Close Close

Life Health > Health Insurance > Health Insurance

RAND Analyst: Some SSDI Examiners Are Easy Graders

Your article was successfully shared with the contacts you provided.

Social Security Disability Insurance (SSDI) case outcomes depend heavily on which examiner handles the case, especially at the initial determination level.

Nicole Maestas, an analyst at RAND Corp., Santa Monica, Calif., made that argument today at a hearing on SSDI program claim decisions organized by the House Ways and Means Social Security subcommittee.

The subcommittee has been holding a series of hearings on the SSDI program, which has been plagued by large caseloads, slow case determination times, a high reversal rate at the claim appeal level, and reports of employee burnout.

Private individual and group disability insurance insurers care about the fate of SSDI because many private disability insurers coordinate the benefits they pay with SSDI benefits.

RAND has found that 59% of SSDI applications now come from applicants complaining of musculoskeletal disorders or mental impairments, Maestas said, according to a written version of her remarks posted by the committee.

Even after adjusting for a variety of case characteristics, such as the applicant’s age and type of health problem reported, the standard deviation for examiner case allowance rates is about 6 percentage points, Maestas said.

That means that, for 15% of the examiners, claim approval rates are 6 percentage points higher than for the average examiner.

About 5% of the examiners have approval rates that are more than 12 percentage points higher than for the average examiner.

At the initial determination level, the percentage of applicants who might have received a different result if they had started with a different examiner could be as high as 60%, Maestas said.

Because the Social Security Administration (SSA) gets and responds positively to so many SSDI appeals, the appeals process reduces the power of the “first examiner” effect, but, even after adjusting for the effects of the appeals process, it looks as if 23% of the applicants might have ended up with a different outcome if they had started with a different examiner, Maestas said.

Applicants’ need to go through appeals to reduce the initial-examiner effect is a problem because getting through the appeals process can take as long as two years, Maestas said.

Moreover, about 63% of the applicants with musculoskeletal problems win appeals for benefits, compared with 39% of the beneficiaries with mental impairments. That means beneficiaries with musculoskeletal impairments have to spend more time pursuing benefits than applicants with mental impairments do, Maestas said.

Liza Ekman, a senior policy advisor at Health & Disability Advocates, Chicago, urged Congress to increase the resources SSA has to run the SSDI program and for the SSA to try to improve the claim determination process by providing more training and guidance for the adjudicators who handle the claims.

SSA also should pay the providers who evaluate applicants more, give claimants more help with filing claims, and do more to keep applicants who are very obviously disabled from having to go through the full application process, Ekman said.

SSA Commissioner Michael Astrue testified that the agency is trying to use technology to improvement the efficiency and quality of examiners’ work.

SSA has one national definition of disability, but Congress requires it to use state-based disability determination services to make the determinations, Astrue said.

The state services are trying to increase uniformity by sharing information about decisions on an intranet, and SSA has an Office of Quality Performance that conducts quality assurance reviews of many samples of work, Astrue said.

Between 2007 and 2011, determination services increased their initial claim decision accuracy to 95.5%, from 93.8%, Astrue said.


© 2023 ALM Global, LLC, All Rights Reserved. Request academic re-use from All other uses, submit a request to [email protected]. For more information visit Asset & Logo Licensing.