What You Need to Know when Social Security Sends You to their Doctor

What You Need to Know when Social Security Sends You to their Doctor

If you applied for Social Security Disability Insurance (SSDI) benefits, you may receive a letter requiring you to take a consultative examination (CE). A CE exam is designed to evaluate your current medical condition and limitations. Receiving a CE request means the disability claims examiner in your state could not determine whether you have a disability, and the severity of the disability, based on the medical information you included in your application for SSDI benefits.  

Each state has a Disability Determination Services (DDS) that reviews disability claims for the Social Security Administration (SSA). The DDS makes recommendations to the SSA on whether a person is disabled under the Social Security law.

SSDI provides monthly benefits if you have a medical condition that is expected to last at least one year or result in death. Before receiving these disability benefits, however, you must prove that you cannot continue working in your most recent job or other jobs for which you may be qualified. Medical records play a key role in proving that you have a disability, which is why a claims examiner wants as much information as possible from your medical file. 

On one hand, you may be reluctant to have a CE, especially if you believe you provided SSA with sufficient information about your disability. On the other hand, by not complying with the CE request, you may jeopardize your opportunity to receive disability benefits. 

Can Your Doctor Perform The Consultative Examination?

While SSA hires independent physicians or psychologists to perform CEs, the SSA says it prefers receiving medical information from the doctor treating the person with a disability. This is why a disability claims examiner might contact the treating physician’s office for the missing information. In your case, it’s possible that you may have already taken a test, assessment, or examination that the disability claims examiner reviewing your application requires. If so, your doctor’s office can send the documents to the examiner. 

In fact, your doctor can conduct the CE if the SSA considers your doctor is qualified, equipped, and willing to do the examination at the fee set by SSA. There is an advantage to having your doctor do the exam, especially if you have been seeing the doctor for quite some time and your doctor can provide relevant details about treating your disability. In this type of situation, SSA will look at the notes your doctor writes about your condition, and your doctor’s opinion or whether your condition is improving, and if, and when, you can go back to work.

While it may be ideal to have your doctor do the CE, this may not happen for several reasons: 

  • Your doctor may not agree to the fee that SSA pays for doing the exam.
  • SSA may want a specialist to do the exam and your doctor may not have the medical specialty SSA requires. For instance, if you have a mental-related disability, SSA would want an examination done by a psychologist or psychologist, rather than a general practitioner. 
  • The claims examiner may have found inconsistencies or conflicts in your file that your doctor’s notes or your other medical records cannot resolve.
  • You may have a reason for wanting another healthcare provider to perform the CE.

If you prefer that your doctor conduct the CE, talk to your doctor about it. If your doctor won’t agree to it, then follow through with the previously scheduled CE.  Be sure to go to the CE at the indicated date, time, and location. Social Security pays for the CE and reimburses you for transportation  If you cannot make the appointment, call and reschedule for another time. Failing to get a CE means that the disability claims examiner may decide that you are not disabled and deny your claim.

What to Expect at a Consultative Examination

The type of CE required depends on the information a claims examiner needs to resolve unanswered questions about your disability. For instance, you may not need an examination if an X-ray, blood test, or other laboratory tests will provide the medical information the disability examiner needs. 

If the doctor asks you about your current condition, tell the doctor about any new symptoms or physical changes that have occurred since you filed your disability claim. For example, if you have a back injury that is now limiting your mobility, describe how this change has impacted your daily activities. In addition, mention any hospitalizations or surgeries you have had due to complications from your disability. You can send this updated information to your disability claims examiner if you haven’t already done so.

The doctor may ask you why you believe your disability prevents you from working. Be specific and honest in answering the questions and include how your health or mental condition affects your ability to do your current job.

After your CE, the doctor sends your test results or the outcome of your examination to the DDS. While each disability case is different, a doctor’s report usually includes:

  • Diagnosis and prognosis of a condition 
  • Results of a test, examination, or lab work
  • A statement about the patient’s ability to work, what type of work activities the patient can still do despite the patient’s disability, or the patient’s inability to work.

Keep in mind that the doctor doing the CE will not treat or prescribe medication for your disability or complications caused by your disability. But, the doctor may note your complaints or other health issues in a report to the DDS.

Approval or Denial After the Examination? It’s Hard to Know

It’s difficult to know exactly how a CE impacts a decision on approval for disability benefits. The disability claims examiner may only want certain information about your condition, which is why you might have a brief examination. In contrast, a more extensive examination could mean that the examiner believes that you provided very few documents to substantiate your injury claim. Or, it may appear to the examiner that you have not been to a doctor in a long time; otherwise, you would have more recent medical records. 

Claims examiners have denied disability benefits based on a lack of information, reasoning that a person claiming to have a serious disability would have gone to the doctor more often for treatment. Besides your medical records, the examiner takes into account your work history, educational background, and other factors before making a decision whether to approve or deny disability benefits.

If the DDS denies your claim, you have a right to appeal the decision. If you decide to appeal, you have within 60 days of the denial to file a written request for an appeal. The appeals process consists of four levels:

  • Reconsideration. SSA will have a claims examiner who was not part of the original decision-making process review your claim. You can submit new evidence for consideration. 
  • A hearing before an administrative law judge. If you cannot attend in person, you can request a hearing to appeal the reconsideration decision via the Internet. 
  • A Social Security’s Appeals Council review. The council will review the administrative law judge’s decision. 
  • A review by the federal courts. Your case will be sent to the federal court in the district in which you live. 

The appeals process is complex, and there’s no guarantee that you will receive approval, even if you appeal. Besides that, appearing before an administrative law judge to answer questions and counter the DSS’s reasonings for your denial can be intimidating when doing it on your own. Keep in mind that the appeals process can take a year or even longer, and your finances may suffer during this time because of your inability to work due to your disability. What’s more, managing your health condition while handling a lengthy appeal may not be in your best interest. 

Some applicants who were denied benefits seek legal advice from a Social Security disability lawyer before moving forward in the appeals process. A lawyer whose practice focuses on Social Security disability knows what information SSA expects to receive before making a determination on whether to approve or deny an SSDI benefits application. Besides being knowledgeable about Social Security’s expectations, a disability lawyer takes the pressure off of their clients by representing them from the beginning to the end of a disability case. 

Not Sure About a Consultative Examination? Contact Joel Thrift Law Today 

A consultative examination is more than just a routine visit with a doctor. At Joel Thrift Law, we can review your disability claim application and advise you of any preparations you may need to make before going to your CE. Our established Social Security disability law firm handles all aspects of disability claims, from filing the initial application, collecting documentation to build a solid claim, to representing claimants in the appeals process.  

If you have been denied disability benefits, we can help you navigate every step of the appeals process, if necessary. Do not jeopardize your case by going it alone. Contact us today to schedule a consultation.