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COLORADO DISABILITY DETERMINATION SERVICESCOLORADO DEFENSE LAWYERS ASSOCIATION

JULY 2014

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COMMON GROUND?

TOPICS TODAY

Disability Determination Services (DDS) Overview

DDS Metrics

The Disability Determination Process

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THE COLORADO DDS

• We make medical disability determinations on behalf of Colorado applicants applying for SSA disability programs.

• 100% federally funded by SSA.

• Types of disability claims worked: • Initial applications for Adult and Child claims• Continuing Disability Review (CDR) Claims

• SSA disability is subject to stringent medical and policy standards . . . A physician-signed med-9 is insufficient.

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THE COLORADO DDS

• A complex federal program: 18-24 months of disability examiner training for complete proficiency• Knowledge of physical and mental impairments related to 12

body systems• Application of 404 medical and vocational decision rules• Navigation of 66 DDS program policies• Mastery of four software applications

• High expectations: The average examiner decides 500 cases and reviews 125,000 pages of medical records per year.

• Significant resources = significant output:• $20.8M budget• 132 FTE approved• 35K cases closed

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Musculoskeletal Mental Malignant

Neoplastic Special Senses Neurological Digestive Respiratory Genitourinary Immune System Hematological Skin Endocrine

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REAL ACCOUNTABILITY!

Federal: Performance to the annual operating plan

State: Performance to operating metrics

Reference DataOffice of Community

Access and IndependenceDisability Determination Services5/8/2014 7 Internal Working Document

Number of Initial Cases Pending (2013/2014)

Oct 2012

Nov

Dec

Jan 2013

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Jan 2014

Feb

Mar

10000

11000

12000

13000

14000

15000

16000

10445

5/8/2014 8

Office of CommunityAccess and Independence

Disability Determination ServicesInternal Working Document

Mean Number of Days to Process Initial Eligibility Decisions

Description of Trend: Performance on this measure continued to improve from the previous month, with current performance at 126.5 days.

Numerator: # of Days to Process Initial Eligibility DecisionsDenominator: # of Initial Applications Processed; Current Monthly Denominator = 3,485

Jan Feb Mar AprMay Jun Jul

AugSep Oct Nov

Dec40

60

80

100

120

140

160

143.3138.4

126.5

CO 2013 CO 2014 US 2013 US 2014 CFR Goal (49.5 Days) OP Goal (115 Days)

Month

Days

5/8/2014 9

Office of CommunityAccess and Independence

Disability Determination ServicesInternal Working Document

Examiner Processing TimeDescription of Trend: Performance has improved since Sep. 2013, with current EPT at 42.8 days.

Numerator: # of Days (from Assign Date to Clearance Date) to Close Disability ClaimsDenominator: # of Disability Claims Closed; Current Monthly Denominator = 3,220

Jan Feb Mar AprMay Jun Jul

AugSep Oct Nov

Dec35

45

55

65

43.8 43.5 42.8

2013 2014 Goal (44.0 Days)

Month

Days

5/8/2014 10

Office of CommunityAccess and Independence

Disability Determination ServicesInternal Working Document

Percentage of Accurate Initial Eligibility Decisions

Description of Trend: Data is based on a rolling 3-month average due to low N size. Performance declined slightly from the previous rolling quarter, with current performance above the goal at 97.6%.

Numerator: # of Accurate Initial Eligibility DecisionsDenominator: # of Initial Eligibility Decisions Sampled by SSA-DQB; Current Quarterly Denominator = 142

1-3/2013

2-4/2013

3-5/2013

4-6/2013

5-7/2013

6-8/2013

7-9/2013

8-10/2013

9-11/2013

10-12/2013

11/13-1/14

12/13-2/14

1-3/201492%

94%

96%

98%

100%

97.6%

CO US Goal (97%)

Rolling Quarters

Perc

ent

DEFINITION OF DISABILITY

The inability to perform any substantial gainful activity . . .

due to a medically determinable physical or mental impairment . . .

which can be expected to result in death or to last for a continuous period of not less than 12 months.

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SSA FIELD OFFICE:APPLICATION

DDS: CASE

DEVELOPMENT

DDS:DISABILITY

DETERMINATION

DDS:CASE

STAGING

SSA FIELD OFFICE:

CASE CLOSED

A PROCESS VIEW FROM 50,000 FEET . . .

1. The process begins and ends at a Social Security Field Office (FO):

a) Takes disability applications and makes financial eligibility decisions

b) Receives DDS medical determinations, makes final decisions and communications

2. In between, the DDS:a) Holds (stages) claims until examiner resources are availableb) Gathers required information (develops) claimsc) Makes the medical disability determinationd) . . . And may fast track special profile cases through the system

CASE DEVELOPMENT . . . INFORMATION REQUESTED

Records from doctors & hospitals

Detailed 15-year work history from claimant

Questionnaires from sources provided by claimants, who know their condition & daily activities.

Comments and questionnaires from the claimant regarding activities, pain, headaches, seizures when alleged

Records and questionnaires from schools 13

SSA FIELD OFFICE:APPLICATION

DDS: CASE

DEVELOPMENT

DDS:DISABILITY

DETERMINATION

DDS:CASE

STAGING

SSA FIELD OFFICE:

CASE CLOSED

DISABILITY DETERMINATION

Records are received and the case is assigned to a disability examiner

The examiner reviews the medical and vocational information against SSA disability parameters

If sufficient information, the examiner may prepare a medical determination

If insufficient information, the examiner may: Call claimant for clarification or additional information Schedule an independent consultative examination Request a Medical Consultant review

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SSA FIELD OFFICE:APPLICATION

DDS: CASE

DEVELOPMENT

DDS:DISABILITY

DETERMINATION

DDS:CASE

STAGING

SSA FIELD OFFICE:

CASE CLOSED

THE MEDICAL CONSULTANT REVIEW*

Reviews records and claimant statements in an electronic or paper file

Reviews questionnaires completed by claimant and other sources

May request a consultative examination or additional medical records

* Medical consultants are independent contractors located at DDS15

THE MEDICAL DECISION PROCESS

Medical determinations generally require review and signature by an appropriate medical or psychological doctor

However . . . In Colorado (and eleven other states), some disability allowance claims for adults may be decided by a Single Decision Maker (SDM). . . A highly qualified examiner

If not an SDM case, the claim goes for review by a DDS Medical Consultant, an Independent Contractor

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MEDICAL DECISIONS . . . Deny a non-severe impairment

If severe, determine if the impairment meets or equals an impairment listing or is medical/vocational allowance

Completes Mental and/or Physical Capacity Forms for Medical/Vocational Decision

Age, Education, Work Experience Factored into Decision

Most decisions are team decisions: Independent Contractor Medical Consultant and Disability Claims Examiner

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IF AN INITIAL DECISION IS NOT FULLY FAVORABLE . . . MAY APPEAL WITHIN 60 DAYS OF THE DECISION

Appeal to the Federal Office of Disability Adjudication and Review (ODAR)

Claims are much older by the time ODAR reviews them; age, medical condition and vocational profile may deteriorate

Over 35% of Colorado initial claims are allowed on the first application

Over 70% of claims allowed nationally are allowed at the DDSs, not ODAR

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