BASIC (09-06)

DI 39545.400 Ensuring Quality and Integrity of Consultative Examination (CE) Reports

Citations:

20 CFR 404.1519p, 20 CFR 404–1519q

A quality CE report contains all of the information relevant to the examination and to the tests that were authorized, and includes accurate information.

A. Policy

DDSs should establish policy guidelines for the following areas to ensure the quality of CE reports:

  • CE provider training

  • Review of CE reports

  • Integrity issues.

B. Procedure – CE provider training

DDSs should provide all new CE providers a good understanding of SSA's disability programs, program requirements for examinations and CE reports and the CE provider’s role in the CE process. DDS training for CE providers should cover the following topics:

  • Certification requirements for becoming and retaining CE provider status with DDS;

  • Overview of SSA’s disability programs and regulations;

  • Basic operations of the disability determination function, including DDS management of the CE process;

  • Elements of a complete CE;

  • CE report content and reporting requirements;

  • Sending CEs via fax, the Electronic Records Express website or other SSA approved secure electronic communications methods;

  • Security of electronic information and HIPAA compliance of the SSA-827

  • Periodic DDS onsite visits to volume providers or certain CE providers when complaints or other circumstances indicate the need;

  • Fee schedule structure;

  • Periodic satisfaction surveys of claimants about their CE;

  • Confidentiality and disclosure of medical information;

  • Explanation of CE review process (DI 39545.400C);

  • Ongoing training may be necessary when there are changes to the program or when deficiencies are identified.

C. Procedure – review of CE reports

  1. Consider reviewing a minimum of 5 percent of all CE reports. Review can be performed in the DDS by quality assurance (QA), supervisor, medical consultant (MC), psychological consultants (PC), etc. and should ensure:

    • completeness;

    • timeliness;

    • internal consistency.

  2. Confirm that all authorized tests were reported.

  3. Verify that the authorizations for any unreported tests were cancelled to ensure payment will not be made.

  4. Compare reports from the same CE provider for different claimants to determine degree of similarity. A high degree of similarity may indicate:

    • lack of sufficient individual claimant evaluation by the CE source; or

    • questionable reliability of the evidence.

  5. Record findings under DI 39545.400C.1. through DI 39545.400C.3. in accordance with the DDS procedures for usual error reporting process.

  6. Report findings of high similarity under DI 39545.400C.4. to DDS management.

    NOTE: Analyze the review findings to determine if and what remedial action is necessary to ensure good CE report quality.

  7. New CE providers should have more concentrated review, as should a CE provider who has received corrective feedback from the DDS.

D. Procedure – integrity issues

  1. Check medical source reimbursements on a random basis to determine whether there is corresponding and appropriate evidence in the claims file and an indication of its receipt in the DDS.

  2. Verify reimbursement was the lower of the amount billed by the source or the maximum allowed under the fee schedule.

  3. Investigate any incidence of missing evidence and take action to review the basis for the decision.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0439545400
DI 39545.400 - Ensuring Qual