Process Reengineering Program; Disability Reengineering Project Proposal

SUMMARY: The Disability Process Reengineering Team of the Social

Security Administration (SSA) announces a proposal to redesign the

disability claims process for Social Security Disability Insurance and

Supplemental Security Income (SSI) Disability and Blindness benefits.

This notice contains the Proposal (as well as background information)

of the Disability Process Reengineering Team (composed of SSA and State

Disability Determination Service (DDS) employees). The aim of the

proposal is to achieve dramatic improvements in customer service to the

public. Accordingly, we seek comments on the proposal to ensure that it

meets the needs of the public. The comments will be weighed in the

Agency's subsequent decisions on implementation.

DATES: To be sure that your comments are considered we must receive

them no later than May 27, 1994.

ADDRESSES: Submit your comments as follows: (1) Mail them to the Social

Security Administration, PO Box 17052, Baltimore, MD 21235, or (2)

telefax them to (410) 966-9884, or (3) deliver them to 4-N-3 Operations

Building, 6401 Security Boulevard, Baltimore, MD 21235, between 8 a.m.

and 4:30 p.m. on regular business days. If you telefax your comments,

please do not also mail a hard copy document.

FOR ADDITIONAL COPIES CONTACT: Social Security Administration, PO Box

17052, Baltimore, MD 21235, (410) 966-8255. The Proposal is available

in alternative formats for visually impaired individuals. Please use

this same telephone number to request the document in an alternative

format.

SUPPLEMENTARY INFORMATION:

Background--What is the Reengineering Program?

SSA began an Agency-wide program of Process Reengineering in the

summer of 1993. The Process Reengineering Program is one way SSA is

seeking to improve its overall service delivery process.

The Process Reengineering Program essentially asks the question,

``If SSA had the opportunity today to design the processes, what would

they look like?'' In other words ``how would we design a process if we

were starting over?'' The Program's objective is to fundamentally

rethink and radically redesign SSA's work processes to achieve dramatic

improvements in critical measures of performance. In this rethinking

and redesign process, the ultimate aim 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

companies, public organizations, academic institutions, and consulting

firms with ``hands on'' experience. The very positive findings from

that investigation, combined with our concerns about our ability to

provide the very best service to the public, led to the conclusion that

a process reengineering effort was absolutely critical to SSA's

objective of providing ``world class'' service to the American public.

Based on analysis of what has worked best in other organizations,

SSA developed a customized reengineering methodology. This methodology

uses a reengineering team approach and combines a strong customer focus

with classic management analysis techniques and computer modeling and

simulation to intensely review a single business process. While the

reengineering team is comprised of employees and experts who are very

knowledgeable about the SSA process being redesigned, the methodology

focuses heavily on obtaining the views of a broad segment of the

public.

What Does the Disability Project Address?

Despite the outstanding efforts of SSA and State DDS employees

throughout the country, we continue to have difficulty providing a

level of service to claimants for disability benefits that approaches

what would be considered ``good'' service. 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

1989, SSA forwarded to the State DDSs 1.6 million claims for disability

benefits in the Disability Insurance and SSI programs. Claims have

increased significantly in every year since that time. In 1994, the

number of disability claims we will forward to the State DDSs is

expected to reach about 2.7 million. The number of requests for

hearings on denied claims is expected to reach 522,000--an increase of

about 60 percent in the last 3 years. The result is that many claimants

have to wait much too long at each stage in 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 focuses on

the process for claiming 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

component of the SSI program.

The scope of the assignment to the disability reengineering project

team did not include making any changes to the statutory definition of

disability or the amount of benefits for which individuals are

eligible. Other issues relating to the disability programs are being

addressed by SSA in other ways, including the continuing disability

review process and the referral of individuals for vocational

rehabilitation services.

What the Proposal Contains

The proposal contained in this announcement is the product of the

disability reengineering team. It begins by providing background on the

current disability determination process. It discusses input received

in person, by telephone and by mail, from almost 3,000 Social Security

and State DDS employees, 750 members of the external community of

individuals and organizations interested in SSA's disability programs,

and from focus groups conducted with members of the public.

We next provide a conceptual proposal for a new disability claims

process; it gives a view of how the new process will work from the

applicant's perspective. Many readers will want to know how these

concepts will actually work in detail. However, the development of that

level of information will not be done until SSA is confident that the

basic concepts presented here have the potential to achieve the level

of service we seek to provide. We are committed to extensive future

dialogue on the next level of detail once we make the final decision on

these concepts.

The proposal contains many charts, some of which may be difficult

to read in the Federal Register format. We considered deleting some of

them but decided that the greater public interest was served by

publishing the entire proposal as it was presented on March 31, 1994,

to the Executive Steering Committee.

How Should Comments Be Presented to the Project Team?

The Project Team seeks public reaction to the concepts in the

proposal. We are particularly interested in your response to the

following questions concerning the proposal's goals:

Does the proposal have the potential to provide a process

that is easy for claimants and those who assist claimants to access and

understand?

Will it enable SSA and the State DDS to make the right

decision the first time a case is adjudicated?

Will it result in dramatically improved process times?

Will it result in a more efficient use of SSA and State

DDS personnel?

Will it create jobs for employees in the process that are

satisfying?

In considering these questions, you are encouraged to identify

factors that would assure that the concepts presented will achieve

these goals. To the extent that the proposal is not seen as achieving

these goals, alternative suggestions about how to do so will be

welcome.

What Happens Next?

The Project Team will receive all comments from the public and

employees. The comments will be analyzed and used to revise and/or

refine the proposal. The final proposal of the team will be presented

to the Executive Steering Committee for the project for its review and

recommendations. Members of this committee include SSA and HHS General

Counsel executives, the presidents of the 8 union locals/councils that

represent SSA employees, a State DDS Administrator, and the presidents

of 6 associations of SSA and State DDS employees that work in the

disability process.

The Commissioner of Social Security will seek the advice and

recommendations of the Executive Steering Committee in making her

decisions on how SSA will proceed.

Dated: March 29, 1994.

Rhoda M. G. Davis,

Director, Process Reengineering Program.

Introduction

A claimant for disability benefits from the Social Security

Administration faces a lengthy, bewildering process. An initial

decision from SSA will likely take more than three months. Anywhere

from 16 to 26 employees will handle the claim before the initial

decision is reached. If that decision is a denial, and the request for

reconsideration is also denied, chances are the claimant will hire an

attorney. It will likely be an additional eight months or more before a

response on the hearing is received, and even longer before a check is

issued or eligible dependents' benefits are paid. As many as 45

employees could handle the claim.

If the claim for benefits is approved after a hearing, the claimant

will view the SSA disability application process as one which requires

jumping through lengthy bureaucratic hoops. Dealing in person or on the

telephone with SSA field office staff and, possibly, the State

disability determination service (DDS) staff at the initial and

reconsideration levels, the claimant must appear at a hearing and

finally talk to a person in a position to make a decision on the claim.

The claimant will rate SSA employees as courteous and knowledgeable,

but the disability determination process as bureaucratic and

unresponsive.

Congress agrees with this assessment; in May 1991, the House Ways

and Means Committee cited SSA for an excellent job of delivering

retirement benefits, but gave SSA a failing grade for the way it

processes applications for disability benefits, with Chairman Dan

Rostenkowski stating, ``* * * those who are unfortunate enough to

become disabled find their problems compounded by inefficiencies at

SSA.''

SSA employees reiterate this belief, as illustrated in the

following statement by a claims representative, ``I wish we could stop

shuffling all this stuff back and forth. I don't really know what the

DDS is looking for, so I try to do the best generic job I can on these

forms.''

The report of the National Performance Review reflected

Administration concern by directing SSA to ``Improve Social Security

disability claims processing to better serve people with disabilities *

* *''.

SSA has reached a critical juncture; disability claims receipts at

the initial claims and appeals levels have reached all time highs--

Fiscal Year (FY) 1995 claims requiring a disability determination will

increase 69 percent over FY 1990 levels; appeals workloads will

increase 75 percent over FY 1990 receipt levels; employees in field

offices, DDSs and hearing offices are overburdened despite recent

significant increases in productivity. As an agency, SSA must vie for

scarce administrative resources in an era of spending limitations and

competing social spending priorities. The ability of SSA to cope with

further workload increases is questionable; it is clear that only

radical change can address the disability service delivery problems

facing the Agency today.

SSA is meeting this challenge with an unprecedented effort to

reengineer the entire disability process--from the point a potential

claimant first contacts the Agency to file for disability benefits,

through the disability allowance or final administrative appeal.

Reengineering the disability process involves asking the question,

``Given what we know about technology and resources available to us

today, how can we best design a disability process for the 1990s and

beyond?'' This report will answer that question by proposing a radical

redesign of disability program policies and procedures, to ensure

dramatic improvements in the way the entire process works and is

managed to serve the American public.

The report represents the collective efforts and recommendations of

the 18-member Disability Reengineering Team, composed of Federal and

State DDS employees, operating under the auspices of the Director of

the SSA Process Reengineering Program, and the SSA Executive Steering

Committee formed to provide advice to the Commissioner on the

disability reengineering process change proposal development.

The Executive Steering Committee provided the following parameters

for the disability reengineering proposal: ``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.''

The recommendations in this report represent the Team proposal to

SSA for reengineering the disability process; this is not a final SSA

proposal. The Commissioner of SSA asks interested parties to comment on

the proposal within the next 60 days. The Team looks forward to

receiving comments from the community concerned with the delivery of

disability benefits.

Current Process

The procedures in the current process have not changed in any

significant way since the Social Security Disability Insurance (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 Supplemental

Security Income (SSI) program and added this to the responsibilities of

SSA. SSA then adopted the DI disability determination procedures for

SSI blind and disabled claims.

Overview

A claim must now pass through from 1 to 4 decisional paths within

SSA to receive a favorable disability decision. The initial claim,

reconsideration, administrative law judge (ALJ) hearing and Appeals

Council review levels all involve multi-step uniform procedures for

evidence collection, review, and decisionmaking.

The process starts at the initial level when an individual first

applies for DI or SSI disability 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 disability determination services where medical evidence is

developed and a final determination is made regarding the existence of

a medically determinable impairment which meets the definition of

disability.

After possible quality assurance review in the DDS or in the SSA

regional Disability Quality Branch, the claim is returned to the field

office. Thirty-nine percent of these claims were paid in FY 1993;

denials are retained pending possible appeal. Allowed DI claims are

sent to one 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 and retention.

An initial claim currently takes an average of 100 days to process

from the time it is filed until a final decision is made according to

SSA's computer-based processing time measurements. However, a better

understanding of how long the process takes from the claimant's

perspective comes from a 1993 study conducted by SSA's 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. Sixteen to 26 employees will handle the claim

during this period.

BILLING CODE 4190-29-P

TN15AP94.003

TN15AP94.004

BILLING CODE 4190-29-C

An appeal of the initial decision can be made within 60 days of the

denial notice (see Fig. 2). Reconsiderations were requested on 48

percent of denied claims in FY 1993. The local field office receives

the request, updates the information, and forwards the claim file to

the DDS for review, possible medical development, and final medical

decision. The determination 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 the

processing centers, while the remaining denials are forwarded to the

field office for retention, pending a request for a hearing before an

ALJ. The average reconsideration itself takes about 50 days according

to SSA's computer-based processing time reports--however, according to

the Office of Workforce Analysis study, a claimant has now been

involved with the SSA process for roughly 8 months from the point of

initially contacting the Agency, and up to 36 different employees could

have handled the claim.

BILLING CODE 4190-29-P

TN15AP94.005

BILLING CODE 4190-29-C

Within 60 days of receiving an unfavorable reconsideration

decision, a claimant can request a hearing before an ALJ (Fig. 3). In

FY 1993, about 75 percent of all reconsideration denials were appealed

to ALJs. At this point, 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. The local field office receives the request for hearing and

forwards 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 final decision.

Allowed DI claims are sent to a processing center for final action

and storage, as well as adjudication of claims for dependents. 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 in case a request for review is filed.

The hearing process itself takes about 265 days according to computer-

based reports. 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.

BILLING CODE 4190-29-P

TN15AP94.006

BILLING CODE 4190-29-C

If still dissatisfied with an unfavorable decision, a claimant or

representative has 60 days to request a review of the ALJ decision by

the Appeals Council (Fig. 4). About 23 percent of hearing decisions are

unfavorable and forwarded to the Appeals Council pending possible

appeal. 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 either deny

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 DI claims are sent to a processing center for final action

and storage, as well as adjudication of claims for dependents. Allowed

SSI claims are returned to the local field office for income and

resource development, and payment. 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.

Trends

The current disability process served SSA and the public well for a

number of years. However, over the last several years, as workloads

have increased dramatically, the current process has been placed under

increasing stress. The upward trend in the number of claims for

benefits SSA has received is reflected as follows:

BILLING CODE 4190-29-P

TN15AP94.007

BILLING CODE 4190-29-C

The growth in claims and benefits awarded is reflected in increases

in the number of beneficiaries SSA pays and the growth in Federal

program outlays over recent years.

BILLING CODE 4190-29-P

TN15AP94.008

TN15AP94.009

BILLING CODE 4190-29-C

The increase in workload has occurred concurrently with significant

downsizing activity in SSA and staffing fluctuations in the State DDSs.

BILLING CODE 4190-29-P

TN15AP94.010

TN15AP94.011

BILLING CODE 4190-29-C

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 FY 1993 were devoted to this task.

BILLING CODE 4190-29-P

TN15AP94.012

BILLING CODE 4190-29-C

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.

BILLING CODE 4190-29-P

TN15AP94.013

TN15AP94.014

BILLING CODE 4190-29-C

At least part of the increase in 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.

BILLING CODE 4190-29-P

TN15AP94.015

BILLING CODE 4190-29-C

The Team's research revealed that the problems of queues, handoffs,

and task time are compounded by problems with the way SSA takes claims,

collects evidence, and determines disability. These problems are

discussed in the following section.

Research Summary and Analysis

Overview of Methodology and Findings

The Team's methodology called for extensive site 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 interviews provided insights into the problems

confronting the disability program and recommendations for solving

these problems. The Team conducted an additional 111 interviews by

telephone.

The Team also interviewed over 750 parties external to SSA--members

of the medical, legal, advocate and interest group community--for their

views. Finally, the Team has analyzed the results of focus groups

involving disability claimants and the general public in order to

determine what SSA customers experience and expect from the disability

process.

The information collected from these activities resulted in the

framework for the analysis and recommendations that follow. At a

minimum, the Team was determined to address the most pressing problems

identified by SSA employees, claimants, and other interested parties.

Not surprisingly, all three groups were in general agreement regarding

many of the problems with the SSA disability process. All agreed that

the current fragmented 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.

Higher allowance rates at the ALJ level lead to the perception that

different adjudicative standards apply at the initial and appeals

levels. The public, in particular, believes that it is necessary to

hire an attorney to maneuver through this process, and voices

resentment at having to do so. Quality reviews and Appeals Council

reviews are often mentioned as areas where opportunities exist for

improving current processes.

The Case for Change

The Public and Third Parties Find the Current Process Confusing

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. 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.

Evidence Collection and Decision Methodology Pose Problems

The collection of medical evidence presents problems as the case is

developed in the DDS. Medical providers who have treated the claimant

often do not understand the requirements for establishing disability,

and find the forms for the collection of medical evidence confusing. In

order 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

to reach a decision on the case is complex and controversial. Criteria

originally developed to identify and evaluate cases simply and rapidly

have grown increasingly complex as a result of court decisions and

changes in medical technology. Today's 330 different vocational rules,

which have been added to SSA's regulations since 1980, can lead to

varying interpretations resulting in inconsistent decisions.

Claimants and their representatives have learned their chances for

a favorable decision improve if they appeal their claim to an ALJ. A

variety of factors may be contributing to this. The facts of many cases

change over time as a claimant's 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. Finally, the fragmented nature of SSA's

policy making, policy issuance, training and review apparatus all

reinforce the differences.

The Fragmented Process Contributes to Difficulties

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 court

cases 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 component's 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.

Customer Research and Demographics

Customer Research

The National Performance Review report, released in the fall of

1993, calls upon agencies to establish customer service standards equal

to the best in the business to guide their operations. Federal agencies

are encouraged to identify ``the customers who are, or should be served

by the agency,'' and survey these customers ``to determine the kind and

quality of services they want and their level of satisfaction with

existing services.''

SSA customers include the individuals who file for social security

or supplemental security income disability benefits, or who are

potential filers for these benefits. They were surveyed through a

series of 12 focus groups conducted throughout the country last fall.

Participants represented a demographically diverse cross-section of

current claimants, including those who had been initially denied, and

who filed for a reconsideration or hearing; new beneficiaries; and the

general public. Two focus groups were conducted with non-English

speaking participants.

Focus group participants were quick to offer their frank opinions;

the general view was that they:

--Wait too long for a decision--this is the most common complaint; the

claim process is a struggle characterized by stress, fear, and the

anger associated with running out of funds;

--Do not understand the program or process--what happens to the claim

after initial contact with SSA is unclear, they view SSA multiple

requests for medical information with skepticism, do not understand

their decision and believe it was reached arbitrarily;

--Want more information and personal contact--while they would prefer

to deal with one person for all claim business, their major preference

is to receive accurate, consistent information from all SSA sources and

to be provided substantive status reports on their claim;

--View the initial and reconsideration denials as bureaucratic

precursors to final approval at the ALJ level--they believe the process

is designed ``to make you go away'';

--Resent the need for attorney assistance to obtain benefits--the

process should not be so complicated that an attorney is needed; and

--Want more active involvement in pursuit of their claim--they want to

make their case directly to the decisionmaker, and would personally

obtain needed additional evidence to speed the decision on their claim.

Demographics

Changes in demographics of the general population and in SSA's

claimant population present challenges as well as opportunities for SSA

as it focuses on claimant needs and reengineers its disability

determination process.

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 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 sketchy 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. Claims for homeless individuals and others

with special needs have increased in recent years. These claimants

require significant intervention and assistance to navigate the

disability claims 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 awarded

this assistance and three-fourths of those awardees were still

receiving benefits when they applied for disability benefits. SSA has

the opportunity to develop productive relationships with these 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 evidence collection.

New Process

Overview

A claimant for disability benefits under the proposed process will

be provided a full explanation of SSA's programs and processes at the

initial contact with SSA. The claimant and third parties will be able

to assist in the development of the claim, deal with a single contact

point in the Agency, and request a personal interview with the

decisionmaker at each level of the process. Additionally, if the

claimant requests a hearing, the issues and evidence to be addressed at

the hearing will be focused, the responsibilities of representatives

clarified and, if the claim is approved, the effectuation of payment to

the claimant, eligible dependents and the representative streamlined.

The new process will result in a correct decision at the initial

level by simplifying the decision methodology, providing consistent

direction and training to all decisionmakers, enhancing the collection

and development of medical evidence, and employing a single quality

review process across all levels.

A single claim manager will handle most aspects of the initial

level claim, 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 medical 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 proposed process will enable the current work force to handle

an increased number of claims, freeing the most highly skilled 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 proposed process will

facilitate employees' ability to do the total job by providing

technology and the support to use that technology.

The New Process--A Brief Description

Under the proposed process, the number of appeal steps will be

reduced and opportunities for personal interaction with decisionmakers

will be increased. At the initial claim level, the claimant will be

offered a range of options for filing a claim, pursuing evidence

collection, and conferring with a decisionmaker, using various modes of

technology to interact with SSA. At the hearing level, the claimant

will have an additional opportunity to participate in a personal

conference and meet with a decisionmaker.

BILLING CODE 4190-29-P

TN15AP94.016

A Disability Claim Manager Will Handle Initial Disability Claims

Processing

Claimants initially will deal almost exclusively with a disability

claim manager--a front-line employee knowledgeable about the medical

and nonmedical factors of entitlement--responsible for making the

initial determination, with technical support if necessary, to allow or

deny the claim.

The disability claim manager will determine the level of

development needed to make a disability decision using a simplified

determination methodology; relying on evidence submitted by or through

the efforts of the claimant (whenever the claimant is able to do this);

requesting medical evidence or a functional assessment; or referring

complex medical questions to a medical consultant for expert advice and

opinion, if necessary. The disability claim manager will contact the

claimant if the decision on a claim appears to be a denial. The claim

manager will explain the situation including the evidence that was

considered, and offer the claimant an opportunity to submit additional

information as well as an option for an interview in-person or via

telephone, before the claim is formally denied.

All initial claims will be subject to a randomly selected

postadjudicative national sample review designed to determine whether

disability policies are being properly applied. Extensive ongoing

training will enable adjudicators to consistently issue correct

decisions. By the time the initial decision is issued, the claim will

have been handled by seven or eight employees.

An Adjudication Officer Will Prepare the Claim for a Hearing

A claimant wishing to appeal an unfavorable initial decision to an

ALJ will continue to have 60 days to file a request for a hearing. The

disability claim manager will assist the claimant with the request, and

forward the claim to an adjudication officer. The adjudication officer

will be responsible for explaining the hearing process to the claimant,

as well as conducting personal conferences, preparing claims, and

scheduling hearings. The adjudication officer will have the authority

to allow the claim at any point prior to the hearing that sufficient

evidence becomes available to support a favorable decision.

An ALJ Will Conduct the Hearing

The ALJ will conduct the hearing and issue the decision. At any

point in the process where the claim is approved, it will be returned

to the claim manager for payment effectuation, whether the claim is DI,

concurrent, or SSI. Denied claims will be forwarded to the Appeals

Council, for retention in the event of civil action. At this point, an

average claimant will have been dealing with SSA for approximately five

months from the first contact with the Agency. A total of up to 14

employees will have been involved with the process during this entire

period.

An ALJ decision will be the final decision of the Secretary,

subject to judicial review, unless the Appeals Council reviews the ALJ

decision on its own motion. The Appeals Council will conduct reviews of

ALJ allowances and denials prior to effectuation, at its discretion,

and on its own motion. The Appeals Council will also review all claims

in which a civil action has been filed, and decide whether the ALJ

decision should be defended as the final decision of the Secretary. If

a claim is selected for own motion review, a total of 17 employees will

have been involved in the process from first claimant contact with SSA

through Appeals Council review.

Claimants Will Receive World-Class Service

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 SSA's Office of Workforce Analysis study) to less than 40

days, enhancing SSA's capacity to provide world-class service.

Available employees will be able to process a greater number of claims,

and devote more time to each claimant, 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 SSA's Office of Workforce Analysis study) to

approximately 5 months.

BILLING CODE 4190-29-P

TN15AP94.017

TN15AP94.018

TN15AP94.019

TN15AP94.020

TN15AP94.021

BILLING CODE 4190-29-C

Detailed Description of New Process

Process Entry and Intake

SSA Will Customize Its Disability Claims Entry and Intake Processes to

Maximize Access, Efficiency, Accuracy, and Personal Service

The disability claims 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. SSA will also be flexible in

providing modes of access to the claims process that best meet the

needs of claimants and the third parties who act on their behalf. SSA

will provide claimants with a single point of contact for all claims-

related business. Finally, SSA will ensure that the disability

decisionmaking process promotes timely and accurate decisions.

SSA Will Make Information About Its Disability Programs Available to

Potential Claimants Prior to Entry Into the Process

SSA will make available to the general public comprehensive

information packets about the Disability Insurance (DI) and

Supplemental Security Income (SSI) disability programs. 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.

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 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 filing 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).

SSA Will Permit Claimants to Choose the Mode of Entry Into the Process

That Best Meets Their Individual Needs

The disability claims entry process will be multi-faceted, allowing

claimants the maximum flexibility in deciding how they will participate

in the process. Claimants may choose to enter the disability claims

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 claims 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 claims processing system to

protect the claimant's filing date and schedule an appointment for a

claims 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 claims 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 claims 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 claims

intake interview. Depending on an individual's circumstances, such

accommodation may involve: referral to the nearest location for

obtaining an 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 claims intake and development. 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.

Similarly, local managers will modify the claims 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 by becoming certified by SSA to do so.

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 claims process without

considerable intervention. As appropriate, outreach efforts may be

facilitated through videoconferencing, teleconferencing or other

electronic methods of obtaining and processing claims information to

provide timely service despite claimants' geographic or social

isolation.

A Disability Claim Manager Will Be Responsible for a Disability Claim

From Intake Through Payment

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 disability and nondisability aspects of the program 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 such as medical and technical

support personnel to provide advice and assistance in the claims

process.

The disability claim manager will rely on an automated claims

processing system that will permit the disability claim manager to:

gather and store claims information; develop both disability and

nondisability evidence; share necessary facts in a claim with SSA

medical consultants and specialists in nondisability technical issues;

analyze evidence and prepare well-rationalized decisions on both

disability and nondisability issues; and produce clear and

understandable notices that accurately convey all necessary information

to claimants.

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 program to the

claimant, including the definition of disability and how SSA determines

if a claimant meets the 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 claimants access to

the decisionmaker and allow for ongoing, meaningful dialogue between

the claimant and the disability claim manager.

Claims Intake and Development Will Be Directed at Reaching a Decision

in the Most Timely and Accurate Manner

The disability claim manager will conduct a thorough screening of

the claimant's disability and nondisability eligibility factors. If the

claimant appears ineligible for either disability program based on the

claimant's allegations and evidence presented during the claim intake

interview, the disability claim manager will explain this to the

claimant. If the claimant decides not to file a claim, the disability

claim manager will give the claimant an informal denial notice.

If the claimant decides to file, the disability claim manager will

complete appropriate application screens from the automated claims

processing and decision support system. Impairment-specific questions

will assist the 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 that 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 where feasible, requesting medical evidence

directly from treating sources, or ordering further medical

evaluations.

The disability claim manager will decide whether to defer

nondisability development (e.g., requesting SSI income and resource

information, or developing DI dependents' claims) or do it

simultaneously with development of the disability 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. 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 disability and nondisability aspects of the claim.

Claimants Will Be Partners in the Processing of Their Disability Claims

Throughout the disability claims process, SSA will encourage

claimants to be full partners in the processing of their claims. 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 claims 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.

SSA Will Recognize That Some Third Parties Can Develop Complete

Application Packages

Certain third party organizations may be willing to provide a

complete disability application package to SSA. Based on local

management's assessment of service area needs and the availability of

qualified organizations, SSA will certify 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 disability and

nondisability 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. The disability claim

manager may elect to contact the claimant for the purpose of verifying

identity or other claims-related issues, as appropriate. SSA will

monitor such third parties to ensure that quality service is provided

to claimants and to prevent fraud.

Claimants Will Have the Opportunity for a Personal Interview Before SSA

Makes an Initial Disability Denial Decision

When the evidence does not support an allowance, the disability

claim manager will provide the claimant an opportunity for a personal

interview before issuing the initial denial determination. The

interview will be in person, by videoconference, or by telephone, at

the claimant's option and as the disability claim manager determines is

appropriate under the circumstances. In appropriate circumstances, the

predenial interview may follow the initial intake interview. The

purpose of the predenial interview will be to advise the claimant of

what evidence has been considered and to identify what further

evidence, if any, is available that bears on the issues. If such

further evidence exists, the disability claim manager will advise the

claimant to obtain the evidence or, as appropriate, assist the claimant

in obtaining it.

Initial Disability Decisions Will Use a ``Statement of the Claim''

Approach

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 during the predenial interview,

and the rationale in support of the determination. The statement of the

claim not only reflects the SSA 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.

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 claims 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 Agency action, if the claimant seeks

further administrative review.

Disability Decision Methodology

The Methodology for Deciding Disability Claims Will Promote Consistent,

Equitable, and Timely Disability 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.

The cornerstone of any 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 * * *'' (section 223(d) of the Social Security Act)

The decision-making approach is the foundation on which SSA will

base the claim intake process and evidence collection. The focus will

be, first, to establish a solid medical basis for documenting that an

individual has a medically determinable physical or mental impairment.

Second, once the evidence establishes a medically determinable

impairment, SSA will use additional medical findings to provide a solid

link between the disease entity and the loss of function caused by the

impairment(s).

Disability Decisionmaking for Adult Claims Will Be a Four-Step

Evaluation Process

The disability decision methodology will consist of four steps that

are based on 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 that is included in

the Index of Disabling Impairments?

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. If a claimant is performing substantial

gainful activity at the time a claim is filed, SSA will determine that

the claimant is not disabled based on the demonstrated ability to

engage in substantial gainful activity.

Under the current process, in determining whether a claimant is

performing or has performed substantial gainful activity, SSA generally

considers the amount of the claimant's earnings, less any impairment-

related work expenses. However, there are several threshold levels of

earnings that need to be considered and, depending on the actual amount

earned, SSA evaluates whether a claimant's work is comparable to that

of unimpaired individuals in the community who are doing the same or

similar occupations, or whether the work is substantial gainful

activity based on prevailing pay scales in the community.

Under the new process, SSA will simplify the monetary guidelines

for determining whether an individual (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. SSA will continue

to exclude impairment-related work expenses in evaluating whether a

claimant's earnings constitute substantial gainful activity. SSA will

continue to use separate earnings criteria to evaluate the work

activity of blind individuals 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 current regulations, SSA considers, as a threshold

matter, whether an individual has a medically determinable impairment

or combination of impairments that is ``severe.'' A severe impairment

is defined as one that significantly limits the individual's physical

or mental abilities to do work activities such as walking, standing,

sitting, hearing, seeing, understanding, carrying out, or remembering

simple instructions, using judgment, etc.

Under the new approach, SSA will consider whether a claimant has a

medically determinable impairment, but will no longer impose a

threshold severity requirement. Rather, the threshold inquiry will be

whether the claimant has a medically determinable physical or mental

impairment. 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.

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. 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 that results from anatomical,

physiological, or psychological abnormalities which, in the opinion of

the Secretary, could reasonably be expected to produce the symptoms or

substantiate any opinion evidence provided. Depending on the nature of

a claimant's alleged impairments, 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 claimant'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 a claimant 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, SSA

will compare the claimant's impairment(s) against an index of severely

disabling impairments. In contrast to the Listing of Impairments in the

current regulations, the index will contain fewer impairments and have

less detail and complexity. The index will describe impairments that

will result in death or impairments that are so debilitating that any

individual would be unable to engage in substantial gainful activity

regardless of any reasonable accommodations that an employer might make

in accordance with the Americans with Disabilities Act. The index will

be designed to be equitable, easy to understand, and consistent with

the statutory definition of disability.

The index will function to quickly identify severely disabling

impairments; the index will not attempt to describe ideal medical

documentation requirements for each and every body system as occurs

with the current Listings. The index 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 index will not attempt to measure the functional impact of

an impairment on the individual; functional impact will be considered

at Step 4 in the process. 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 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 inferences or

conclusions about the effect of a claimant's impairments on his or her

ability to function merely because a claimant's impairment(s) does not

meet the criteria in the index. Finally, SSA will no longer use the

concept of medical equivalence'' in relation to the index, as it now

uses in applying the Listing of Impairments.

Step 4--Ability to Engage in Any Substantial Gainful Activity

In the final step in determining disability, SSA will consider

whether an individual has the ability to perform substantial gainful

activity despite any functional loss caused by a medically determinable

physical or mental impairment. If an individual retains the ability to

perform substantial gainful activity, then an individual does not meet

the statutory definition of disability.

Presently, there are no generally accepted measurement criteria for

determining an individual's ability to function in relation to work-

related activities. Currently, SSA assesses residual functional

capacity by analyzing the objective medical findings and other

available evidence and translating this information into functional

loss and residual capacity for work activities.

Additionally, there are also no definitive sources for identifying

the physical and mental requirements of ``baseline'' work functions

that are required to engage in substantial gainful activity. SSA

currently relies on the Department of Labor definitions regarding the

physical and mental demands of work in the national economy, and relies

on related reference sources and independent experts regarding the

existence of particular occupations and jobs in the national economy.

Under the new process, SSA will define the physical and mental

requirements of substantial gainful activity and, will measure as

objectively as possible whether an individual meets these requirements.

How SSA will achieve this is described in the following sections.

SSA Will Develop Instruments That Provide A Standardized Measure of

Functional Ability

Under the current process, SSA relies on available clinical and

laboratory findings, treating source opinions, the claimant's

description of his or her abilities and limitations, and third party

observations of the claimant's limitations in determining the

claimant's residual functional capacity. Residual functional capacity

is the claimant's remaining capacity for work activities despite the

limitations or functional loss caused by his or her impairments.

Under the new process, SSA will develop, with the assistance of the

medical community and other outside experts from public and private

disability programs, standardized criteria 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 that results from anatomical, physiological, or

psychological abnormalities which could reasonably be expected to

produce the functional loss. However, extensive development of all

available clinical and laboratory findings is not necessarily effective

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 individual's abilities to perform a

baseline of occupational demands that includes the principal dimensions

of work and task performance, including primary physical,

neurophysical, 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. Functional assessment instruments will be

designed to realistically assess an individual's abilities to perform a

baseline of occupational demands.

SSA will be primarily responsible for documenting functional

ability using the standardized measurement criteria. In the near term,

SSA will solicit functional information 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

measurement criteria 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 individual's 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.

The prospect of universal health coverage may offer a unique

opportunity for SSA to work with the public and private sector to

develop standards that both can use. For example, medical insurance

payors (whether public or private) may want some way of measuring the

effectiveness and necessity of treatment that is prescribed by the

individual's treatment source; SSA will want these same types of

measures to determine how well an individual is able to function

despite his or her impairment(s). Similarly, if all individuals have

treating sources under universal health coverage, SSA can expect that

complete functional assessment measurements will be readily available

from a treating source. Finally, universal health coverage may enable

SSA to access medical records from health care providers who may be

operating under some contractual or other relationship with Federal

agencies and/or a statutory requirement that health care providers

cooperate in providing evidence as a condition of receiving Federal

funds.

SSA will use the results of the standardized functional measurement

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.

SSA Will Identify Baseline Occupational Demands That Represent

Substantial Gainful Activity

Under the current regulations, after assessing a claimant's

residual functional capacity, SSA evaluates whether the claimant can

meet the physical and mental demands of his or her past relevant work.

Past relevant work is usually work that a claimant performed in the

last 15 years.

If the claimant is unable to perform his or her past work, SSA then

evaluates whether the claimant can perform other work in the national

economy. In making this decision, SSA relies on medical-vocational

guidelines (the ``Grid''). The Grid rules represent major functional

and vocational patterns and reflect the analysis of various vocational

factors (age, education and work experience) in combination with the

claimant's residual functional capacity (which is used to determine the

claimant's maximum sustained work capacity for sedentary, light,

medium, heavy or very heavy work).

In promulgating the Grid rules, SSA has taken administrative notice

of the existence of unskilled jobs that exist in the national economy

at the various functional levels. Therefore, when all the findings of

fact regarding a claimant's functional ability and vocational factors

coincide with the corresponding criterion of a rule, the existence of

other work in the national economy is conclusively established.

However, if any finding of fact does not coincide with the criterion of

a rule, the rules can only provide a framework for decisionmaking. In

these situations, adjudicators must consult vocational resources or

obtain expert testimony to resolve the question of whether other work

exists in the national economy that the claimant can perform.

Under the new approach, SSA will conduct research and, working in

conjunction with outside experts, will specifically identify the

activities that comprise a baseline of occupational demands needed to

perform substantial gainful activity. In the current process, an

example of comparable ``baseline'' criteria are the functional

requirements of unskilled, sedentary work. In establishing the

functional activities 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;

(2) The occupations are those that can be performed in the absence

of prior skills or formal job training; and

(3) The baseline of occupational demands that becomes the standard

for evaluating the ability to perform substantial gainful activity

considers any reasonable accommodations that employers are expected to

make under the Americans with Disabilities Act.

The Effect of Age on Ability to Perform Substantial Gainful Activity

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 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.'' 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 Who Are Not Nearing Full Retirement

For an individual who is not nearing full retirement, SSA will

compare the individual's functional abilities against the functional

demands of the baseline work. SSA will no longer rely on the medical-

vocational guidelines and/or expert testimony to identify whether work

exists in the national economy that the claimant can perform. 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, regardless of age, 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, 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 Who Are Nearing Full Retirement

For individuals who are nearing full retirement, SSA will compare

the individual's functional abilities against the functional demands of

the individual's 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 individual's functional abilities to the baseline work, and a

finding of not disabled will be appropriate if the individual is

capable of performing the baseline work. In such claims, the fact that

the individual has no previous work is usually not related to the

existence of his or her impairment(s), and a finding of disability will

not be appropriate for these individuals if they retain the capacity

for the baseline work.

The Effect of Education on Ability to Perform Substantial Gainful

Activity

The statute also 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. Education is generally completed in

the remote past when compared to the age at which the majority of

disability claimants file for benefits. 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.

In relying on standardized functional assessments, SSA will be

measuring both the individual's physical and mental abilities, and

education will be appropriately reflected in the assessment of an

individual's cognitive abilities. However, further evaluation of a

claimant's educational level will not be required because, in

establishing the functional activities that comprise an appropriate

baseline of occupational demands, SSA will not assume that individuals

have prior skills or significant formal job training. Thus, additional

formal education will have little impact on an individual's ability to

perform the baseline of occupational demands.

SSA Will Rely on Medical Consultants to Provide Necessary Expertise in

the Decisionmaking Process

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. 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; perform public relations and training with the medical

community; and participate in SSA quality assurance efforts.

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). (Section 1614(a)(3)(A) of the

Social Security Act).

Disability Decisionmaking For Childhood Claims Will Be a Four-Step

Evaluation Process

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. 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 the functional ability to perform

activities that are comparable to an adult's ability to engage in

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 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, 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, 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. 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 that results from anatomical,

physiological, or psychological abnormalities which, in the opinion of

the Secretary, could reasonably be expected to produce the symptoms or

substantiate any opinion evidence.

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 documented by medically acceptable clinical and laboratory

techniques and the impairment 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 not attempt to describe ideal medical documentation requirements

for each and every body system.

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. As with adults, the childhood index will not attempt to measure

the functional impact of an impairment on the child; functional impact

will be considered at Step 4 in the process. 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 inferences or 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 Adult Ability to Engage in Substantial

Gainful Activity

In evaluating disability in adults, SSA will evaluate an

individual's functional ability to perform work-related activities

consistent with the ability to engage in any substantial gainful

activity. The difficulty with evaluating childhood claims is the

standard against which any functional measurement criteria are

compared. For older children, it is relatively easy because at some age

(somewhere between 14 and 18) the standard approaches the adult

standard, i.e., ability to engage in substantial gainful activity.

However, for younger children, the standard can be more difficult to

describe. Under the current process, SSA uses a standard that measures

the degree to which a child engages in age-appropriate activities which

corresponds fairly well with developmental milestones for different age

categories. However, the difficulty with this approach is that it may

not appropriately define how much functional loss or interference with

growth and maturity is comparable to inability to perform any

substantial gainful activity.

Consistent with the adult approach, SSA will develop baseline

criteria for a child's activities that are comparable to an adult's

ability to perform substantial gainful activity. In establishing a

baseline of functional activities, the functional abilities for a child

will represent a realistic comparison to an adult's ability to work.

Functional Assessment Instruments

Consistent with the approach for adult claims, SSA will develop,

with the assistance of the medical community and educational experts,

standardized criteria 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 that

results from anatomical, physiological, or psychological abnormalities

which could reasonably be expected to produce the functional loss.

These functional assessment instruments will be designed to

measure, as objectively as possible, a child's abilities to perform a

baseline of functions that are comparable to the baseline of

occupational demands for an adult. SSA will conduct additional research

to specifically identify activities that are comparable to those that

comprise a baseline of occupational demands needed to perform

substantial gainful activity by adults.

SSA will be primarily responsible for documenting functional

ability using the standardized measurement criteria. Ultimately, the

course of documenting and developing for the functional abilities for

childhood claims will mirror the adult approach.

Comparability Standard

SSA will develop realistic standards which represent activities

that are comparable to an adult's ability to engage in substantial

gainful activity. The standards will focus on a skill acquisition

threshold designed to measure broad areas of skill that are required to

ultimately develop the ability to engage in substantial gainful

activity. If the child is progressing satisfactorily in the development

of these skills, then the child will not have an impairment of

comparable severity and SSA will not find the child disabled.

Evidentiary Development

SSA's Ability To Issue Timely and Accurate Disability Decisions Depends

on the Efficient Collection of Quality Medical Evidence

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.

Traditionally, the procurement of medical evidence has involved

multiple, often repetitive, requests for information from a variety of

health care providers. Health care providers believe that these

requests burden them with far too much paperwork and offer far too

little in the way of compensation for the time invested. Conversely,

adjudicators often find that this evidence is primarily treatment-

oriented and fails to provide the highly specialized clinical

information required by the current Listings, or the functional

information that is frequently necessary at various points in

disability decision-making process. Health care professionals,

particularly physicians, readily concede that their training is

oriented towards diagnosis and treatment, not the assessment of

function. Thus, the timely collection of medical information depends to

a significant degree on health care providers who have only a

tangential interest and understanding of the disability program, its

requirements, and, most importantly, the vital role that health care

providers' information has in the disability decision process.

Evidence Collection Will Focus on Core Diagnostic and Functional

Information Necessary to a Disability Decision

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 SSA will

use 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. SSA will develop medical evidence that is sufficient to

satisfy the core elements but target evidentiary development so that

SSA obtains only the evidence that is necessary to reach an accurate

decision on the ultimate question of disability.

Treating Sources Will be the Preferred Sources for Medical Evidence

SSA will give primary emphasis to obtaining medical information

from treating sources by way of 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. SSA will develop, in

conjunction with the appropriate health care professionals and other

public and private disability programs, standardized criteria which can

be used to measure, as accurately and objectively as possible, an

individual's functional ability. SSA will also seek health care

providers' assistance in educating the medical community on the

clinical application of these instruments. Once developed and

universally accepted as the appropriate standard by the medical

community, the standardized measurement criteria will be widely

available. If a standardized functional assessment is available from a

treating source, SSA will obtain that information and accept it as

probative evidence. SSA may also request that the treating source or

another examining source perform the standardized functional assessment

at SSA expense.

SSA Will Use a Standardized Form To Request Medical Evidence From

Treating Sources

SSA will develop a standardized form which effectively tailors the

request for evidence to the specific diagnostic and functional

assessment information necessary to make a disability decision. The

standard form will also be available in electronic form to permit

treating sources to submit evidence 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 on a single document.

In appropriate circumstances, SSA will accept a treating source's

statement on the standardized form as to these issues without resorting

to the traditional, wholesale procurement of actual medical records.

Depending on the nature and extent of an individual's impairments and

treating sources, statements from multiple medical sources may be

appropriate. In completing standard 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 is

consistent with evidence collection methods used by private disability

insurance carriers, which request specific medical records in

individual claims, as appropriate to the individual circumstances, or

at random as part of a quality assurance program. SSA will monitor

treating source completion of the standardized forms and verify

evidence when appropriate.

SSA Will Provide Incentives for Treating Sources To Cooperate in the

Development of Medical Evidence

SSA will acknowledge the value of treating source information by

establishing a national fee reimbursement schedule for medical

evidence. Additionally, the fee reimbursement schedule will utilize a

sliding-scale mechanism to reward the early submission of medical

information. 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 focus professional educational efforts and medical

relations outreach at the local and/or regional level to ensure that

treating sources are kept informed of program requirements and made

aware of specific evidentiary needs or problems as they arise in the

adjudication process.

SSA Will Use Consultative Examinations When There is No Treating Source

Able or Willing To Provide Necessary Evidence or There Are Unresolved

Conflicts in the Record

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, SSA 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, both initially and as

program changes occur.

Administrative Appeals Process

The Administrative Appeals Process Will Be Simple and Accessible and

Maintain Public Confidence in the Integrity of the Process

The administrative appeals process will be simplified to increase

the accessibility of the process. The public perceives multiple,

mandatory appeal steps as 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

in this manner will not only promote more timely decisions but also

ensure that claimants do not inappropriately withdraw from the claims

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 function so that it

maintains the public's 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, SSA will explain the basis

of a decision in clear and understandable language. Finally, SSA will

ensure that disability claims are decided on the merits of the evidence

and that SSA regulations and 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 during the predenial interview,

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 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.

The Next Level of Administrative Appeal Will Be an Administrative Law

Judge Hearing

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 administrative law judge

(ALJ) hearing. If the claimant disagrees with the initial

determination, the claimant may, within 60 days of receiving notice,

request an ALJ hearing.

An Adjudication Officer Will Conduct All Prehearing Proceedings

If a claimant decides to request 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 and appeals procedures. The adjudication officer will be the

focal point for all prehearing activities but will be expected to work

closely with the ALJ, medical consultants and the disability claim

manager, when appropriate. The adjudication officer will explain the

hearing process; advise the claimant regarding the right to

representation; 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 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. 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, as appropriate. The adjudication officer

will have full authority to issue a revised favorable decision if the

evidence so warrants. If the adjudication officer issues a favorable

decision, the adjudication officer will refer the claim back to the

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 set a date for the hearing that is 45 days after the

hearing request. The adjudication officer may exercise discretion in

establishing an earlier or later hearing date depending on the

individual circumstances. Electronic access to ALJs' calendars will

facilitate timely 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. ALJs'

primary function will be hearing and deciding claims.

The Administrative Law Judge Hearing Will be a De Novo, Nonadversarial

Proceeding

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 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 review by the agency, thus giving the agency

full power 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, an attorney. 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

claimant's interests, particularly when the claimant is unrepresented.

However, an improved initial determination process with its focus on

early and comprehensive evidentiary development, predenial personal

conferences, 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 appropriate), from SSA personnel.

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 back to the

disability claim manager to effectuate payment.

The Administrative Law Judge Decision Will Be the Final Decision of the

Secretary Subject to Judicial Review Unless the Appeals Council Reviews

the Administrative Law Judge Decision On Its Own Motion

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 decides to review 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.

Favorable Appeals Council decisions will be returned to the disability

claim manager to effectuate payment.

Additionally, the Appeals Council will have a role in a

comprehensive quality assurance system. As part of this system which is

described in greater detail below, the Appeals Council will also

conduct its own motion reviews of ALJ decisions (both allowances and

denials) 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. The Appeals Council's review will

be limited to the record that was before the ALJ.

Quality Assurance

Quality Assurance Will be a System of Agency Accountability

SSA will be accountable to the public, the ultimate judge of the

quality of SSA service, and SSA 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. SSA will devote

resources to building quality into the system of adjudication to ensure

that the right decision is made the first time. SSA will also

systematically review the quality of the overall system of adjudication

to ensure the integrity of the administrative process and promote

uniform application of agencies policies nationally. Finally, SSA will

measure customer satisfaction against the SSA standards for service.

Ensuring That the Right Decision is Made the First Time Requires an

Investment in Employees

SSA's ability to ensure that the right decision is made the first

time depends on a well-trained, competent, 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 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.

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. Employees will be

encouraged to provide feedback on the value of these continuing

education opportunities, including the quality of training materials,

methods, and instructors.

Employees, other than ALJs (because of Administrative Procedure Act

limitations), who complete initial training and pass a set of

performance evaluations based on national quality standards will

receive a certificate of competence. This certificate will attest that

the employee has successfully completed both initial training and a

probationary period on the job. Certification will be renewed yearly

upon successfully completing required training and having no less than

a fully satisfactory performance rating. Those employees not certified

initially or renewed will be provided an improvement plan with goals

and time targets for improved performance.

In addition to formal program training, SSA will rely on a

streamlined and targeted system of in-line quality reviews and

monitoring of adjudicative practices. The elements include a mentoring

process for new employees and peer review for experienced employees.

SSA will encourage peers to discuss difficult claims or issues and

resolve them informally whenever possible. 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. As part of this process, 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.

To ensure that adjudicators have the necessary program tools to

issue accurate decisions, SSA will use a single mechanism for the

presentation of all substantive policies used in determining

eligibility for benefits. Additionally, an integrated claims processing

system will provide the necessary technological support for

adjudicators at all levels of the administrative process. Among other

things, the claim processing system will facilitate the preparation of

accurate decisions by providing on-line editing capacity to identify

errors in advance and decision support software to assist in analysis

and decisionmaking.

Although 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 still monitor quality on a systematic,

national basis. Accordingly, all employees will be subject to and

receive continuous feedback from comprehensive end-of-line reviews as

described in the following section.

Quality Measurement Will Focus on Comprehensive End-of-Line Reviews

Another 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. This system will include

comprehensive review of the whole adjudicatory process including both

disability and nondisability issues, allowances and denials, and at all

levels of decisionmaking. The review will focus on whether accurate

decisions were made at the first possible step 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. Reliance on an integrated claim processing system will

facilitate the selection of a statistically valid sample of claims for

this review.

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.

SSA Will Conduct Surveys to Measure Customer Satisfaction

To measure whether SSA has met or exceeded the public's service

expectations, SSA must measure their level of satisfaction with the

level of service SSA provides. Customer surveys 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

SSA Will Measure Disability Service From the Perspective of the

Claimant

SSA's management information 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.

New Process Enablers

Reengineering is dependent upon 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 determination

process.

Process Unification

Under the Social Security Act, the Secretary has been granted broad

authority to promulgate regulations to govern the disability

determination process. In addition to the regulations, SSA publishes

Social Security Rulings and Acquiescence Rulings. Social Security

Rulings are precedential court decisions, policy statements, and policy

interpretations that SSA has adopted as binding policy. Acquiescence

Rulings 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.

These source documents provide the basic framework for the policies

that regulate eligibility for benefits. Administrative law judges (ALJ)

and the Appeals Council use these source documents in making disability

decisions. However, they are not directly used by decisionmakers at the

first two levels of the process, i.e., initial and reconsideration

determinations. Guidance for these decisionmakers is provided in a

series of administrative publications specifically designed for and

aimed at the audiences responsible for adjudicating these claims.

The Program Operations Manual System instructions provide the

substance of law, regulations, and rulings for adjudication issues in a

structure format that does not necessarily repeat the wording of the

source documents for field offices, State disability determination

services (DDS), the processing centers, and quality assurance

reviewers. The Program Operations Manual System is supplemented by

other administrative issuances to clarify or elaborate specific policy

issues. The Program Operations Manual System also provides basic

operating instructions to the initial, reconsideration and quality

components responsible for processing claims. The Hearings, Appeals,

and Litigation Law Manual provides operating instructions and summaries

of court decisions to hearing offices and the Appeals Council.

Neither the Program Operations Manual System or the Hearings,

Appeals, and Litigation Law Manual is binding on ALJ decisionmaking

because this material is not considered Agency policy under the

Administrative Procedures Act. Only those regulations and

interpretative rulings published in the Federal Register, in accordance

with the Administrative Procedures Act guidelines, can be binding on

ALJs. Other decisionmakers are bound by interpretative guidance in the

Program Operations Manual System and supplemental issuances. This

situation fosters the perception that different policy standards are

used at different levels of decisionmaking in the claims process.

SSA will develop a single presentation of all substantive policies

used in the determination of eligibility for benefits. All

decisionmakers will be bound by these same policies. These policies

will be published in accordance with the Administrative Procedures Act.

In addition, to facilitate the flow of work in the new process, a

single operating manual will be developed.

Public and Professional Education

Public and professional education is essential for the proper

understanding of and participation in the disability claims process.

The goal is to ensure that those individuals and 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.

SSA will make information widely available for the general

population. Pamphlets, factsheets, posters, videos, information on

diskettes and on computer bulletin board systems will be developed.

This information will be written in a simple, straight forward and

understandable manner. It will be available in many languages and

dialects and will accommodate vision and hearing impaired individuals.

Videotapes will be available to show in SSA offices, welfare offices

and in places where medical care is provided. It will explain the

definition of disability, stressing the durational and level-of-

severity requirements while giving real life examples. Insured status

requirements for SSA disability insurance (DI) and income and resource

limitations for supplemental security income (SSI) will be explained in

general terms.

This same information will be distributed to third parties who may

be referral sources for disability claims. It will serve to provide

them with basic information about medical and nonmedical eligibility

criteria and the options available for filing claims.

SSA will work with nationally and locally interested and involved

groups to develop direct lines of communications about the disability

process and program. These efforts will not be limited to providing

information, but will include opening and maintaining a dialogue about

the disability process as part of an ongoing organizational

relationship.

Professionals who work with the disabled population will require

more detail. The current ``Understanding SSI'' booklet will be enhanced

to include more information on the disability aspects of the SSI

program--including the requirements and process, as well as the options

available to claimants or interested third parties to speed up the

process. A similar booklet for the DI program will be developed. These

booklets will serve as training manuals and reference tools, and will

include information and examples about providing functional

assessments. Special efforts will be made to have coverage of these

booklets included in courses which are part of a social service

delivery curriculum at the post-secondary and graduate levels.

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.

Treating physicians, medical providers and other treating

professionals need up-to-date information on medical evidence

requirements. SSA will 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.

Claimant Partnership

As part of their partnership with SSA, claimants will be encouraged

to actively participate at all levels of the adjudication process and

will be fully informed of their rights and responsibilities. SSA's

interaction with claimants will facilitate claimant responsibility and

active participation in the processing of their claims. The resources

of interested and capable third parties will be garnered to assist

claimants and SSA in fulfilling their partnership responsibilities.

The majority of claimants are able to complete simple forms, attend

appointments, and obtain medical and nonmedical documentation, either

on their own or with the assistance of third parties. Other claimants

are unable to accomplish some of these tasks, even with the assistance

of third parties. Still others have substantial difficulty fulfilling

any of these tasks, 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.

What SSA Will Do

SSA's interaction with claimants will focus on enabling their

participation in the process. Understandable public information

materials and application packets will be widely available.

Explanations of the program, the process, and claimant responsibilities

will be furnished at the point individuals first make contact with SSA.

SSA will also work with third parties, such as family members and

community-based organizations, to provide additional claimant support.

In addition, SSA will provide ongoing assistance and appropriate

status information throughout the process. The opportunity for personal

contact with the disability claim manager will be afforded to each

claimant prior to the issuance of an initially unfavorable decision. A

claimant will be advised of evidence that has been considered in making

the disability determination and provided an opportunity to present

additional evidence for consideration.

Claimants will be provided the opportunity to fully participate in

the appeals process. Decision rationales, appeal rights, and

representation rights will be explained in clear, understandable

language.

What Claimants Will Do

Early, ongoing dialogue between claimants and SSA will ensure that

claimants have access to information and resources they need to

actively pursue their claims and make informed choices.

Claimants will be asked to do more to facilitate development of

supporting information when they are able, particularly with respect to

medical evidence. When they file for disability benefits, claimants

having had medical treatment will be asked to request that their

treating sources complete standardized forms. Information about this

requirement will be publicized in the general community and given to

claimants and third parties when they first contact SSA. Third parties

will be encouraged to assist claimants who are unable to fulfill this

obligation on their own. However, when necessary, a disability claim

manager will assist claimants in obtaining 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 develop fax, E-mail, and other electronic means

for physicians to provide direct certification information.

There will be situations where claimants have no treating sources,

or where treating sources provide insufficient medical evidence to make

a disability determination. SSA will work with willing treating sources

and other medical providers to assist in developing medical evidence

(including testing and examination) in these circumstances.

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.

Claimants will be able to fully participate in the appeals process

with or without a representative. During the appeal process, claimants

and/or their representatives will have primary responsibility for

compiling an evidentiary record. SSA will provide appropriate

assistance for unrepresented claimants.

Assistance to Claimants

Many claimants today rely on other individuals; private and public

organizations; and for-profit and nonprofit organizations to pursue

their claims. Although they assist claimants, these individuals and

organizations do not serve as official representatives. In most

instances, those who assist in the process have the best interests of

the claimant in mind. However, some individuals and organizations have

been instrumental in attempts to defraud programs or take unfair

advantage of claimants. In the future, 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. This

would include a combination of volunteer services and reimbursement for

transportation on a contract basis. These services will be immediately

available as the need dictates.

--Enhancement of medical provider capacity to identify potentially

eligible patients, secure claims and provide medical evidence. This

type of activity has been successfully demonstrated through the use of

seed monies from SSA in the SSI outreach program. An additional

financial benefit to the providers will be realized through concurrent

Medicaid eligibility for patients.

--Software with compatible format design which will allow direct input

of claims-related information to SSA. This will be available to

claimant advocates and medical providers ensuring the rapid and

accurate transmission of information. After a certification process,

eligible users will be kept apprised of software, procedural, and

policy changes. SSA will perform ongoing document verification to

ensure the integrity of claims submitted by such users.

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. While eligibility requirements vary significantly for

programs such as Food Stamps, Aid to Families with Dependent Children,

General Assistance, foster care and adoption assistance, and Veterans

Benefits, effective working relationships can be built around

agreements that expand sharing of authorized information and awareness

of program requirements.

Other programs will be able to use SSA-developed decisional support

systems to evaluate potentially eligible persons prior to referral.

This information will be transferred to SSA through compatible

databases. To further enhance these relationships, disability claim

managers will be available in remote locations, such as Department of

Veterans Affairs homeless program sites, where the workload warrants

their presence. With appropriate information available at these sites,

the on-site disability claim manager will be able to complete the

entire initial application process, with access to other program

experts through information systems. Local managers will be encouraged

to develop and maintain appropriate working relationships with local

Federal, State and third-party resources.

The Payoff Will be Greater Customer Satisfaction

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

The teamwork concept is a fundamental ingredient in the new

process. 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 administrative

law judge (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. Everyone will achieve a greater sense of

participation, closure, and accomplishment because of shared

responsibility for performing the whole process. Team members will

maintain ownership of the process and the outcomes. The teams will

function effectively and efficiently because:

--All members will have electronic access to the claim throughout the

process and thus be better able to engage in meaningful discussions

with the claimant.

--Handoffs, rework, and non-value steps will be significantly reduced

and fewer employees will be involved in shepherding each claim through

the process. This will enhance SSA's capacity to provide world-class

service by allowing employees to devote more time to each claimant,

providing more personalized service.

--Team members will be knowledgeable but will also be able to draw upon

each other's expertise on complex issues.

--Improved automated systems will enable members of the team to work

together using a shared data base even when they are not co-located.

--Communication between team members and other disability claim

managers will encourage consistent application of disability policy.

--Customer service is the primary focus at all steps of the process and

an integral part of the teams' goals. This focus and commitment will

increase claimant satisfaction.

--Team members will work closely with social service and medical/

professional agencies and advocacy groups in the service area to

improve their ability to obtain the necessary medical and functional

information to appropriately evaluate disabling conditions.

--Varying levels of job complexity will provide the opportunity for

personal development, growth, and learning.

Disability Claim Managers

Disability claim managers will be responsible for intake of DI and

SSI disability/blindness benefit claims, development of all evidence

(medical and nonmedical) required to adjudicate those claims, final

adjudication of claims, ongoing communication with claimants, and

issuance of notices and/or payment actions. In carrying out these

responsibilities, disability claim managers will work in a team

environment with medical and nonmedical experts who provide advice and

assistance with complex case adjudication, as well as support personnel

who handle more routine aspects of case development and payment

effectuation. Tasks will be facilitated by a fully automated intake

process, developmental and decisional expert system applications,

personalized automated notices, and automated payment computations.

Disability claim managers will be able to:

--Provide claimants with current and accurate information about their

claims;

--Anticipate documentation needs and eliminate development that is not

necessary in favorable determinations;

--Eliminate time lost and rework caused by frequent handoffs and

queues;

--Access expert advice through shared databases, thus eliminating the

need to transfer files;

--Provide claimants with complete information if their claims are

proposed for denial and enhance claimants' ability to rebut such

outcomes easily and early in the process; and

--Effectuate payment quickly, thus avoiding the need for recontacts and

verification of nondisability factors of eligibility.

Adjudication Officers

Adjudication officers will be responsible for claims from the point

of receiving hearing requests until they are ready to be heard by ALJs.

In carrying out their responsibilities, adjudication officers will work

in a team environment with medical and nonmedical experts, requesting

advice and counsel from ALJs as necessary.

Adjudication officers will be able to:

--Address the claimants' questions and concerns regarding their claims;

--Identify and discuss issues in dispute with claimants and determine

the need for additional evidence. If the claimant is represented,

conduct personal conferences with the representative and prepare

written stipulations as to those issues not in dispute;

--Review claim records prior to hearings and issue revised decisions if

additional information or evidence so warrants or refer claims for

medical consultation; and

--Take responsibility for all evidentiary development and refer

prepared records to the ALJs.

Administrative Law Judges

Administrative law judges (ALJ) will be responsible for hearing and

deciding appeals. ALJs will receive support from technical and medical

personnel, including decision writers. ALJs will also work with

adjudication officers and disability claim managers as necessary.

ALJs will be able to:

--Review and focus on fully developed claims records prior to hearings;

--Deal with claimants who have already made informed decisions

regarding representation before they appear at hearings; and

--In most circumstances, close the record at the conclusion of

hearings, deliberate on issues and render prompt decisions.

BILLING CODE 4190-29-P

TN15AP94.022

BILLING CODE 4190-29-C

Workforce Enrichment/Empowerment

The work in the new process will raise job satisfaction and

increase employee skills in the following way:

Employees involved with the initial level of claims will perform

multiple tasks instead of singular activities, thus their roles will

expand to encompass more of the ``whole'' job. This increases the sense

of accomplishment as employees experience the direct relationship

between their actions and the final product. Those at the prehearing

step will also be able to do more of the ``whole'' job, including

taking action to allow claims much earlier in the process. For medical

consultants and ALJs, tasks will be eliminated that are not

commensurate with professional skill levels. Employees will feel more

of a sense of ownership for the services they perform as a member of a

team focused on serving claimants.

Entry level positions will be developed in which employees work as

part of the team while gaining experience and qualifying for greater

responsibility. Adequate resources and sufficient training and

mentoring will allow them to acquire the skills they need to process

the claim from intake through adjudication rather than guessing what

someone else needs or using the current all-encompassing approach to

information gathering.

The new process will rely heavily on increased employee empowerment

applying information technology and 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: Fees, New Rules and Standards of Conduct

The Social Security Act and implementing 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 in the pursuit of their claims. Since the

inception of the disability program, representatives have played a

significant role in the disability process. The rate of representation

in SSA disability claims has risen from approximately 55% in fiscal

year (FY) 1982 to 75% in FY 1993. 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. While the rate of representation has risen,

so too has the average fee for representation. The average fee received

by representatives has jumped from approximately $1,500 in FY 1987 to

$2,500 in FY 1993, further adding to the dismay of claimants. As more

claimants seek representation and fees continue to climb, SSA has a

heightened responsibility to monitor representational activity and to

safeguard the interests of claimants. The proposed process will utilize

new rules of representation and standards of conduct to ensure that

representatives, as key players in the disability process, fulfill

their responsibilities and adequately serve the needs of the claimants

they represent.

Under the present statutory and regulatory scheme, representatives

are not permitted to charge and collect a fee in any case without first

obtaining the approval of the Secretary. There are two distinct

procedures available to representatives for obtaining fee approval. The

``fee petition'' method requires the representative to itemize the

services rendered and the time expended. The Secretary must evaluate

each individual petition and determine the reasonable fee, considering

such factors as case complexity, time expended, skills needed, and the

results obtained. There is no maximum fee set by law for this

procedure.

The second method, commonly referred to as the ``fee agreement

procedure'', involves an agreement between the claimant and the

representative whereby the fee is agreed to be no more than 25% of the

retroactive benefits due, or $4,000, whichever is less. The agreement

must be executed and submitted to the Secretary prior to the

determination of the claim. While there is a maximum fee under this

procedure, the Secretary does not have to conduct an individual

evaluation of the reasonableness of the fee unless either the claimant,

the representative, or the administrative law judge (ALJ) files a

protest of the fee. The fee may be reduced by the Secretary only on the

basis of evidence of the failure of the representative to adequately

represent the interests of the claimant or on the basis of evidence

that the fee is clearly excessive for the services rendered. Under

limited circumstances, the representative may ask the Secretary to

increase the fee.

In addition to approving all fees under both DI and SSI of the

Social Security Act, there are withholding and direct payment of fee

provisions that apply only to DI claims where an attorney is involved.

Specifically, the Secretary must withhold and pay to the attorney the

lesser of (1) 25% of the retroactive benefits due the claimant, or (2)

the fee approved by the Secretary under either the fee petition or fee

agreement procedures. The intent of this procedure is to provide an

incentive for attorneys to accept Social Security claims work in order

to increase claimant access to attorneys. In FY 1993, SSA paid nearly

$300 million in fees to attorneys out of claimants' retroactive DI

benefits. This withholding and payment provision does not apply to SSI

claims because Congress did not find it appropriate to reduce a

claimant's benefits in order to pay an attorney in a means-test

program. However, even though SSA does not withhold and pay attorneys

fees in these cases, it is estimated that SSI claimants paid over $133

million in fees to their representatives in FY 1992. Thus, the total

cost to claimants for representation in 1993 approached the $500

million mark.

Since the inception of the fee agreement procedure in 1991, fee

agreements have been rapidly replacing fee petitions as the vehicle for

procuring agency approval of fees. SSA received 52,297 fee agreements

in FY 1992, representing 39% of all fee approval requests. In FY 1993,

fee agreements jumped to 87,395, accounting for 63% of all fee approval

requests. Fees are generally higher under the fee agreement procedure,

averaging $2,800 in FY 1993 as compared to an average fee of $2,200 for

fee petitions. One of the factors causing higher fees under the fee

agreement procedure is the lengthy processing time for disability

claims; the longer it takes to issue a decision, the greater the

retroactive benefits due the claimant. Under the fee agreement

procedure, the fee is based on the amount of retroactive benefits due,

and there may be little or no correlation to the time expended by the

representative or the skills involved in rendering representational

services. By eliminating fragmentation and handoffs, the proposed

process will significantly reduce processing time. SSA will issue

decisions faster, the amount of resulting retroactive benefits will be

reduced, and resulting fees will likewise be reduced.

However, as the fee agreement procedure continues to claim an ever-

increasing share of the total number of fee requests filed each year,

more and more fees will be based upon a predetermined, mathematical

formula rather than by an independent evaluation of the quality of

services rendered. In order to maintain the emphasis on quality in

representational matters, the proposed process will adopt new

representation rules and standards of conduct to effectively safeguard

the rights and interests of claimants. These new regulations will:

--Establish qualifications for representatives, attorneys and non-

attorneys, to ensure that claimants receive competent representation;

--Define the duties and responsibilities of representatives, including

the duty to fully develop the record in a timely manner and to respond

to requests to submit evidence;

--Establish a code of professional conduct for representatives in all

matters before SSA, including conduct at prehearing conferences,

hearings, and interaction with SSA employees and claimants generally;

--Provide a forum for claimants to air their grievances and file

charges against representatives for failure to provide adequate

representation or otherwise violating the rules of representation and

standards of conduct;

--Provide meaningful sanctions against representatives, including

suspension and disqualification from appearing before the agency in a

representative capacity, for violating any of the provisions contained

in 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 personal choice. In addition, the proposed process will

reduce the trend of inflationary fees by eliminating the artificially

high retroactive benefits that result from excessively long processing

times. Finally, while current statutes and regulations attempt to

protect claimants from fee abuses, they fall short of extending to

claimants the assurances which they need most: that the representatives

they 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. The new rules and standards of conduct provide the framework for

these assurances.

Information Technology

Information technology will be a vital element in the redesign of

the 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. Existing Agency design plans for Intelligent

Workstation/Local Area Network (IWS/LAN) and a Modernized Disability

System are critical enablers for successful implementation of the

proposed process redesign. Reengineering of the disability process is

on the critical path of the design and development of the Modernized

Disability System and implementation of IWS/LAN.

The Modernized Disability System and IWS/LAN will provide an

integrated system to support the entire reengineered disability

process. This system will provide electronic connectivity throughout

the process. Current SSA systems that support disability processing

operate independently of each other. Field offices, DDSs and hearing

offices all have their own systems. The DDSs have their own baseline

automation systems, but for the most part can only use the systems

within the particular State on that State's machines. Likewise, hearing

offices have a disability processing system that applies only to claim

processing inside the hearings and appeals organization. Each

organization independently inputs claim information into their systems

and no automated information can be passed outside the organization for

subsequent, much less parallel, claim processing.

The reengineered process relies on the ability to build a single

electronic claim record as it goes from point to point in the

disability process. This includes the ability for any facility to

process the medical and nonmedical segments of claims for another

facility. This is the primary benefit of the IWS/LAN and Modernized

Disability System architectures. Both architectures are a prerequisite

for enabling reengineering of the entire disability process.

The Enabling Platform

The IWS/LAN architecture and Modernized Disability System design

will support a major objective of the redesigned disability process-

seamless, reengineered electronic processing of disability claims from

the first contact with the claimant to the final decision, including

all levels of administrative appeal. All employees will use the same

hardware, the same claim assignment and scheduling software, the same

claim processing 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. Therefore, data will need to be input and

validated one time only, leading to more consistent decisions in

establishing both the medical and nonmedical aspects of DI and SSI

claims. All employees will also have access to decision support systems

for those complex entitlement decisions. Since all facilities will be

able to access the same record, all SSA representatives will be able to

respond to inquiries from the same base of information. This will

produce more consistent and accurate Agency responses to inquiries.

SSA will continue to move aggressively toward the goal for complete

electronic, paperless processing with all aspects of the claims

process. Key tenants of reengineered electronic, paperless processing

will be encouraging electronic information exchanges with medical

evidence providers--and then keeping information received

electronically in that same (or a similar) digitized format for claim

processing, use of cost effective scanning/imaging of decision

supporting paper records, abstraction and/or summarization of key,

paper-based information by employees via direct keying, and finally,

dire

This text is long and has been trimmed here. Open the source document for the complete record.