Consultative Examinations (CEs) in Social Security Disability Claims

 

Find Out What to Expect When You See the Disability Doctor and How the CE Exam Report Affects Your Claim

 

If you are reading this article, the Social Security Administration (SSA) has likely ordered you to undergo a consultative examination (CE).

 

Or maybe you know someone else who received Social Security disability insurance (SSDI) benefits or Supplemental Security Income (SSI) after their mandatory CE. And you want to understand why the SSA has not scheduled a doctor’s appointment for you.

 

This article discusses what happens when Social Security orders a CE or other medical tests and how the consultative exam report affects your disability application. In addition, you will find tips for using a favorable CE report to get disability benefits and some options when the consultative examiner’s opinions harm your claim.

 

Keep reading to learn more about what to expect and do after seeing Social Security’s doctor.

 

And call my law firm today to talk with some of the best disability attorneys in the state: (804) 251-1620 or 757-810-5614.

 

 

What is a Consultative Examination in Disability Claims?

 

A consultative exam is a physical or mental evaluation or medical test purchased for you by the Social Security Administration (SSA). 

 

The SSA considers a thorough CE to involve all the elements of a standard exam in the applicable medical specialty.

 

What are Examples of the Types of CEs and Medical Tests Ordered by the SSA?

 

Standard consultative examinations and medical tests purchased by Social Security include the following: 

 

• Physical examinations with primary care physicians

 

• Mental health (psychological) exams with psychologists or psychiatrists if you allege PTSD, depression, anxiety, schizophrenia, or ADHD

 

• Exams with pediatricians in child disability cases

 

• Laboratory tests

 

• Diagnostic imaging (X-ray, CT, MRI)

 

• Musculoskeletal tests (McMurray’s Test, Phalen’s Sign, Tinel’s Sign, Waddell Signs, etc.)

 

• Visual Acuity Test

 

• Spirometry/Pulmonary Function Testing

 

• Electrocardiography

 

• Peripheral Vascular Arterial Dopplers

 

• Ultrasound

 

• Stress Test

 

• Fasting Blood Glucose Test (especially if you have diabetes mellitus)

 

• Auditory Brainstem Response

 

• Deep Tendon Reflexes

 

• Electroencephalography (EEG)

 

• Sleep Study

 

• Neuropsychological examination if you suffered a traumatic brain injury (concussion, post-concussion syndrome, stroke, etc.)

 

The SSA will buy only the specific exams and tests it thinks it needs to decide your claim. For example, it the SSA will not purchase a complete medical exam if it deems an X-ray sufficient.

 

Further, the SSA will only order non-invasive medical tests; it will not approve a consultative exam or medical test with a significant risk of harm, such as a myelogram or a cardiac catheterization.

 

Who Decides that I Need a Consultative Exam?

 

Disability Determination Services (DDS), a state agency funded by the federal government, is responsible for giving the initial determination on your application and considering any request for reconsideration. 

 

DDS must try to obtain and develop medical evidence to perform this role. But if DDS cannot get sufficient information from your treating doctors or adult disability function report to decide, it may ask you to attend a consultative examination.

 

When is Social Security Likely to Buy a Consultative Exam?

 

Code of Federal Regulations Section 404.1519a explains the situations that may require a consultative examination. These scenarios include the following:

 

• When the medical records are inconsistent, insufficient, or incomplete

 

• When the SSA is unable to get medical reports from one of your medical sources for reasons beyond your control, such as the physician’s death, retirement, or noncooperation

 

• When specific testing is needed to decide if you meet one of Social Security’s listings and you have not had the test performed

 

• When you have not received a permanent impairment rating for catastrophic injuries (amputation, back injury requiring a spinal fusion, burn injury, cervical spine condition, torn rotator cuff, etc.)
  

 

Can I ask the SSA to Buy a CE?

 

Yes.

 

You can submit a request for a consultative exam.

 

This request should include the type of exam you want and why you need it.

 

Administrative law judges seem more open to granting requests for CEs than DDS.

 

When Will Social Security Refuse to Order a Consultative Exam?

 

The SSA will not buy a CE in the following situations:

 

• When you seek disability insurance benefits but do not meet the insured status requirement in the calendar quarter you allege you became disabled. The SSA determines your insured status by reviewing your work credits. 

 

• When your insured status expired in the past (also called a remote date last insured) and the evidence shows you will have difficulty establishing an onset date of disability before you lost insured status. 

 

• When it appears you have substantial gainful activity (SGA)
  

 

This is only a sample of situations where the SSA will reject any requests for a CE. 

 

Do I Have to Pay for the CE?

 

No. 

 

Social Security pays for consultative examinations it approves, including fees for missed appointments. 

 

Each state sets the fees for CEs.

 

Who Will Social Security Ask to Perform the CE?

 

Only qualified medical sources can perform an SSA consultative examination. Acceptable sources include:

 

• Licensed physicians (medical or osteopathic doctors).

 

• Licensed psychologists.

 

• Licensed optometrists (for claims involving visual disorders only).

 

• Licensed podiatrists.

 

• Qualified speech-language pathologists.

 

• Certified audiologists.

 

• Licensed physician assistants.

 

• Licensed advanced practice registered nurses (APRNs). 

 

In addition, the CE doctor must have the equipment necessary to perform the test or exam requested by the SSA.

 

The SSA’s Regulations say your treating medical provider is the preferred source for the purchased consultative exams or medical tests if they are qualified, equipped, and willing. However, in my experience, treating physicians rarely perform CEs.

 

One explanation for this observation is that Social Security uses a different medical source than your treating provider if it finds “conflicts or inconsistencies in your file” that your doctor cannot resolve. And often, there is a conflict between a treating physician who supports your claim and a DDS disability claims examiner who leans toward denying it.

 

Second, if your treating physician supports your disability claim, they will complete a disability letter or questionnaire. Therefore, there is no need for your treating doctor to perform a CE.

 

Another reason your doctor may reject the SSA’s request for a consultative exam is the fee paid by Social Security. The amount paid for CEs is lower than what the physician can earn in their regular practice.

 

So instead of seeing treating physicians perform consultative exams for patients, I see companies and doctors with medical practices whose business models focus on performing only CE or defense medical exams in workers comp or civil litigation (auto accident cases) perform consultative exams regularly.

 

Will the Consultative Examiner Become My Treating Physician?

 

No, unless you establish that relationship later.

 

The consultative exam does not establish a physician-patient relationship. Nor is the CE provider required to continue treating you after performing the medical tests and evaluation ordered by the SSA.

 

Not expecting an ongoing doctor-patient relationship may explain the poor “bedside” manner many claimants report after a CE.

 

Is the CE Doctor a Social Security Employee?

 

No.

 

The Social Security Administration or other federal government agencies do not employ the consultative exam physician.

 

However, the CE provider may depend on these exams for a significant amount of their income.

 

Can I Object to the CE Doctor Chosen by Social Security?

 

Yes.

 

You or your attorney may object to a specific consultative examiner.

 

This pleading must explain the reason(s) you object. For example, the CE doctor’s office may be far away, and you do not have transportation. Or the consultative examiner is an OB/GYN when you need a neuropsychologist for your head injury and cognitive deficits. Or the doctor performed a defense medical examination (also called an independent medical exam (IME)) in your workers comp case and called you a malingerer (which means you faked or exaggerated your disability).

 

Whatever the reason, the SSA will assign a different CE physician if you show good cause for a change.

 

Is Social Security Sending Me to a Doctor a Good Thing?

 

Usually not.

 

Getting a letter asking you to see a physician selected by the SSA means the person examining your claim needs more evidence to award or deny your claim.

 

And you will have difficulty getting an SSDI or SSI award if the evidence is insufficient because of your failure (or inability) to get medical care. Even if you have a good reason, such as lack of health insurance or financial means, failing to get consistent medical treatment is one of the top reasons you could lose your disability claim.

 

In addition, sending you to one of its disability doctors may mean Social Security disagrees with your treating physician’s opinions.

 

What Does the CE Provider Do?

 

The consultative examiner will perform the evaluation or medical tests ordered by the SSA, then prepare a report for DDS or the ALJ.

 

Your exam’s quality and the written report’s thoroughness will vary.

 

Although I have seen some comprehensive CE reports that help disability claimants, many of these papers leave much to be desired – especially the physical consultative exam findings.

 

How Long Will the Disability Exam Take? 

 

The length of consultative examinations varies. 

 

Social Security provides scheduling intervals defined as the time a CE doctor should set aside. These intervals are as follows:

 

• General medical exam: At least 30 minutes

 

• Musculoskeletal or neurological exam: At least 20 minutes

 

• Psychiatric examination: At least 40 minutes

 

• Psychological exam: At least 60 minutes (or more if psychological testing takes place) 

 

• Other tests: At least 30 minutes, or whatever length accepted medical practices prescribe

 

However, many claimants report brief consultative examinations – less than 15 minutes.

 

What Do I Need to Bring to the CE?

 

At a minimum, you should bring identification to the consultative exam.

 

In addition, I recommend bringing a copy of your treating physician’s assessment form to the exam (if your doctor completed one) and giving it to the CE provider.

 

I recommend this for two reasons.

 

First, at least one ALJ told me she could only send fifteen pages of medical records to the consultative examiner for review, and your treating doctor’s letter should be under that limit.

 

Second, a well-written disability report from your treating physician should summarize your medical history, state your diagnosis, provide conclusions on your ability to perform physical and mental tasks sustainably, and list the objective and subjective findings supporting these opinions. Having this information in one place can help persuade the CE doctor to adopt your treating physician’s findings, increasing your likelihood of success.

 

What Happens After I See the Social Security Doctor?

 

DDS (or the ALJ if your claim is at the hearing level) will ask the consultative exam physician to send the results of your evaluation or medical test.

 

Then the SSA will use these reports to evaluate the severity of your medical impairments and how it affects your ability to work full-time.

 

What Should the Consultative Examination Report Include? 

 

The Social Security disability CE report should follow the standard principles for a medical examination and provide enough information to enable a separate reviewer to determine the nature, severity, and duration of your medical impairments and your ability to perform basic work-related tasks. 

 

Although the consultative examiner should include the information described below and may give an opinion on your ability to perform activities of daily living and physical and mental tasks in a work environment, the CE report should not include an opinion as to whether you are “disabled.” Only the SSA can make that determination because it is a legal question.

 

Now let us examine what the CE report should include:

 

Identification

 

• Your name, date of birth, and claim number (which is often your Social Security number)

 

• Whether you provide proof of your identity (a driver’s license, passport, military ID, student ID, etc.)

 

• A physical description of you

 

Medical History

 

• A list of medical records reviewed by the consultative examiner

 

• The name of the person giving the medical history: For example, in child cases, the parent may provide the history, or a spouse may describe the problems to the CE doctor in claims involving mental deficits. 

 

• A list of past operations, hospitalizations, and diagnostic procedures with service dates

 

• Names of your treating providers

 

• An assessment of your reliability

 

• When you stopped working

 

• A list of current medications

 

• A narrative describing the primary medical impairment you allege prevents you from working. This description must include the impairment’s onset, progression, symptoms, response to treatment, and aggravating factors

 

• Social history: Tobacco, alcohol, and drug use

 

• Family medical history

 

Physical Examination and Objective Findings

 

• The consultative examiner’s observations of your appearance and demeanor

 

• Driving status: For example, did you drive to the appointment, walk, ride with a friend, or take public transportation

 

• Blood pressure

 

• Pulse rate

 

• Nutritional status (obesity, underweight, etc.)

 

• Behavior

 

• Physical and negative findings from physical tests given

 

• Lab Test results

 

Medical Opinion

 

• The CE provider’s will say the nature and extent of your medical conditions, diseases, or injuries

 

• Discrepancies in the medical history and objective findings

 

• Any limitations in functions, such as lifting, carrying, pushing, pulling, sitting, standing, walking, climbing, stooping, bending, balancing, crawling, kneeling, handling, fingering, reaching, feeling, hearing, or seeing 

 

• Any limitations in interacting with others, dealing with work stressors, or maintaining attention, pace, persistence, and concentration at work 

 

How Does Social Security Review Consultative Examination Reports?

 

Social Security looks at the following factors to determine how much weight to give to the CE report:

 

• Whether the CE doctor gave the specific information that DDS or the ALJ asked for

 

• Whether the report provides evidence for its conclusions

 

• Whether the consultative examination is consistent with the other medical evidence, including clinical findings, diagnostic imaging, laboratory tests, and symptom complaints
  

 

• Whether the CE physician ignored relevant and material complaints identified in your other medical records; indeed, Social Security’s Regulations give the following examples of valuable information the CE report should mention (blindness in one eye, amputations, pain, alcoholism, depression, etc.)

 

Is a Consultative Examination the Only Evidence I Need to Get Disability Benefits?

 

Yes – for some of you.

 

But I would not count on it.

 

Although the CE exam can help with approval for SSDI or SSI, and I have won cases for some clients whose only supportive medical evidence was the consultative examination, you should try to get into regular treatment. Your chances of winning are higher if multiple doctors support your disability claim and documents showing you sought regular health care.

 

Will the SSA Award My Claim Automatically if the CE Doctor Says I Am Disabled?

 

Although a favorable consultative examination report is a good sign you will get approved for disability, a favorable decision is not automatic.

 

The CE findings are not binding on DDS or the administrative law judge (ALJ) presiding over your disability hearing.

 

But you should use this evidence to your advantage.

 

What Should I Do if the Consultative Doctor’s Opinion Hurts My Disability Claim?

 

You have several options if you disagree with the CE report.

 

First, ask all your treating physicians (family doctor, orthopedic surgeon, counselor, etc.) to review the CE’s findings and write a letter explaining why the CE doctor is wrong. Of course, this option only works if your treating doctors support your claim.

 

Second, even if your treating doctor refuses to challenge the CE doctor directly, ask your physician to complete a Residual Functional Capacity (RFC) assessment form with their opinions on your abilities. Some judges give greater weight to the views of a long-time treating physician than a one-time CE doctor (as they should).

 

Third, you or your attorney can call the consultative examiner and discuss their findings. The goal of this contact is to get the CE doctor to change their opinions and support your claim so you win your disability hearing. Although the SSA permits this tactic, many consultative examiners will refrain from these conversations.

 

Fourth, your disability lawyer can ask the ALJ to subpoena the consultative exam physician to your hearing so that your attorney can cross-examine them on the report.

 

Fifth, if the ALJ refuses to subpoena the CE doctor, your attorney can ask permission to submit interrogatories (written questions) to the doctor to weaken that person’s credibility or challenge their expertise and opinions.

 

Sixth, your attorney can make a motion in limine to strike the CE report from the record if the opinions are based on an unsatisfactory foundation (incorrect information, etc.) or if the CE doctor lacks the qualifications to assess your specific medical impairments.

 

Helping Disabled Adults Get Approved for SSDI and SSI

 

Many of you must appeal multiple denials before the SSA allows disability benefits.

 

You can take on this system alone while hurting and out of work.

 

Or you can turn to my law firm.

 

We handle disability claims in Virginia, Maryland, D.C., Pennsylvania, West Virginia, North Carolina, and Florida. And we want to start prosecuting your case today.