RESULTS OF REVIEW
Reimbursement Has Not Improved the Timeliness of
MER Collection
In authorizing payment for MER under the DI program,
Congress intended that the records would be received more timely
and, as a result, claims processing time reduced. Since statistics
on MER collection times were not maintained, we were unable to determine
the portion of claims processing times related to MER collection.
Nonetheless, the following evidence shows that the time required
to obtain MER accounts for a considerable portion of claims processing
times and contributes to delays in the disability determination process.
Based on this evidence, we concluded that reimbursing medical sources
for MER has had no apparent impact on improving the timeliness of
MER collection.
We reviewed the processing times for DI and SSI claims
from FYs 1985 to 1994. As shown in Appendix A, claims processing
times for DI and SSI increased by 42 percent and 39 percent,
respectively. We also reviewed the trend in DDS purchases of CEs
during the same time period. CE purchase rates remained relatively
constant, with only a 3.7 percent decrease from FYs 1985
to 1994. These statistics indicate that reimbursing medical sources
has had no apparent impact on improving the timeliness of the disability
determination process or reducing the purchases of CEs.
HHS/OIG reported that delays in MER collection resulted
in an increase in claims processing times. HHS/OIG reviewed a sample
of 398 pending disability claims from 5 DDSs and found
that: (i) 153 claims, or 38 percent, were awaiting
receipt of medical records an average of 77 days after DDS received
the disability claims; and (ii) follow-up requests had to be
made for 222, or 56 percent, of the 398 claims.
SSA formed a Disability Redesign team to study and
develop recommendations to improve the disability process. The team
reported that "SSAs ability to provide timely and accurate
disability decisions depends to a significant degree on the quality
of medical evidence it can obtain and speed with which it can obtain
it." The team added that "the medical evidence collection
process accounts for a considerable portion of the total time involved
in processing disability claims."
The Connecticut MER Collection Process
Connecticut General Statutes created by Connecticut
Public Act No. 91-137 and Connecticut Public Act No. 92-78 precluded
the charging of fees for MER obtained in support of a claim or appeal
under the Act. The Connecticut General Statutes require all
medical providers to furnish the claimant (or appointed representative)
a complete copy of a claimant`s MER within 30 days.
The Connecticut legislation was sought by the Connecticut
legal services organization, Legal Assistance to Medicare Patients
(LAMP). LAMP believed that medical providers were imposing prohibitive
charges for medical records which, in some cases, could cause claimants
to be denied benefits because they could not afford to purchase medical
records. LAMP also believed that facilitating claimant access to
free medical records would make benefits more accessible and decrease
State expenditures under a variety of State-funded programs.
The Connecticut DDS MER costs were almost eliminated
in FY 1994 (see following table), the first full fiscal year after
the legislation was enacted by DDS, effective July 2, 1993.
DDS still incurs a minimal MER cost from out-of-State providers who
were not included under the provisions of the Connecticut legislation.
Also, DDS was able to reassign four full-time clerical staff who
had been responsible for processing MER billings prior to enactment
of the legislation to other duties.
CONNECTICUT DDS |
Fiscal Year |
MER Costs |
DI Processing Times (Days) |
SSI Processing Time (Days) |
CE Purchase Rate |
1992 |
$783,262 |
71.4 |
82.2 |
38 Percent |
1993 |
448,071 |
65.9 |
73.4 |
45 Percent |
1994 |
310 |
72.0 |
80.0 |
41 Percent |
1995 |
1,432 |
62.9 |
69.3 |
38 Percent |
As shown in the above table, the legislation has not
had a negative effect on either claims processing times or CE purchases.
In fact, DI and SSI processing times from FYs 1992 to 1995 improved
by 8.5 days and 12.9 days, respectively. In addition, CE
purchase rates have remained relatively constant, with the FY 1992
rate the same as the FY 1995 rate.
The legislation requires that medical sources provide
MER to DDS within 30 days of the request. Although the legislation
does not provide any penalty, DDS officials stated that most providers
respond within 30 days. The officials further stated that the
providers exceeding the 30-day limit were the same providers who
historically have been slow in processing MER requests.
We selected for review a judgmental sample of 200 MER
requests where the Connecticut DDS issued disability decisions between
the period April 9 through April 22, 1996. We found
that MER was received within 30 days or less for 138, or 69 percent,
of the 200 requests. For the remaining 62 requests, MER
was not received at all for 43 requests and received after 30 days
for 19 requests. In discussing these results with DDS officials,
the DDS officials stated that these results were representative and
believed that receiving 69 percent of DDS MER within 30 days
was a reasonable estimate.
We interviewed 11 Connecticut DDS officials, including
the Director, the Medical Relations Officer, a Disability Unit Supervisor,
and 8 disability examiners. The common response from these officials
was that the legislation had no adverse effect on the disability
determination process.
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