSA perspective, the results will be better service
to customers through timely, fully supported decisions rendered at all
decisional levels; better use of SSA resources focused on helping those
who need assistance; and greater public confidence in the disability
adjudication process.
Workforce Maximization
Teamwork and workforce empowerment are fundamental ingredients in
the new process. In carrying out their duties and responsibilities,
adjudicators will work in a team environment with internal medical and
nonmedical experts, who provide advice and assistance for complex case
adjudication, as well as with technical and other clerical personnel
who may handle more routine aspects of case development and payment
effectuation. The disability claim manager will be the focal point at
the initial claim level, assisted by technical and medical support
staff. The adjudication officer will be the focal point at the
prehearing level, relying on technical and medical support staff, as
well as interacting with the disability claim manager and the ALJ, as
necessary. The ALJ will be the focal point at the hearing level,
receiving support from technical and medical support staff, and also
interacting with the adjudication officer and disability claim manager,
as necessary.
Each team member will have at least a basic familiarity with all
the steps in the process and an understanding of how he/she complements
another's efforts. Team members will be knowledgeable but will also be
able to draw upon each other's expertise on complex issues.
Communication among team members will encourage consistent application
of disability policy. Improved automated systems will enable members of
the team to work together using a shared data base even when they are
not co-located. Handoffs, rework, and non-value steps will be
significantly reduced and fewer employees will be involved in
shepherding each claim through the process.
Employees will perform multiple tasks instead of singular
activities, thus their roles will expand to encompass more of the
``whole'' job. This will enable employees to experience the direct
relationship between their actions and the final product. Adequate
resources and sufficient training and mentoring will allow employees to
acquire the skills they need to process claims from intake through
adjudication. Employees will feel more of a sense of ownership for the
services they perform as a member of a team focused on serving
claimants.
The new process will rely heavily on increased employee
empowerment, applying information technology and using professional
judgment to complete tasks more effectively and efficiently without
constant checking, direction and micro-management. Recognition and
reward processes will be revised to emphasize contributions to team
outcomes and acquisition of knowledge bases. Continuous quality
improvement activities will foster ongoing incremental process change.
Representatives: New Rules and Standards of Conduct
The Social Security Act and regulations have long recognized the
representational rights of claimants and have provided an
administrative framework designed to ensure that claimants will have
access to the legal community and others in the pursuit of their
claims. Representatives currently have the option for authorization of
fees through two procedures: 1) the fee petition method, whereby the
representative presents an itemization of services rendered and time
expended, and SSA determines a reasonable fee; and 2) the fee agreement
method, whereby the claimant and representative agree to a fee of 25
percent of the retroactive benefits due or $4,000, whichever is less.
Focus groups of claimants and the general public have indicated
that the disability program is too complex to understand and the
process too fragmented and difficult for them to navigate alone. While
many claimants resent having to pay a representative to establish
entitlement to government-sponsored benefits, they feel that they have
no choice if they want to be successful in this pursuit. Although the
current regulations provide protection for claimants from fee abuses,
these rules fall short of assuring claimants that the representatives
they retain are qualified and will adequately represent their
interests.
In the new process, SSA will continue to have a responsibility for
monitoring representational activity and for safeguarding the interests
of claimants. The new process will establish rules of representation
and standards of conduct to ensure that representatives fulfill their
responsibilities and serve the needs of the claimants they represent.
These new rules will, among other things, ensure that claimants receive
competent representation; establish a code of professional conduct for
representatives in all matters before SSA; and provide sanctions
against representatives, including suspension and disqualification from
appearing before the Agency in a representative capacity, for violating
the rules of representation and standards of conduct. Without
disturbing the statutory intent of facilitating claimant access to
representatives, the simplified and user-friendly new process may well
result in more claimants pursuing their claims without representation.
However, the issue of representation will remain a matter of a
claimant's personal choice. The new rules and standards of conduct
provide the framework for assuring that representatives claimants
retain will be qualified, will have the obligation to fully develop the
record on their behalf, will adequately represent their interests, and
will be accountable for misconduct or dereliction of duty.
SSA will also conduct outreach efforts with the legal community, to
ensure that information about the disability programs is widely
available to the organized bar and the Federal judiciary. Policy
documents, regularly updated electronically, and rules of
representation will be available at forums sponsored by the organized
bar and in initial orientation and continuing legal education programs
designed for Federal judges.
Information Technology
Information technology will be a vital element in the new
disability claim process. To the fullest extent possible, SSA will take
advantage of the ``Information Highway'' and those technological
advances that can improve the disability process and help provide
world-class service. The new process will rely on seamless, electronic
processing of disability claims from the first contact with the
claimant to the final decision, including all levels of administrative
appeal. Existing Agency design plans for Intelligent Workstation/Local
Area Network (IWS/LAN) and a Modernized Disability System will provide
an integrated system and the electronic connectivity necessary to
support the new disability process.
In a seamless electronic environment, all employees will use the
same hardware, the same claim assignment and scheduling software, the
same decision support software, the same case control system, the same
fiscal and accounting software, the same integrated quality assurance
functionality, and the same management information system throughout
all stages of the process. In this environment, data will need to be
input and validated once and multiple employees may access a single
claim record simultaneously.
Information technology will be applied to enhance access to
services by claimants, their representatives, and other third parties.
Claimants will be able to conduct business with SSA via telephone,
self-help workstations, kiosks, videoconferencing, and electronic data
transfer at SSA facilities and other satellite locations. SSA will
conduct forums and produce video and computer-based training materials
for third parties who wish to participate in assisting claimants to
file applications and gather medical evidence. Wherever possible,
physicians and health care organizations, advocates, community
counseling services, and other professionals who regularly provide
assistance to SSA claimants will be supplied with SSA software to
electronically complete Agency forms. Data will be transferred to SSA
using agreed upon methods. SSA will allow authorized representatives
appropriate access to electronic claim folders. Paper versions of
treating source forms will be designed so that the data can be read by
scanning equipment into SSA claim processing systems. A single vendor
payment system will be used to pay certain evidence providers for
information which they provide SSA. To further paperless processing,
SSA will adopt a ``signature on file'' policy for the claimant's
evidence release authorization to eliminate routing of paper medical
release forms.
The ability of decisionmakers to conduct thorough interviews and
evidence evaluation, and timely and accurate claim adjudication is
predicated on the implementation of the functionality provided by the
IWS/LAN hardware and software components, and the decision support
features of the Modernized Disability System. Expert system software
will be included in SSA claim processing systems to assist disability
decisionmakers in the analysis and evaluation of complex eligibility
factors, and to ensure that the correct procedures for disability
evaluation are followed. While conducting interviews, disability
decisionmakers will rely on decision support features that ask
impairment-specific questions. The decision support system will use the
accumulated data of the electronic record to assist in the preparation
of the predecision notice, the statement of the claim, and decisions
rendered on appeal. Where disability decision team members cannot be
physically co-located, they can remain in communication by using two-
way TV and other videoconferencing technologies. Disability policy will
be developed and stored in a format that can be integrated into
computer systems as the source of context-sensitive help screens and
decision-support messages.
Quality assurance features fully supported by the Modernized
Disability System will be integrated throughout the new process. For
example, the national end-of-line quality review sample will be
electronically selected and automatically routed to appropriate staff.
In-line programmatic quality assurance, enhanced by the use of decision
support systems, will be programmed into the computer applications and
will help to identify errors of both oversight and substance, and also
support routine analysis to aid in avoiding future similar errors. An
on-line technical review will occur each time information is added to
the electronic record.
Quality assurance and productivity measures will be incorporated in
a new, total-process management information system. Meaningful, timely
management information for the disability process is dependent on a
seamless data processing system used by all components which affords a
common case control system and a common data base. SSA's claim
processing systems integrated on an Agency-wide IWS/LAN platform will
provide this seamless environment.
Cost and Benefits
Introduction
SSA's strategy of coming to closure on an ideal, high-level
disability process design before undertaking detailed operational and
implementation planning has been consistent from the beginning of the
reengineering project. Although this project management approach served
SSA well, it has made the very necessary task of cost/benefit
projections unusually challenging. The following cost/benefit forecasts
will need to evolve as implementation details are developed. The
administrative cost numbers presented here cannot be applied to SSA's
administrative budget without further analysis.
SSA will move forward on all aspects of the process redesign plan;
however, because of the extensive research and development required for
implementation of the simplified disability determination methodology,
we have not considered the effect of this redesign feature in our cost/
benefit planning. In addition, because the ability of a single employee
to master the disability claim manager position is dependent on full
adoption of a simplified disability determination methodology, the
impact from that process redesign feature has also been separated out
from our cost/benefit planning at this time.
Service Improvements
Service to the public, as defined by average processing time, would
improve dramatically--from around 150 days to pay an initial disability
claim today to 60 days after implementation of the new process. Hearing
processing time would also improve from about 550 days to 225 days.
These figures were derived from running a computer simulation model of
the new process.
Program Costs
Under the supposition that SSA's current initial claim and
administrative appeal process leads to correct disability
determinations within the proper universe of people today, and because
SSA is not proposing any changes in the statutory definition of
disability, the redesigned process in and of itself would have no long-
term effect on program outlays.
Administrative Costs and Savings
The project life period for implementing disability reengineering
is from October 1, 1994 to September 30, 2000. However, the full
benefits from the redesigned process will not be realized until
September 30, 2001.
Cumulative administrative costs during the life of the project are
estimated at $148 million. The largest percentage of these costs will
be directed to special workforce training on the new process--a
critical enabler if the redesign plan is to work. The redesign will not
require additional investments in information technology spending over
current SSA plans.
Cumulative administrative savings through FY 2001 are estimated at
$852 million. The bulk of these savings will come from more efficient
use of Federal and State workyears to process the anticipated
disability initial claim and appeal workloads during the project life
period. This savings estimate does not factor in Agency resource needs
for working existing backlogged disability cases.
Subtracting cumulative administrative costs of $148 million from
cumulative savings of $852 million will result in a pay back to the
government of $704 million through FY 2001.
Ongoing administrative cost savings will be over $305 million
annually, beginning in FY 2001. This figure includes spending increases
for enhanced employee education, better office security, and expanded
claimant services.
The administrative cost savings associated with this project--$704
million during the implementation period, and $305 million annually,
thereafter--will allow the Agency to reallocate existing resources to
give more attention to other important workloads.
SSA's workforce profile, with respect to disability process
workloads, would include at least the same number of professional
positions currently employed at the federal and state level. However,
the overall design, if fully implemented with all the process
enablers--especially enhanced automation--would require fewer clerical
and support positions to handle projected workloads.
Conclusion
SSA is committed to implementing a new disability determination
process that will deliver significantly improved service to the public,
remain neutral with respect to program dollar outlays, and will be more
efficient to administer.
Administrative cost savings from the process will allow the Agency
to reallocate resources to give increased attention to other important
workloads.
However, the redesigned process cannot be implemented without the
full funding, development, and installation of a new case processing
computer system. In addition, unless SSA invests substantially more
funds for research and development of the simplified disability
determination methodology, the full benefits of the redesigned
process--including better public service and the potential for even
greater long-term administrative efficiencies--will not be possible.
Implementation Strategy
Overview
The disability process redesign is a high-level process description
that provides a broad vision of how a new process would work but leaves
operational, organizational, and other details for later development
and implementation. SSA must now begin to transition from the high-
level analysis into this latter phase. As SSA implements the new
process, the five objectives of the redesign effort must continually be
kept in the forefront of implementation planning, execution and
assessment: the process will be user-friendly for claimants and those
who assist them; the right decision will be made the first time;
decisions will be made and effectuated quickly; the process will be
efficient; and the new process will provide employees with a satisfying
work environment. The success of the new process must be measured
against these objectives and emphasis must continually be on overall
measurement from the customer's perspective, and not individual
component results. Implementing a process of the magnitude of the new
disability claim process will require a strategy that is comprehensive,
creative, and inclusive. The following provides a general framework for
how implementation activity will proceed.
Implementation Framework
Planning for the implementation of the new process vision requires
a comprehensive approach that moves forward on multiple fronts
simultaneously. Although the new process will not be fully implemented
until FY 2001, SSA must start on October 1, 1994 (the beginning of FY
1995), to initiate activities, changes and improvements that will
establish the plan and pace for the long-term full implementation of
the new process. The goal is to make near-term, visible improvements
while at the same time building for long-term results.
Multiple Track Approach
Immediate or near-term implementation activities are those that can
begin in FY 1995 and will be fully implemented nationwide by the end of
FY 1996, or for which the research and development or site testing can
be initiated within the next two fiscal years. These activities include
streamlining and simplification initiatives or other procedural
elements of the new process that can be implemented using existing
administrative or regulatory discretion. They also include client-
service activities associated with improving the claimant's access and
entry into the disability claim process; the development and site
testing of options for streamlining parts of the administrative appeals
process; the provision of consistent training and direction to
disability decisionmakers; and the establishment of new measures and
the testing of new quality assurance mechanisms. Additionally, because
the decision methodology associated with the new process depends on
significant amounts of research, consultation, development and
refinement, SSA must identify the specific research needs, develop the
appropriate scope of work and award research contracts as near-term
activities.
Long-range implementation items are those requiring extensive
research and development that could not be tested fully before FY 1999
or could not be fully implemented nationwide before FY 2001. These
activities are those associated with the full development, testing and
refinement of a new decision methodology. They also include the
implementation of advanced technology enhancements that provide a
single, fully-integrated disability claim processing system which
supports paperless claim processing and provides interactive
capabilities for claimants and those who assist them, and for providers
of evidentiary information.
The remaining mid-term items or activities are those elements of
the new process that can be developed and tested in FYs 1997 and 1998
and/or fully implemented nationwide by FY 1998. Mid-term activities
would include such items as the phased testing and implementation of
new service options; full development, testing and implementation of a
streamlined appeals process; the testing of more advanced technology
enhancements; and the activities associated with developing the
decision methodology based on the results of research efforts completed
by the end of the near term.
Flexibility and Testing
SSA recognizes that full implementation of the new process vision
is an iterative process that requires development, testing, additional
information gathering and possible modification of process changes as
they are implemented. Although SSA is committed to moving forward
quickly to begin implementing the new process, SSA has embraced an
equally strong commitment to rigorous testing and refinement of process
changes before they are fully or permanently implemented. Testing may
include, but is not limited to, geographic or time-limited site
testing, using ``laboratory'' settings, or relying on specific case
studies. Formalized testing is most appropriate for process changes
that depend on longer-term research and development, phased
implementation or major organizational change. In selecting sites for
initial implementation activity, SSA will take advantage of the
interest and capability of different offices, states, or regions to
demonstrate the viability of immediate improvements or identify early
successes in improved service or efficiency. Implementation sites will,
of course, be provided with the necessary resources to support their
efforts.
Even with extensive testing, the nature of public policy
formulation, as well as sound management principles, dictate that SSA
remain flexible in developing, refining and implementing the specific
elements of the new process vision. Ultimately, if the results of the
iterative process necessitate modifications to the process vision, SSA
is prepared to make those modifications. SSA is committed to change,
not for its own sake, but because it is necessary to meet present and
future challenges as it strives to provide high-quality, responsive,
world-class service to its customers.
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Employees Will Make Change Happen
Overall leadership, control, and coordination of all implementation
activities are vested in the Implementation Manager, who will report to
the Commissioner and Principal Deputy Commissioner. As part of these
responsibilities, the Implementation Manager, with the assistance of a
support team, will establish implementation priorities, develop
specific timelines, and provide oversight to ensure that implementation
decisions are consistent with the new process visions and the five
process objectives.
Although the Implementation Manager will be the focal point for all
implementation activities, it is the employees and organizational
components in the SSA and DDS communities who will make the new
disability claim process a reality. Front-line employees will be asked
to directly participate in the development, testing and implementation
of process changes. They will also provide feedback on the
effectiveness of the these changes. Task management teams will be
chartered to address specific implementation issues and their duration
will depend on the nature of their issue. For example, task teams that
might be expected to require a longer-term existence are those dealing
with decision methodology or organizational readiness and change
management. The task teams will bring together staff from the affected
SSA and DDS components to provide the necessary guidance for actual
implementation action by organizational components. Central office
components, working with their Regional office counterparts, will be
responsible for ensuring that necessary implementation actions are
effectuated.
SSA will rely on an internal Advisory Group, comprised of SSA
executives and union and association leaders to provide advice and
guidance on implementation activities and facilitate communication
about implementation plans.
Non-SSA Experts and Interested Parties
SSA will use an inclusive process that seeks input from a variety
of non-SSA communities including, but not limited to, disability
advocates, physicians, other health care and rehabilitation providers,
and the private disability and health insurers. The goal of this
inclusive process is to foster creative relationships with non-SSA
experts so that SSA can have access to specialized expertise and advice
as implementation activities progress.
Open Lines of Communication
SSA's unprecedented effort to establish new and beneficial
communication channels during the various phases of the disability
claim process redesign lays the groundwork for continued communication
during implementation. The internal and external contacts and the
avenues of communication established during the public dialogue period
will continue and will be an integral part of the implementation
process. SSA will continue open lines of communication about
implementation of the new process with individuals and organizations
who have a stake in the disability process, including front-line
employees, representatives from Federal and State employee unions and
associations, other Federal agencies, the Congress, the judiciary, and
disability advocates. SSA will use all appropriate avenues of
communication, including written materials, telecommunications, and
personal briefings, to ensure that necessary information about
implementation activities is regularly and widely disseminated and to
develop appropriate feedback channels. Additionally, SSA will explore
new opportunities and means of communicating with both internal and
external audiences to permit meaningful exchanges of information.
Appendix I: Methodology
Business Process Reengineering
The Process Reengineering Program is the culmination of a rigorous
SSA investigation of the reengineering efforts and methodologies of
those companies, public organizations, academic institutions, and
consulting firms with the most ``hands on'' experience in this field.
The positive findings from this detailed review, combined with concerns
about existing business processes within SSA and the quality of SSA
service to the public, led management to the conclusion that a process
reengineering effort was critical to the SSA objective of providing
``world-class'' administration and service.
Based largely on analysis of what has worked best in the private
and public sectors, a customized reengineering methodology was
developed within SSA. It uses a reengineering team approach that
combines a strong ``customer'' focus with classic management analysis
techniques, and computer modeling and simulation, to intensely review a
single business process. The objective is not to make small,
incremental improvements in the various pieces of the process, but to
redesign it as a whole, from start to finish, so that it becomes many
times more efficient and, in so doing, significantly improves SSA
service to the public.
A senior SSA manager was selected to serve as Director of the
Process Reengineering Program. The Director leads all SSA process
reengineering efforts, is the primary liaison with the Commissioner and
Executive Staff, nominates topics for examination, chairs project
steering committees, and directs a small professional staff and
revolving group of managers/consultants.
SSA uses special, multi-disciplinary teams of individuals to
conduct reengineering analyses and identify the best ways to redesign
and significantly improve processes. Teams are comprised of outstanding
employees, all of whom are subject matter experts in operational,
programmatic, policy, systems, administrative, and other areas relevant
to the business process.
Reengineering teams focus on identifying those procedural and
policy changes to the process that will: make it more claimant and
service oriented; greatly increase productivity and process speed; take
advantage of opportunities offered by new technology; and improve the
empowerment and professional enrichment of the employees who are part
of the process. Although teams follow the same basic reengineering
protocol, continual customization is both expected and encouraged.
Disability Process Reengineering Project
An Executive Steering Committee was formed to meet on a regular
basis to provide advice to the Commissioner on development of the
disability reengineering process change proposal, and to ensure that
support occurred at the highest levels of the Agency. The Executive
Steering Committee established the following parameters and
expectations for the project which are driven by targets set forth in
the Agency Strategic Plan and based on percentages of service and/or
productivity:
Parameters and Expectations for Reengineering the Disability
Determination Process (9/15/93)
Definition of Process
The ``process'' to be reengineered is the initial and
administrative appeals system for determining an individual's
entitlement to Social Security and Supplemental Security Income
disability payments. It includes all actions from an individual's
initial contact with SSA through payment effectuation or final
administrative denial. The system for determining whether an individual
continues to be entitled to receive disability payments is not part of
this ``process.''
Rationale: The process to be reengineered must be defined broadly
to increase the opportunity for improvement. The continuing disability
review system is not included because it is conceptually and
practically distinct from the initial disability determination process.
Parameters
Every aspect of the process except the statutory definition of
disability, individual benefit amounts, the use of an administrative
law judge as the presiding officer for administrative hearings, and
vocational rehabilitation for beneficiaries, is within the scope of
this reengineering effort. However, analysis and ideas for change
should proceed and be presented on two tracks: improvements achievable
without changes in statute or regulations and innovations that may
require such change.
Rationale: The timing of legislative or regulatory change is beyond
SSA's control. Such change could not reasonably be expected to be
implemented in less than 2 years. However, limiting the reengineering
effort to aspects of the process not requiring change in statute or
regulations was rejected as limiting too greatly the possibility of
major improvement/innovation in the process. The two-track approach
provides for both shorter term incremental improvements and longer
term, more radical change.
Expectations
1. Unless otherwise specified here, the recommendations for change
should be consistent with the goals and objectives set forth in the
Agency Strategic Plan.
2. Recommendations for change, taken as a whole, should not cause
changes in benefit outlays unless as a necessary result of improvements
in service, such as more timely processing and payment of claims.
3. Process changes should improve service and/or productivity, on a
combined basis, by at least 25 percent by the end of FY 1997 over
levels projected in the FY 1994 budget (it would require about an
additional $500 million currently to realize such improvement) and
decisional accuracy should not decrease. By FY 2000 additional actions,
including any necessary statutory and regulatory changes, should
provide a further 25 percent improvement.
The Executive Steering Committee facilitated ongoing communications
between components and the Team, and communicated the need and reason
for reengineering the disability process. They were familiar with the
current process problems and were kept apprised of research completed
by the Team. In February, the Executive Steering Committee was expanded
to include the Presidents of the American Federation of Government
Employees, the National Federation of Federal Employees, and the
National Treasury Employees Union locals, councils and chapters
representing SSA employees; and the Presidents of the SSA and State
Disability Determination Services (DDS) professional and management
associations recognized by SSA as having an interest in disability
issues. A list of Executive Steering Committee members appears at the
end of this appendix.
The 18 members of the Disability Reengineering Team, all of whom
are SSA or State DDS employees, have varied and extensive backgrounds
in all aspects of the disability program. A list of Team members
appears at the end of this chapter. Team members attended a high
quality, intensive 3-day SSA reengineering methodology training
session, and completed extensive reading assignments on reengineering.
Some Team members visited organizations who had reengineered their
business processes to learn about successes as well as opportunities
for improvement. The Team used the following methods to obtain the
information necessary to develop a redesigned disability process.
Briefings
Members of the Team received extensive briefings from staff in all
SSA components that work with any aspect of the disability process
including experts in SSA policy, quality assurance, management
information, operational, and appellate processes. Dr. Frank S. Bloch,
Professor of Law and Director of the Clinical Education Center at
Vanderbilt, briefed the Team on the results of his study comparing
disability programs and processes of the United States, Canada, and
Western Europe. His work encompasses eligibility requirements and
program goals, benefit award structure and short-term benefits,
administrative organization, and procedures for claim processing and
appeals.
Scan Visits
The Team's conducted extensive fact-finding visits and interviews
with members of the disability community. Team members visited 421
locations in 33 States and conducted over 3,600 interviews. Almost
2,900 of these involved front-line employees, managers and executives.
The Team conducted an additional 111 interviews by telephone. The Team
also interviewed over 750 parties external to SSA for their views. They
also publicized surface/electronic mail addresses and fax and voice
telephone numbers for those who were not contacted or had additional
information to provide.
Individuals and groups both internal and external to the process
were interviewed for ideas about a new process. The Team solicited a
wide spectrum of opinions about problems with the current disability
process and directions for redesign. In addition to individuals in the
SSA and DDS communities, the team talked to a wide variety of externals
including physicians, health maintenance organizations and hospital
officials, disability advocates, attorneys, professional association
groups, Federal judges, other Federal agencies, and Congressional
staffs.
Prior to site visits and contacts, Team members provided
individuals and organizations with general information about the
reengineering effort, key research areas, and some unconventional ideas
about the disability process so that the interviewees would have an
opportunity to think about process issues. The Team encouraged
interviewees to provide open and honest opinions, suggestions, and
ideas. The interviews provided useful insights into the problems
confronting the disability program and recommendations for solving
these problems.
Focus Groups
A series of 12 focus groups were held throughout the country to
obtain input from members of our claimant population and the general
public regarding their experiences with and expectations of the SSA
disability process. The focus groups provided the Team valuable
information about claimants' expectations and preferences, as well as
concerns about the current process. The following is a list of the
focus group sites and composition.
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Benchmarking
``Internal benchmarking'' refers to the identification and
understanding of site-specific best practices that currently exist
within the Agency and is focused on the improvement and standardization
of internal operations. The Team completed this phase of benchmarking
by reviewing lists of sites engaging in ``best practices'' which were
submitted by various SSA components, and visiting or telephoning as
many of these SSA and DDS offices as possible.
``External benchmarking'' is essentially the same, except the
search for best practices and proven process innovations is expanded to
comparable companies and organizations outside of SSA. It is focused
outside the organization and is concerned with the relative performance
of one specific function or process. The table below identifies the
companies/organizations the Team used as benchmarking partners.
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Process Analysis
The Team utilized a document prepared by the SSA Office of
Workforce Analysis in April 1993 which outlines the ``as-is''
disability claim and appeal processes of SSA. The document contains a
description of claim processing tasks performed by line-employees in
the seven operational components that deal with the disability claim
process. Team members also collected, reviewed, and researched an
extensive amount of existing procedural guides, laws/regulations,
studies conducted by internal and external components, processing time
and quality management information, workflows, cost data, etc.
Computer Modeling
Computer models are close representations of work processes that,
if properly constructed, allow for better understanding, testing or
forecasting, and study. Team members worked with modeling professionals
in SSA to build the models used to predict the operation of a
redesigned process. A model was built to represent both the current and
proposed processes. The model helped the Team assess the best features
and performance of the new disability process; to better judge the
magnitude of change from one process to another; and to do some ``what-
if-nothing-changes'' analysis to get a feel for the impact of
inactivity. A summary of the model assumption and results appears in
Appendix II.
Release of Initial Team Proposal
The product of the Team's effort was a redesign proposal that was
presented to the Commissioner and Executive Steering Committee on March
31, 1994. The proposal provided the Team's view of the best process
improvement and process innovation ideas. The proposal is a high-level
concept that provides a broad understanding of how a redesigned process
would work but leaves operational, organizational, and other details
for later development.
The Team distributed the proposal as widely as possible throughout
SSA, the State DDSs, and to interested public and private individuals
and organizations with the goal of seeking reactions, items of concern
and additional ideas for improvement. Copies of a shorter 25-page
version of the Proposal were distributed to all SSA and DDS employees
in early April 1994. Copies of the complete 132-page Proposal and
Background Report were also distributed to each SSA DDS facility in
sufficient numbers to make it easily available to staff. A 30-minute
videotape containing remarks by Commissioner Chater and a presentation
of the proposal by members of the Reengineering Team was distributed
for use in all SSA and DDS facilities. Group feedback discussions with
SSA and DDS employees were held in all ten regions and in SSA
headquarters components. A survey was distributed to each SSA and DDS
employee to assist employees in providing comments.
The Proposal and Background Report was published in the Federal
Register on April 15, 1994 (59 FR 18188). A 60-day comment period was
established to invite public comment on the proposal. A public hearing
on the proposal was held in Washington, DC on May 16, 1994. Team
members conducted extensive briefings on the proposal with interested
parties, including employee unions, professional association groups,
disability advocates, the legal community, other Federal agencies, and
Congressional staffs.
During the comment period that ended on June 14, 1994, the Team
received over 6,000 written responses from all interested parties. The
Team reviewed and analyzed each comment received. A summary of the
comments is included in Appendix III. In response to reactions received
during the comment period, the Team made changes to the original
proposal and submitted a revised proposal to the Commissioner and the
Executive Steering Committee on June 30, 1994.
After extensive consultation with the members of the Executive
Steering Committee, SSA senior staff, representatives from employee
unions and associations, disability advocates and others, the
Commissioner accepted the Team's recommendations for a redesigned
disability process.
Reengineering Design Partners
Director, SSA Process Reengineering Program
Rhoda Davis--Office of the Commissioner, Baltimore, MD
Disability Process Reengineering Team
William Anderson--Office of Disability, Baltimore, MD
Mary Ann Bennett--Office of Budget, Baltimore, MD
Bryant Chase--Office of the Deputy Commissioner for Systems, Baltimore,
MD
Kayla Clark--Office of Hearings and Appeals, Seattle, WA
Judith Cohen--Office of Supplemental Security Income, Baltimore, MD
Judge Alfred Costanzo, Jr.--Office of Hearings and Appeals, Pittsburgh,
PA
Kelly Croft--Office of Workforce Analysis, Baltimore, MD
Mary Fischer Doyle--Office of Hearings and Appeals, Falls Church, VA
Virginia Lighthizer--Chicago Region, Detroit Conner Branch Office,
Detroit, MI
Rebecca Manship--Disability Determination Service, Sacramento, CA
Mary Meiss--Office of Hearings and Appeals, Philadelphia, PA
Michael Moynihan--Office of Disability and International Operations,
Baltimore, MD
Donna Mukogawa--Office of the Regional Commissioner, Chicago, IL
William Newton, Jr.--Office of Disability and International Operations,
Baltimore, MD
Ralph Perez--Atlanta Region, Miami South District Office, Miami, FL
Dr. Nancie Schweikert--Disability Determination Section, Nashville, TN
Ronald Sribnik--Office of Regulations, Baltimore, MD
Sharon Withers--Philadelphia Region, Welch District Office, Welch, WV
Process Reengineering Program Executive Steering Committee
Shirley Chater--Commissioner, SSA
Lawrence Thompson--Principal Deputy Commissioner, SSA
Rhoda Davis--Director, Process Reengineering Program, SSA
Dennis Brown--Moderator, Association of OHA Analysts
Bruce Bucklinger--President, OHA Managers' Association
Robert Burgess--President, National Association of Disability Examiners
Mary Chatel--President, National Council of Social Security Management
Associations, Inc.
Herbert Collender--President, SSA/AFGE National Council of Payment
Center Locals (Council 109)
Renato DiPentima--Deputy Commissioner for Systems, SSA John Dyer--
Deputy Commissioner for Finance, Assessment and Management, SSA
Richard Eisinger--Senior Executive Officer, SSA
George Failla--Director, Office of Information Resources Management,
SSA
Gilbert Fisher--Assistant Deputy Commissioner for Programs, SSA
Howard Foard--Assistant Deputy Commissioner for Policy and External
Affairs, SSA
Hilton Friend--Acting Associate Commissioner for Disability, SSA
John Gage--President, SSA/AFGE SSA Headquarters (Local 1923)
Randolph Gaines--Acting Associate General Counsel, SSA
Robert Green--SSA Regional Commissioner, Boston
Joseph Gribbin--Associate Commissioner for Program and Integrity
Reviews, SSA
James Hill--President, National Treasury Employees Union (Chapter 224)
Arthur Johnson--Chief Spokesperson, SSA/AFGE General Committee
Charles Jones--Director, Michigan Disability Determination Services
David Knoll--President, SSA National Federation of Federal Employees
Council of Consolidated Locals
Demos Kuchulis--President, National Association of Senior Social
Security Attorneys
Antonia Lenane--Chief Policy Officer, SSA
Huldah Lieberman--Assistant Deputy Commissioner for Operations, SSA
Rose Lucas--President, SSA/AFGE National Council of Data Operations
Centers (Council 221)
James Marshall--President, SSA/AFGE National Council of SSA/OHA Locals
(Council 215)
Larry Massanari--SSA Regional Commissioner, Philadelphia
Francis O'Byrne--President, Association of Administrative Law Judges,
Inc.
Ruth Pierce--Deputy Commissioner for Human Resources, SSA
Daniel Skoler--Associate Commissioner for Hearings and Appeals, SSA
Witold Skwierczynski--President, SSA/AFGE National Council of SSA Field
Operations Locals (Council 220)
Earl Tucker--President, SSA/AFGE National Council of Social Security
Regional Offices, Program Integrity Review (Council 224)
Janice Warden--Deputy Commissioner for Operations, SSA
Andrew Young--Deputy Commissioner for Programs, SSA
Additional Support from:
Dominic Fulgieri--Implementation Planning Staff, Baltimore, MD
Rosanne Hanratty--Implementation Planning Staff, Baltimore, MD
Kathleen Jones--Implementation Planning Staff, Baltimore, MD
Linda Kaboolian--Kennedy School of Government, Harvard University,
Cambridge, MA
Miriam Kahn--Process Reengineering Staff, Baltimore, MD
Becky Klepper--Implementation Planning Staff, Baltimore, MD
Kenneth Nibali--Process Reengineering Staff, Baltimore, MD
Leonard Ross--Office of Workforce Analysis, Baltimore, MD
John Shaddix--Office of Telecommunications, Baltimore, MD
Carolyn Shearin-Jones--Implementation Planning Staff, Baltimore, MD
Sandi Sweeney--Process Reengineering Staff, Baltimore, MD
Wendy Tayback--Implementation Planning Staff, Baltimore, MD
Latesha Taylor--Process Reengineering Staff, Baltimore, MD
Linda Thibodeaux--Process Reengineering Staff, Baltimore, MD
Appendix II: Model Results
Summary Information
The Team worked with modeling professionals in the SSA Office of
Workforce Analysis (OWA) to build computer representations of both the
current and the redesigned disability processes. The computer model was
built using FORTRAN programming language. Data based on assumptions,
task times and lapse times were input into the model. In making
assumptions, the team relied on historical data to the extent that such
information was available. The Team also relied on an April 1993 OWA
study that outlines the current disability claim process, including all
administrative appeals, and describes the tasks performed by line-
employees in the seven operational components that are involved with
the disability claim process.
Using a computer model allowed the Team to assess the impact of
changing from one process to another. Although the model did not
generate an actual visual simulation of either the current or the
redesigned process, the model did generate comparative data about the
relative impact of specific features and expected performance. The
sections that follow provide key comparative information regarding
overall processing times and employee work investment based on the
model results.
Overall Processing Times
Under the redesigned process, the time from a claimant's first
contact with SSA until issuance of a final initial decision will be
reduced from an average of 155 days (as cited in the OWA study) to less
than 40 days. Available employees will be able to process a greater
number of claims and devote more time to each claimant, thus providing
more personalized service. The time from a claimant's first contact
with SSA until issuance of a hearing decision will be reduced from an
average of a year and a half (as cited in the OWA study) to
approximately 5 months.
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Employee Work Investment
The table below provides a comparison of the number of different
employees that are likely to make some work investment in a claim at
each decisional level in the current and redesigned processes. The
following abbreviations were used in describing the types of employees
involved at each level.
AAJ--Administrative Appeals Judge
AC--Appeals Council
ALJ--Administrative Law Judge
AO--Adjudication Officer
CA--Claims Authorizer
CR--Claims Representative
DCM--Disability Claim Manager
DDS--Disability Determination Service
DE--Disability Examiner
DW--Decision Writer
FO--Field Office
HAA--Hearing and Appeals Analyst
HO--Hearing Office
MC--Medical Consultant
MG--Management
OPIR--Office of Program & Integrity Reviews
PSC--Program Service Center
QA--Quality Analyst
SA--Staff Attorney
Sup--Support Staff
TA--Technical Assistant
TECH--FO Technician
TSC--Teleservice Center
TSR--TCS Representative
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Assumptions, Task Times and Lapse Times
Listed below are key assumptions, task times and lapse times that
the Team used to model the redesigned process. The task times are shown
in minutes and represent the estimated time it will take an employee to
complete the described task. For each task time entry, three task time
numbers are shown. The middle number represents the most common task
time, while the first and last number represent the low and high
extremes for that task. The lapse times are shown in work days, rather
than calendar days, and represent the number of days between actions or
tasks.
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Appendix III: Summary of Comments on Reengineering Proposal
Overview
During the comment period that began on April 1, 1994 and ended on
June 14, 1994, the Team received over 6,000 written responses from SSA
and DDS employees, employee unions, professional associations, members
of the public, claimant representatives, physicians, State governors,
claimant advocate groups, Federal components, and other interested
parties. Fifty-three percent of the written responses came from SSA
employees, 21% came from DDS employees, and 26% came from individuals
and organizations external to the SSA/DDS community. Members of the
Team read, analyzed, and collated every one of those 6,210 comments so
that no idea, reaction, or nuance would be overlooked.
For the commenters who presented written reactions to the overall
proposal, 52% were favorable to the overall concept, 39% were
unfavorable, and 9% were neutral. Approximately 10% of these commenters
believed no reengineering was needed. Beyond the request for written
comments, additional means of gauging reaction to the proposal were
also employed: group employee feedback discussions were held in over 80
sites across the country with almost 2,000 SSA and DDS employees
participating; a public meeting was held in Washington, D.C.; and Team
members conducted briefings and spoke with more than 3,000 individuals
and organizations about the proposal during the comment period.
There was a very mixed reaction to the proposal. Very few verbal or
written responses were totally favorable or unfavorable toward the
proposal--those liking it had concerns about some elements while those
generally disliking it found portions which they believed would be
improvements over the current process. Many commenters, regardless of
expressing praise or concern, addressed very limited aspects of the
proposal without providing a reaction to the overall proposal.
Profile
The comments expressed can be categorized as follows:
--SSA received widespread praise for taking on the task of redesigning
the disability claim process. The prevalent belief was that dramatic
improvements are needed to provide better service and handle workloads
more effectively. Whether fully supporting the proposal or not, most
commenters expressed concern that the system is broken and that only
radical redesign will solve the problems that currently exist.
--The most popular concepts were (listed from most to least frequently
mentioned):
Elimination of the reconsideration step;
The disability claim manager as single Agency point of
contact in the initial claim;
A single presentation of substantive policies for all
decision makers;
Encouragement of the claimant to be a partner in the
development of the claim;
Elimination of the mandatory Appeals Council review step;
Increased reliance on the use of information technology;
Increased public awareness and education about program
requirements;
Evidence development tailored to claimant circumstances;
Disability claim managers empowered with full
decisionmaking authority; and
The general aspects of the proposed disability
methodology.
--The greatest concerns centered around (listed from most to least
frequently mentioned):
Personal safety of disability claim managers;
Ability of one person to fulfill the disability claim
manager role;
Pre-denial personal interview with disability claim
manager;
The general aspects of the proposed disability
methodology;
Encouragement of the claimant to be a partner in the
development of the claim;
The disability claim manager as single Agency point of
contact in the initial claim;
Development and use of an Index of Disabling Impairments;
Use of standardized forms to request evidence from
treating sources;
Reliance on treating source certification of existing
evidence; and
Potential bias of disability claim managers.
--Many of the responses centered around how the proposal would be
implemented and what organizational changes would be needed to make the
new process work.
--There were concerns about whether the proposal would meet the
objective of not increasing or decreasing program costs with fairly
divided opinions about whether the new disability methodology would
allow or deny more claims than the current methodology. Reliance on
treating sources as preferred sources of medical evidence and personal
bias resulting from disability claim manager face-to-face meetings with
claimants were often cited as the reason for the belief that there will
be an overall increase in allowed claims. The new four-step evaluation
process was cited as the most common reason for the belief that there
will be an overall increase in denied claims.
[FR Doc. 94-22491 Filed 9-16-94; 8:45 am]
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