What Are Consultative Exams for Social Security Disability?

When you apply for Social Security Disability benefits, claims examiners may approve or deny your application. But did you know they can also say “maybe?” They can ask for more information. They may ask for a consultative examination.

If claims examiners don’t think that they have sufficient information to decide on an application, they may ask the applicant to undergo a consultative examination. The outcome of your application may depend on the information gathered from a consultative exam.

The Arizona SSDI attorneys at Pekas Smith Disability Attorneys explain consultative exams for Social Security Disability.

What Are Consultative Exams for Social Security Disability?

Consultative exams for Social Security Disability are medical exams to gather evidence and information as part of the benefits application process. When claims examiners need more information, they can ask the applicant to undergo a medical examination. The exam is called a consultative exam because its purpose is to gather information rather than treat the patient.

I’ve been asked to undergo a consultative examination – what now?

When you apply for Social Security Disability benefits, you may be asked to undergo a consultative examination. Rather than simply denying your application because it is incomplete, claims examiners may wish to gather more information. Specific tests and findings may help them decide a claim.

What is the law for consultative exams in Social Security Disability applications?

Title 20 – Employees’ Benefits, Chapter III – Social Security Administration, Part 404 – Federal Old-Age, Survivors and Disability Insurance, Subpart P – Determining Disability and Blindness, part of the Code of Federal Regulations, discusses the use of consultative examinations in assessing qualifications for Social Security Disability benefits.

The law covers several aspects of exam administration, including what circumstances may prompt an exam, authorization and monitoring of the exam, and who is qualified to conduct it.

Why the Government Asks for a Consultative Examination for SSD

The government may ask for a consultative examination for an SSD application when:

  • There are inconsistencies in the evidence that need to be resolved
  • The evidence as a whole is insufficient to decide the claim
  • Records don’t contain the necessary information
  • Evidence is missing for reasons beyond your control, like the death of a care provider or their noncooperation
  • More technical or specialized evidence is needed
  • A change in condition may affect your ability to work, so the current severity of your impairment is not known

Whether to purchase a consultative examination is decided on a case-by-case basis.

Who pays for a consultative exam for an SSDI application?

The government pays for a consultative exam for an SSDI application. The healthcare professional conducting the exam must agree to a fee schedule that is set by the state overseeing the application.

If you or your representative arrange for an exam, you must pay for it. If a government-sponsored exam reveals the need for additional testing, it must be authorized by the government if they’re going to pay for it.

Who may conduct a consultative examination?

Usually, the applicant’s care provider is the preferred person to conduct a consultative examination. They’re already familiar with the applicant’s history and course of treatment.

To conduct a consultative examination, the person must be:

  • Licensed
  • Sufficiently trained and experienced
  • Equipped with instruments and materials
  • Understanding of disability programs and requirements
  • Willing to accept the fee for services

An examiner may use support staff to aid in the examination if they are qualified.

The person undergoing the exam will be told the date, time, place, and examiner. Distance from the applicant’s residence may be a factor in determining where to have the exam.

While the applicant’s treating care provider is usually the first choice for a consultative examination, there are reasons they may not be used. For example:

  • The treating care provider chooses not to perform the exam
  • Fee schedules are unacceptable to them
  • The examination is needed to resolve conflicts or inconsistencies in their record
  • Claimant wants to go somewhere else for a good reason
  • Reasons exist that the person may not be a good source of information

Content of a Consultative Examination

The Social Security Green Book provides guidelines for consultative examinations as part of the SSDI application process.

A general consultative examination and report must include the following:

  • The claimant’s identifying information, including proof of identity provided by the claimant, like a driver’s license, passport, military or school identification
  • Medical history, records, and documents reviewed
  • Impairment and alleged reason for not working, provided in narrative form, a discussion of symptoms, the progress of the impairment, treatment, exacerbating or minimizing factors, daily activities, and impact of the condition
  • Past medical history, current medications
  • Review of specific organ systems
  • Social history, including tobacco, alcohol, and drug use
  • Occupational hazard exposure
  • Family history
  • Results of the physical examination

A physical examination includes things like vital signs, appearance, ordered laboratory and imaging tests, and findings that are both positive and negative. Cooperativeness and effort of the examinee should be reported where appropriate.

The examiner should state a medical opinion, assessing the person’s ability to work, the nature of their medical condition, and how the condition limits them. Finally, they must give findings that are specific to the person’s disorder. The requirements for each system and specific disorders are stated in the Social Security Green Book.

What to Do If You Receive a Request for a Social Security Consultative Examination

If you receive a request for a Social Security consultative examination, you must attend. Cooperate and provide complete information, but you don’t need to provide information beyond what is asked of you. Under 20 C.F.R. § 416.918, if you fail to attend a consultative examination, your benefits may be denied or terminated.

If you don’t speak English, you may have an interpreter present for your examination.

Contact Our Social Security Disability Lawyers in Arizona

If you have been asked to undergo a consultative examination as part of a Social Security Disability application, Pekas Smith Disability Attorneys may help you.

Call or message the Pekas Smith Disability Attorneys to talk about your situation with a lawyer.

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