Nov. 2017 - According to a recent GAO Report, the Social Security Administration (SSA) does not have a formal or systematic approach for designating certain medical conditions for the Compassionate Allowance initiative (CAL). CAL was established in 2008 to fast track claimants through the disability determination process who are likely to be approved because they have certain eligible medical conditions. In lieu of a formal process for identifying conditions for the list of CAL conditions, SSA has in recent years relied on advocates for individuals with certain diseases and disorders to bring conditions to its attention. However, by relying on advocates, SSA may overlook disabling conditions for individuals who have no advocates, potentially resulting in individuals with these conditions not receiving expedited processing. Further, SSA does not have clear, consistent criteria for designating conditions for potential CAL inclusion, which is inconsistent with federal internal control standards. As a result, external stakeholders lack key information about how to recommend conditions for inclusion on the CAL list.
To identify disability claims for expedited CAL processing, SSA primarily relies on software that searches for key words in claims. However, if claimants include incorrect or misspelled information in their claims the software is hindered in its ability to flag all claimants with CAL conditions or may flag claimants for CAL processing that should not be flagged. SSA has guidance for disability determination services (DDS) staff on how to manually correct errors made by the software, but the guidance does not address when such corrections should occur (see figure). Without clear guidance on when to make manual changes, DDS examiners may continue to take actions that are not timely and may hinder expedited processing for appropriate claims, and this can also impact the accurate tracking of CAL claims.
SSA has taken some steps to ensure the accuracy and consistency of decisions on CAL claims, including developing detailed descriptions of CAL conditions, known as impairment summaries. These summaries help examiners make decisions about whether to allow or deny a claim. However, nearly one-third of the summaries are 5 or more years old. Experts and advocates that GAO spoke to suggested that summaries should be updated every 1 to 3 years. This leaves SSA at risk of making disability determinations using medically outdated information. In addition, GAO found that SSA does not leverage data it collects to assess the accuracy and consistency of CAL adjudication decisions. Without regular analyses of available data SSA is missing an opportunity to ensure the accuracy and consistency of CAL decision-making.
Why GAO Did This Study
SSA in October 2008 implemented CAL to fast track individuals with certain conditions through the disability determination process by prioritizing their disability benefit claims. Since then, SSA has expanded its list of CAL conditions from 50 to 225. GAO was asked to review SSA's implementation of CAL.
This report examines the extent to which SSA has procedures for (1) designating CAL conditions, (2) identifying claims for CAL processing, and (3) ensuring the accuracy and consistency of CAL decisions. GAO reviewed relevant federal laws, regulations, and guidance; analyzed SSA data on disability decisions for CAL claims from fiscal years 2009 through 2016 and on CAL claims with manual actions in fiscal year 2016; reviewed a nongeneralizable sample of 74 claim files with fiscal year 2016 initial determinations; and interviewed medical experts, patient advocates, and SSA officials in headquarters and six DDS offices selected for geographic dispersion and varied CAL caseloads.
What GAO Recommends
GAO is making eight recommendations including that SSA develop a process to systematically gather information on potential CAL conditions, communicate criteria for designating CAL conditions, clarify guidance for manual corrections on CAL claims, update CAL impairment summaries, and use available data to ensure accurate, consistent decision-making. SSA agreed with GAO's recommendations.
For more information and to view the Full Report https://www.gao.gov/products/GAO-17-625