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
OBJECTIVE
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.
BACKGROUND
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.
SCOPE
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.
RESULTS OF REVIEW
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.
CONCLUSIONS
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
APPENDICES
APPENDIX A
MAJOR CONTRIBUTORS TO THIS REPORT
Office of the Inspector General
William Fernandez, Audit Director
Fredric Uehling, Deputy Director
Carol Cockrell, Senior Evaluator
Richard Reed, Auditor
|
www.socialsecurity.gov
