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Audit Report - A-07-97-61003

Office of Audit

Usefulness of the Social Security Administration’s Region VII Quality Assurance Process to State Disability Agencies (A-07-97-61003) - 11/10/97


The objective of this management advisory report was to determine how quality assurance review results for initial disability determinations are used to improve operations of the State Disability Determination Services (DDS) in Region VII.


The Social Security Act requires the Commissioner of Social Security to review the medical determinations made by the State agencies to the extent necessary to ensure a high level of accuracy.

The medical eligibility determinations of disability under the Disability Insurance and the Supplemental Security Income programs are made by each States’ DDS. Office of Program and Integrity Reviews’ (OPIR) sampling software selects the DDS cases for quality assurance (QA) reviews. The DDS is alerted to specific claims selected for QA review when attempting to effectuate a claim. When a claim is selected for review, it can’t be effectuated, i.e. a medical determination can’t be entered into the National Disability Determination Services System, until the QA review is complete. OPIR’s regional staff (ROPIR) perform the QA reviews. There are about 140 QA reviews conducted per quarter per State.

Once the Disability Quality Branch (DQB) of ROPIR completely reviews each case, the results are entered on the Data Verification Form (DVF). The data from the DVF are transmitted to OPIR in Baltimore where the data are compiled and reported on the monthly Federal Quality Assurance Review Initial Disability Determinations report.

The accuracy rates from the report are compared to the mandated initial performance accuracy rates to determine whether DDSs have performed acceptably in terms of decisional accuracy and documentation requirements.

Regulations require that the DDSs must meet an initial performance accuracy rate of 90.6 percent, one of three mandatory threshold levels. If two of the three threshold levels (one of which must be performance accuracy) are not met for two consecutive calendar quarters, the DDS is "in failure," and the Social Security Administration (SSA) is required to provide support to the DDS to improve performance.

OPIR/ROPIR is responsible for helping DDSs to maintain an acceptable performance accuracy rate. One way that OPIR/ROPIR helps DDSs to improve performance accuracy is through the sample enrichment process. If the accuracy rate goes below 91 percent for either allowances or denials in a 3-month period, sample enrichment is activated (stratified by either allowances or denials). Sample enrichment increases sample cases from 70 to 196 in the ensuing 3-month period. By increasing the number of cases to be reviewed, OPIR/ROPIR decreases the risk of sampling error and increases the chances of pinpointing problems in the DDSs’ evidence-collecting and decision-making processes. The enriched sampling remains activated for at least 3 months or until the deficient strata returns to an acceptable level. In addition to the knowledge gained by DDSs from the results of QA reviews, ROPIR also provides regular feedback through the Disability Quality Report on decisional accuracy, so that the DDSs can regularly monitor their performance.


Our objective was to determine how QA results generated by ROPIR in Region VII are used to improve operations of State DDS agencies. We reviewed QA work conducted between October 1, 1995, and December 31, 1996. We performed our review at SSA offices in Baltimore, Maryland, and Kansas City, Missouri, and at DDS offices in the States of Kansas, Iowa, Missouri, and Nebraska. Field work was conducted from March through June 1997 and included:

  • reviewing SSA policy and procedures regarding the QA review process;
  • observing the QA case folder review process in ROPIR;
  • interviewing OPIR /ROPIR personnel;
  • obtaining initial performance accuracy rate documentation from October 1, 1995, through December 31, 1996;
  • reviewing prior initial QA sample enrichments for effects on performance;
  • interviewing 11 State DDS QA personnel in Kansas, Iowa, Missouri, and Nebraska;
  • reviewing the mechanism for reporting the results of the QA reviews to DDSs;
  • reviewing the timeliness in performing QA reviews and reporting results; and
  • evaluating the training and assistance provided to DDSs to improve performance.


The State QA personnel were appreciative of the assistance provided by OPIR/ROPIR and reported a good working relationship with DQB staff of ROPIR. They also indicated that the reporting or feedback mechanisms used by OPIR and ROPIR were useful to them. In particular, ROPIR’s monthly Disability Quality Report was viewed as very helpful in focusing on problem areas when the initial performance accuracy rates dropped. The monthly report is helpful because it contains: (a) tables on accuracy rates by type of case, decision basis, and body systems; (b) descriptions of each case error; and (c) case rebuttal information.

During the review period, there were 8 incidents among all 4 DDSs (out of the total of 120 possible incidences) in which the initial performance accuracy rates for either allowances or denials dipped below 91 percent. In each incident, sample enrichment was implemented and the initial performance accuracy rates in question increased in the subsequent months to above the 91 percent level. The sample enrichment technique, along with feedback like the monthly Disability Quality Report, appeared to assist DDSs in the medical determination process to ensure that initial performance accuracy rates improved to and were maintained at an acceptable level above the regulated threshold of 90.6 percent.

At the request of the DDS, additional assistance in the form of training provided by ROPIR’s DQB staff is available. During the audit period, two of the four DDSs requested and received training in medical evaluation from ROPIR’s medical consultant staff. Both DDSs found this training extremely helpful, and reported that the interaction of the DQB and DDS medical staffs improved their understanding of medical assessments and aided them in resolving disagreements with medical decisions. Three of the four DDSs (including the two above) indicated during our audit that they would like more in-person contact between DDS and ROPIR medical consultants. The DDSs stated that these meetings would improve their understanding of making medical assessments and decisions on a continuing basis, and would improve their working relationship with ROPIR to an even higher degree.

We reviewed the timeliness of the QA reviews and reporting of results to the DDSs and found that SSA has no written policy and procedures for this process. However, ROPIR in Region VII has an Examiner Pending Case List which is printed twice a week and indicates the age of each claim. A ROPIR supervisor stated that this list is used to ensure that the oldest claims are worked as soon as possible, and that the average turn around time for a case was about 14 days. DDS QA employees reported no significant timeliness problems related to ROPIR performing the reviews and returning cases to the DDSs.


Based on our review, the QA review process was used effectively by ROPIR in Region VII to improve the operations at the DDSs. The DDS staff suggested that SSA further facilitate discussions between DDS and ROPIR medical consultants.

- Pamela J. Gardiner




Office of the Inspector General

William Fernandez, Audit Director
Fredric Uehling, Deputy Director
Carol Cockrell, Senior Evaluator
Richard Reed, Auditor

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