COLORADO DISABILITY DETERMINATION SERVICES

1. COLORADODISABILITY DETERMINATION SERVICES Colorado Defense Lawyers Association July 2014

2. COMMON GROUND?

3. Disability Determination Services (DDS) Overview • DDS Metrics • The Disability Determination Process Topics today

4. 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. THE COLORADO DDS

5. 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 THE COLORADO DDS • Musculoskeletal • Mental • Malignant Neoplastic • Special Senses • Neurological • Digestive • Respiratory • Genitourinary • Immune System • Hematological • Skin • Endocrine

6. Real accountability! Federal: Performance to the annual operating plan State: Performance to operating metrics

7. Number of Initial Cases Pending (2013/2014)

8. 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 Decisions Denominator: # of Initial Applications Processed; Current Monthly Denominator = 3,485

9. Examiner Processing Time Description 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 Claims Denominator: # of Disability Claims Closed; Current Monthly Denominator = 3,220

10. 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 Decisions Denominator: # of Initial Eligibility Decisions Sampled by SSA-DQB; Current Quarterly Denominator = 142

11. 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. Definition of Disability

12. A PROCESS VIEW FROM 50,000 FEET . . . • The process begins and ends at a Social Security Field Office (FO): • Takes disability applications and makes financial eligibility decisions • Receives DDS medical determinations, makes final decisions and communications • In between, the DDS: • Holds (stages) claims until examiner resources are available • Gathers required information (develops) claims • Makes the medical disability determination • . . . And may fast track special profile cases through the system

13. 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

14. 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

15. 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 DDS the Medical consultant review*

16. 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 the medical decision process

17. 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 medical decisions . . .

18. 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 if an initial decision is not fully favorable . . . May Appeal within 60 days of the decision