Social Security Disability, Chronic Pain, and the Opinions of Doctors

This is about a post on Gordon Gates' blog--he is a social security disability attorney handling cases in Maine and New Hampshire--that I found very interesting.

In his post (DDS and Claims Involving Chronic Pain ), he comments about three disability claims that were denied at the reconsideration level recently. All three claims involved chronic pain and all three had good medical source statements, or RFC forms, supplied by the claimants' treating physicians.

Gates states that there's a disconnect at DDS, the state disability processing agency where disability examiners render determinations on disability cases and he further states that DDS either disregards or improperly interprets a social security regulation and a social security ruling with regard to the weight, or influence, that should be allotted to the opinion of a treating physician, provided that the physician's opinion is not out of line with the medical opinion obtained from the same physician.

Ok, this post really caught my attention. Why? Because people who have first-hand involvement in the social security administration's disability claim process have different viewpoints, insights, and "knowledge wells"--based on their specific experiences which are a function of their specific jobs.

Disability representatives (the non-attorney variety) and disability lawyers see things from the vantage point of individuals who spend their days reading medical records, case files, and going to hearings. Claims reps (the people who do the intake for disability applications at social security field offices) see claimants at the very beginning of the process when they conduct disability interviews and see their files at the relative end of the process when the case has been returned with a medical decision. Examiners, of course, receive social security disability and SSI disability files from claims reps at social security field offices. Examiners are responsible for evaluating medical records and rendering decisions on initial-level claims and reconsideration appeals.

On the subject of how a strong RFC form (that has been obtained from a claimant's treating physician) should be viewed by DDS (disability determination services) and the examiner handling a claimant's case, I agree completely with Gordon.

The opinion of the treating physician, provided that it is consistent with the indications of residual functional capacity in the medical records, should have primacy. After all, the DDS examiner (I used to be one) is not a doctor. And the unit medical consultant (an M.D.) who works in concert with the examiner in processing the disability claim has never met nor treated the claimant.

Yet...it is routine for DDS agencies (there's at least one per state and some decentralized states have several) to discard the valid opinion of a treating physician in favor of the residual functional capacity assessment delivered by the doctor...working at DDS (I'll be quite honest, many of them are absolute hacks--no offense to the good ones).

You have to ask yourself----Why? I believe I know why. And I've been saying it since I originally launched the site, www.disabilitysecrets.com

There is a culture of denial at DDS agencies that exists because unit supervisors (in my old agency, there were more than 25 units of examiners and DDS doctors and there are probably more now) do not like to look bad. How can they look bad? When their agency receives "returns" from something known as DQB or disability quality branch.

It works like this: An examiner decides a case and then the case is intercepted by DQB for a quality review. If DQB decides that the case that was marked for approval should have been a denial, then the case is returned to the DDS from which it came and the supervisor of that unit has a "return".

They don't like returns. They think it makes them look bad. And, to upper management, it does. So, since most cases being returned from DQB are cases that were marked for approval, what effect does this have on the system? The effect is that processing unit supervisors begin to exert influence over the examiners in their units to use a decision policy that favors...making more denials than approvals.

And, in this warped sub-system, DDS agencies have become separate systems unto themselves. It's not surprising, therefore, that the social security reg and the social security ruling to which Gordon Gates is referring is not even a consideration for examiners. Trust me when I say this: disability examiners are generally oblivious to it.

And that's why I also say as well that though RFC forms can handily assist with winning a case at a disability hearing, they may fall on deaf ears at the level of a disability application or disability reconsideration.

The answer to this ridiculous nonsense? Put all DDS agencies under direct federal control. Yes, federalize them and make DDS a part of the social security administration for real.

This won't happen, I suspect, because then the federal government would have to raise the salaries of disability examiners to bring them in line with what the social security field office workers makes (they make quite a bit more). And that won't ever happen, IMO. Not before, and certainly not in today's budget climate.

BTW, hats off to Gordon Gates for gathering RFC forms for his clients at the lower levels. I don't think most disability attorneys do this, perhaps because they see it as non-productive. However, a disability representative who does this is certainly trying hard to win his client's cases as soon as possible, and is clearly working in their best interests. And the sooner a case is won, the sooner a claimant can stop edging toward total financial destruction.






Additional information on Social Security Disability at www.disabilitysecrets.com




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