TN 3 (01-12)

DI 39569.100 Conflict of Interest

This section describes the Social Security Administration’s (SSA) policy to avoid actual, as well as the appearance of, conflicts of interest (COI).

A. Disability Determination Services (DDS) guidelines for avoiding COI

1. Avoiding COI situations

All DDS employees and contractors, including medical consultants (MCs) or psychological consultants (PCs), responsible for processing or adjudicating disability cases must avoid any potential conflict between SSA’s interest and their own personal interests. In order to avoid potential COI, DDS employees must disqualify themselves in questionable situations. Disqualified DDS employees must not handle, and are prohibited from accessing, the applicant’s file. Disqualified employees may help supply information needed to support a claim, when appropriate.

SSA relies on the public trust of DDS employees. It is the DDS employee’s ethical obligation to report potential COI as soon as he or she learns of it. It is not the responsibility of DDS management to monitor employees for potential conflicts.

SSA expects employees to disqualify themselves and alert DDS management to a potential COI in cases involving a personal acquaintance or family member (whether as a claimant, provider of medical evidence, or appointed representative). The DDS Administrator (or designee) may disqualify the DDS from adjudicating a claim involving parent agency staff or family members of parent agency staff. The disqualification prevents any perception of a conflict.

DDS employees must disqualify themselves from acting on any official matter that involves:

  • a relative;

  • a personal acquaintance; or

  • their own Social Security records.

2. State and federal COI

Federal law does not prohibit DDS employees from representing Social Security claimants. However, state law or regulations may prohibit such representation.

See Also:

GN 03980.030, State Agency Disability Determination Employees – Federal Conflict of Interest

B. MC and PC guidelines

MCs and PCs may work for SSA directly, or review and adjudicate claims in state agencies. Consultants must avoid all implications of possible COI between their services for SSA and their medical practices.

1. Avoiding COI

SSA does not consider assignment of claims for review from another DDS or federal component as COI. However, MCs and PCs who work for SSA directly as employees or under contract must not participate in any of the activities listed below.

  • Work concurrently for a state agency or be under contract with a DDS.

  • Perform consultative examinations (CEs) without prior approval.

  • Acquire or maintain, directly or indirectly, any financial interest in a medical partnership, corporation, or similar relationship that performs CEs for SSA. This restriction also applies to any members of their families.

  • Participate in the review of a case when the MC or PC has prior knowledge of that case; e.g., the claimant was a patient. However, the MC or PC may submit medical evidence based on prior treatment or examination of a claimant.

  • Work as a consultant for an appointed representative.

NOTE: The RO assists the DDS in resolving questionable familial or financial arrangements or issues.

See Also:

2. Obtaining approval for exceptions to COI Policy

There are exceptions to the COI policy related to qualified treating sources, availability of qualified sources, and other special conditions. However, the DDS must always obtain prior regional office (RO) approval for an MC or PC to perform CEs. The RO may grant approval in situations when:

  • an MC or PC is the treating source and is qualified to do the CE;

  • the DDS has an insufficient number of qualified medical sources available who are willing to perform CEs (e.g., in sparsely populated States where there is a limited physician population); or

  • no other option is available because of conditions under which the CE must be performed, e.g., the claimant is confined in an institution or other facility in which other CE providers are unwilling to perform evaluations.

NOTE: Disqualified federal or state MCs and PCs can review claims if the MC or PC (or his or her partner or affiliate) has provided a CE under these exceptions. Submit documentation to support the need for the exception with the request for RO for approval.

C. How to handle COI issues

Take a common-sense approach to potential COI situations.

1. COI procedure for DDS employees, MCs, PCs, and contractors

Alert the DDS Administrator (or designee) to the COI.

2. COI procedure for DDS Administrator or designee

Consider and, if appropriate, take the following actions for potential COI situations.

  • Transfer the case to another employee who has similar responsibilities but no personal interest in the case.

  • Request RO assistance to transfer the case to another DDS when assignment within DDS is not possible (e.g., DDS has a small staff). Clearly document potential COI is the reason for transfer.

  • Request RO assistance with jurisdiction or adjudication if the Administrator also needs to disqualify himself or herself (e.g., claim is filed for a family member, relative, previous employee, or personal or business acquaintance). Clearly document potential COI is the reason for transfer.

3. COI procedure for Regional Office

Submit potential COI situations via email (with attachments, images, etc.) to the Office of Disability Programs for approval when you feel the circumstances are questionable.

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DI 39569.100 - Conflict of Interest - 01/20/2012
Batch run: 01/20/2012