About a week ago the following news report out of Buffalo, New York indicated that consultative exams (CEs) would be postponed due the dangers of the Coronavirus outbreak, and now, Social Security has seemingly placed all of these exams on hold nationwide.
Social Security uses CEs for medical evidence in determining whether a disability claimant meets the rules to qualify for disability benefits. If there is not enough evidence available to make a disability determination the claimant is sent to an independent exam, but obviously during the outbreak of a pandemic, these exams, and the risks associated with the spread of the virus, the practice of these exams have become too dangerous. Below are Social Security’s guidelines for CEs when they are allowed to continue.
Consultative Examination Guidelines
If the evidence provided by the claimant’s own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by re-contacting the treating source for additional information or clarification, or by arranging for a CE.
The treating source is the preferred source of purchased examinations when the treating source is qualified, equipped and willing to perform the additional examination or tests for the fee schedule payment and generally furnishes complete and timely reports. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:
- The treating source prefers not to perform the examination;
- There are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source;
- The claimant prefers another source and has a good reason for doing so; or
- Prior experience indicates that the treating source may not be a productive source.
The type of examination and/or test (s) purchased depends upon the specific additional evidence needed for adjudication. If an ancillary test (e.g., X-ray, PFS or EKG) will furnish the additional evidence needed for adjudication, the DDS will not request or authorize a more comprehensive examination. If the examination indicates that additional testing may be warranted, the medical source must contact the DDS for approval before performing such testing.
Fees for CEs are set by each State and may vary from State to State. Each State agency is responsible for comprehensive oversight management of its CE program.
The practice of suspending CEs it the right move by Social Security to fight the spread of the Coronavirus, but it does not come without drawbacks. If CEs are put on hold Social Security may determine cases without evidence from these exams, which most definitely will result in medical denials on these claims. If Social Security puts all of these decisions on hold until a CE can be rescheduled will delay decisions for claimants for many months when some of these claimants would have been approved and entitled to benefits, so there are no easy solutions to the problem.
