Disability claimants are awarded Social Security Disability Insurance (SSDI) benefits if they have a severe health condition that is expected to last at least 12 continuous months and that does not allow them to perform substantial gainful activity (SGA). Claimants must also have sufficient work credits to be insured for SSDI, and should not be currently working or making too much money.
Who decides if I am disabled?
Assuming that a claimant meets the nonmedical requirements for SSDI, their application is sent to the appropriate Disability Determination Services (DDS) office for a medical review. At the DDS office—which may also be referred to as the Bureau of Disability Determination or the Disability Determination Division—disability examiners will review the claimant’s medical records from all of their treating sources (doctors).
If the claimant’s medical records are insufficient to make a disability determination, if the treating sources do not provide information to the Social Security Administration (SSA), or if the claimant is not currently under the care of a doctor, the disability examiner may schedule a consultative examination (CE).
The goal of the consultative examination is to generate more information, including medical testing or medical evidence, about the claimant’s medical condition so that the disability examiner can make a better informed disability decision.
Can I see my own doctor for the CE?
In many cases, the consultative examination can be performed by the claimant’s original treating doctor. This can be ideal, especially since the doctor should have a good understanding of the claimant’s condition(s) and their resulting limitations.
The SSA may, however, have to have another consultative examiner perform the test if the claimant’s doctor is not qualified, is not able or willing to perform the exam, if there are inconsistencies in the file that need to be resolved by a third party, or if the treating source is not considered a “productive” source.
What happens at a consultative examination?
The consultative examination is a medical examination performed by a qualified medical source (licensed in the state with adequate training) that is hired by the SSA. The SSA requires that the medical examiner have a “good understanding” of the evidentiary requirements for a disability determination.
The exam is not considered medical treatment, but rather an evaluation of the claimant’s current physical or mental condition. The consultative examiner performs tests or medical evaluations based on the information needed by the SSA to make a disability determination.
After the examination, the consultative examiner is responsible for reporting back to the SSA with information regarding the claimant’s medical history and the physical examination, as well as findings from the medical testing.
According to the SSA, the goal of the CE report is to provide enough information that the disability examiner can review the report and determine the "nature, severity and duration of the impairment, and the claimant's ability to perform basic work-related functions."
Is a CE helpful for your case?
Claimants who have not received proper medical care generally assume that the SSA will send them to a consultative examination and that the disability examiner will get the report and have sufficient evidence to find them disabled.
While many consultative examiners may be fantastic and perform thorough consultative examinations, many claimants complain that their consultative examination were cursory at best. In fact, some claimants have complained that their consultative examination was only five to 10 minutes in length, and did not provide enough information to prove that they were disabled.
With this in mind, it’s easy to deduce that the best way to improve one's chances of winning SSDI benefits is not to rely on the consultative examination, but rather to develop a meaningful and beneficial doctor-patient relationship that can provide good, consistent medical evidence that a claimant is unable to work.
What happens after the consultative examination?
After the consultative examination is completed, the examiner will send a copy of their report to the DDS examiner. The examiner will review the report and all additional information, and make a disability determination.
If the claimant is approved for SSDI benefits, they will receive notification from the field office containing information about their benefits, including the estimated payment amount and payment date.
Claimants who are denied benefits will receive a denial letter from the SSA field office, with information about how to appeal their denial. All denials must be filed within 60 days from the date of the denial letter.