HA 01320.031 Allegations of Improperly Completed or Deficient Consultative Examination Reports or Misconduct by Consultative Examination Providers

A. General

If the Office of Appellate Operations (OAO) staff or adjudicators receive an allegation of consultative examination (CE) provider misconduct, fraud or similar fault, or lack of qualifications they will follow the instructions in this section.

NOTE:

Reports of claimant or representative allegations are distinct from, and do not supersede, the existing procedures for OAO adjudicator referrals of potential CE provider misconduct provided in Hearings, Appeals, and Litigation Law (HALLEX) manual HA 01320.030 C.1., and reporting fraud or criminal violations by employees, contractors, claimants, or other members of the public to the Office of the Inspector General (OIG) as described in HALLEX HA 01130.009. Adjudicators should continue to refer issues of potential misconduct for further consideration using existing procedures and considerations.

In determining whether to grant review due to an allegation(s) involving a CE provider, the Appeals Council (AC) will consider the circumstances under the error of law standard as explained in HALLEX HA 01330.003. If the allegation(s) was raised at the hearing level, the AC will confirm the HO and ALJ followed the procedures in HALLEX HA 01210.033.

B. Processing Allegations

1. Reporting Allegations of CE Provider Misconduct, Fraud or Similar Fault, or Lack of Qualifications

If a claimant or representative alleges CE provider misconduct with the request for review, including allegations of fraud or similar fault, lack of qualifications, or patterns of deficient CEs and reports, OAO staff and adjudicators will report the allegation to the Executive Director's Office in an email with the subject line, “Claimant Allegation of Consultative Examination Provider Misconduct.”

Reports detailing claimant or representative allegations should include the following:

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The claimant's name and Social Security number;
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The name of the CE provider;
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The verbatim allegation(s) (when possible); and
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The exhibit number or location of the allegation(s) in the claim(s) file.

2. Handling Information Related to Another Party Intentionally Submitted to Support Allegations of Patterns of Misconduct or Fraud or Similar Fault

OAO staff must not associate information relating to non-parties with the claimant's record.

If a claimant submits a CE report prepared for an individual who is not a party to the hearing, the AC will acknowledge the allegation and handle the evidence following the procedures in HALLEX HA 01320.024 C.1..

NOTE:

If the AC discovers an adjudicator at the hearing level has relied on evidence that does not relate to a party to the hearing, the AC will generally grant review to take corrective action due to an “error of law” (HALLEX HA 01330.003).

OAO staff and adjudicators will refer allegations relying on evidence involving a non-party to OAO management consistent with the instructions in subsection B.1.

C. Evaluating Allegations of Fraud or Similar Fault by a CE Provider

If, with a request for review, a claimant or representative submits a new allegation that fraud or similar fault was involved in the providing of evidence in a CE report, the AC will follow HALLEX HA 01395.001 and HA 01395.012 to evaluate and address the allegation.

If the allegation was already raised at the hearing level, the AC will evaluate whether the hearing level adjudicator processed the allegation according to HALLEX HA 01295.012 and HA 01210.033. If the AC finds a hearing level adjudicator relied on inadmissible information to support a fraud or similar fault finding in a hearing decision, the AC will generally grant review due to an “error of law.”

NOTE:

If the AC issues a decision finding there was no reason to believe that fraud or similar fault was involved in the providing of the suspect CE report material to the outcome of the case, then the AC should consider whether the CE report is complete as described in subsection D., below. The AC must then evaluate the persuasiveness of any complete CE report consistent with 20 CFR 404.1520b, 404.1520c, 416.920b, and 416.920c for claims filed on or after March 27, 2017.

D. Evaluating Allegations of Deficiencies in CEs and CE Reports and Unqualified CE Providers

If, with a request for review, a claimant submits a new allegation that a CE report is deficient because either the CE was inadequate, the report is inaccurate, the report was not properly signed, or the CE provider was not qualified, the AC will carefully evaluate the allegation and whether the requirements for a CE report were met to determine whether to grant review.

1. CE Report Requirements

Under agency regulations, all CE reports obtained in connection with a claim(s) must comply with the following requirements:

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The CE report must be complete enough to help determine the nature, severity, and duration of the claimant's impairment(s) and the claimant's residual functional capacity (20 CFR 404.1519n(b) and 416.919n(b)).
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A complete CE involves an examination with all the elements of a standard examination in the applicable medical specialty (20 CFR 404.1519n(c) and 416.919n(c)). A complete CE is only necessary when dictated by the particular facts of the case (20 CFR 404.1519n(d) and 416.919n(d)).
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When a complete CE is involved, the report includes the elements identified in the regulations (20 CFR 404.1519n(c) and 416.919n(c)). If the evidence the agency needs does not require a complete CE, the CE report need not contain all of these elements identified in the regulations (20 CFR 404.1519n(d) and 416.919n(d)).
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All CE reports must be personally reviewed and signed by the medical source who actually performed the CE (20 CFR 404.1519n(e) and 416.919n(e)). A rubber stamp signature of a medical source or the medical source's signature entered by any other person is not acceptable (20 CFR 404.1519n(e) and 416.919n(e)).
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The agency will not use an unsigned or improperly signed CE report in denials, cessations, or allowances with closed periods of disability or later onsets (20 CFR 404.1519o and 416.919o).

2. Issues of CE Report Deficiencies at the AC Level

If a CE report does not meet the requirements provided in subsection D.1, the AC will consider whether a grant review action is appropriate to resolve the deficiencies.

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If a less than fully favorable ALJ decision relies upon an improperly signed CE report, the AC will generally grant review based on an “error of law” and remand the case for further actions consistent with 20 CFR 404.1519o and/or 416.919o and HALLEX HA 01250.020.
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If a fully favorable hearing level decision relies upon an improperly signed CE report, OAO staff and adjudicators should check if the hearing office has an outstanding development request to obtain the signature with the DDS. If a development request has not been initiated by the hearing office, OAO staff should consult their manager for appropriate action.
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If the CE report is inadequate or incomplete for a reason other than a missing signature, the AC will evaluate whether the decision is supported by substantial evidence. See HALLEX HA 01330.004. As necessary and appropriate, the AC may grant review to request that the ALJ undertake additional development pursuant to HALLEX HA 01210.033 D. 2.

3. Evaluating Allegations that a CE Provider is Unqualified

If a claimant or representative alleges a CE provider is not licensed or has been disqualified, the AC must evaluate the allegation on a case-by-case basis, relying on the medical evidence of record. See HALLEX HA 01320.030 B.

If the claimant or representative alleged at the hearing level that a CE provider was not licensed or has been disqualified, OAO adjudicators will evaluate whether the hearing level adjudicator processed the allegation in accordance with HALLEX HA 01210.032 B and HA 01210.033 D.

OAO staff and adjudicators will report all new allegations that a CE provider is unqualified per the instructions in subsection B.1. In addition, the AC will consider whether a referral is appropriate under HALLEX HA 01320.030 B and C.

NOTE 1:

In evaluating such allegations, the AC will keep in mind that the agency may only use qualified medical sources as CE providers, licensed in the State in which the examination was performed, who have not been barred from participation in Social Security Administration programs (20 CFR 404.1519g and 416.919g. (See also Program Operations Manual System (POMS) DI 22510.001A.2.d. and DI 39545.175A). Under HALLEX HA 01210.030, when the hearing level adjudicator admits a CE report into the record as an exhibit, that adjudicator will also admit a written statement of the medical source's qualifications.

NOTE 2:

The AC will not rely on or associate evidence that relates to a non-party submitted to support an allegation that a CE provider is disqualified. See subsection B.2., above and HALLEX HA 01320.024 C. However, as part of its review, the AC will ensure the CE provider is qualified under agency policy.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/2501320031

HA 01320.031 - Allegations of Improperly Completed or Deficient Consultative Examination Reports or Misconduct by Consultative Examination Providers (I-3-2-31) - 03/03/2025
Batch run: 04/20/2025
Rev:03/03/2025