CBS: Failing the Disabled "System-wide culture to deny claims" -- no, not an insurance co.

[TygrBright]

Source: CBS Website/News Broadcast

>>When Farner filed a claim against a lifetime of paying into federal Social Security disability, she was turned down -- twice. Even though a rejection letter acknowledged she was severely disabled. But not disabled enough: Unable to perform work of any kind.

"It's a very tough standard," said Michael Astrue, commissioner of the Social Security Administration. "And you can argue whether that should be the standard or not, but I'm stuck with that."

A two-month CBS News Investigation uncovered a system whose own standards have been called into question - a federal agency reeling from budget cuts and high staff turnover. Doctors making decisions outside their specialties, and inexperienced examiners under pressure to keep costs down.<<

Read more: http://www.cbsnews.com/stories/2008/01/15/cbsnews_investigates/main3718129.shtml

---

Also in the news today: Merck & Schering-Plough have been shining on people at risk for stroke, heart attacks, etc., with a bogus 'miracle drug'. As seen earlier here on DU:

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=102&topic_id=3138735&mesg_id=3138735

Geez, a twofer. Two great stories about what to expect from the health care system in one day.

So, someone wanna make a case about how America's health care system "is not either broken, so stop saying that!" Or better yet, how we have "the best health care in the world!"

Right.

Really.

disgustedly,
Bright

[midnight]

1. "Doctors making decisions outside of their specialty" Doesn't

that say it all.

[Sadie5]

2. I saw the news article

I think it was on CBS, not sure. I was surprised they were telling the truth for once. While the politicians run wild spending the SS money, these poor folks can barely afford to eat or pay rent. It sure is broken, hope the next prez(Edwards) can fix it.

[McCamy Taylor]

3. Sadly, her case has been the norm for a long time. If you are educated and you

have the use of your eyes (or just one eye)and an ear and your dominant arm, you will be denied social security disability the first time, because they will say that you can work a desk job with appropriate ADA modifications. So, just be prepared to file an immediate appeal with an attorney. Or better yet, get an attorney before you ever file.

Had the woman's work history been entirely blue collar, i.e. welding, she would have qualified on the grounds of being physically unable to do the only work she was qualified to do. It is much easier to get social security disability if you lack the education to do desk work.

[BB1]

5. well that's just as sick, isn't it?

to have to get a lawyer before you even file for anything, because you're almost convinced some-one will turn you down.
What's the point in having the system in the first place?

[happyslug]

17. In my opinion, NO, the initial application you do NOT need an Attorney.

On any denial,you should file the appeal and get an attorney. Notice I say file FIRST then get an attorney. In the Appeal all you have to say is that you are still disabled on the i.e. form to file the appeal Write "I am disabled". That preserves your rights. You do NOT need to say more then that on the appeal form.

On the initial application you have to give SSA ALL of your doctors, and all of your problems. Any errors you make can be corrected on the appeal for an Administrative Law Judge (ALJ) review.

Remember this, the initial application is handled by the Bureau of Disability Determination (BDD). The BDD applies the Social Security Disability law as SSA would like it to be, the ALJ must apply the law as it is. This difference explains the 50-80% reversal rate given on appeal. That is way in excess of any reasonable error rate, but if two sets of rules are being used at each level, that explains the high reversal rate at the ALJ level. Above the ALJ level reversal rates end up in the area of 5%, a standard reversal rate in most courts, not th e%0-80% reversal rate done by ALJ. The reason for this is only the ALJ's decision is re-viewable by higher courts so ALJs MUST apply the law as it is. The BDD has to apply the law as they have been told by SSA to do.

Thus, if you denied at the initial application, file an appeal and hire an attorney who will review the case and see if there is any merit. Upon any denial by the ALJ, the Attorney will inform you of your appeal rights, and the low rate of appeal ABOVE the ALJ level.

My point apply for SS disability if you believe you can not work. If you want to discuss what that means with an attorney. There is NOT much an attorney can do at the initial level, but he is very valuable at the ALJ level.

[radfringe]

6. Or better yet, get an attorney before you ever file.

that was the first thing I told our neighbor when he mentioned he will need to apply. He has parkinson and other things going on - he use to be a truck driver. Meds/treatment isn't helping much.

he went from driving trucks to working in the repair/maintenance department - but even that is getting very difficult.

he has letters/doctors report etc.

told him he also needs a lawyer, and to start the paperwork rolling now.

[fed-up]

4. is it standard for Social Security to send me to a chiropractor for evaluation for neck issues? nt

[wolfgangmo]

8. IME's

IME's or "Independent" Medical Examiners. As an administrator of a medical clinic I can tell you that IME's are not independent and are not unbiased. In fact in our experience and the experience of our colleagues we have talked to about IME's, they NEVER give a report that doesn't find that the patient isn't all better and able to return to work immediately.

They are paid outrageous money <$1500 for 15 minutes exam and writing a report - let's call it between $3000 and $6000 per hour> to take deny people. The insurance companies maintain the fiction that these people have no incentive to give anything other than an unbiased view.

Another fact is that doc's who do IME's are considered scum by other docs. They are usually the docs who don't have a regular practice of their own and frankly couldn't maintain one

And finally a story. I had the occasion to talk to the IME of one of our patients recently. I pointed out that he had made many verifiable mistakes in his report which we could substantiate with X-rays, MRI's etc. This was not my opinion versus his opinion. He said that the follow up x-ray and MRI showed that the disk of our patients spine was healed when it clearly showed that it was still damaged. The X-ray and MRI reports stated that in plain english .

He just shrugged and said he stands by his report and so does the insurance company that is dropping all coverage of this patient. As we wrapped up the meeting I asked him how he slept at night. He looked at me like something he had stepped in on the road and then said, "in a much nicer bed than you can afford, I'm sure." What a sanctimonious prick.

This is what happens with SS and with private insurance. The system is broke. We need to take private insurance out of the game completely. And we need to get the private insurance lobbyists out of the game of writing the rules for SS and other government bodies.

FYI, this just in. The USA just moved down the food chain again. A national survey for ER's found that wait times in ER's is getting pretty lengthy. We now wait longer than Canada, most of latin america, the EU, and large swaths of asia. Who are we still ahead of? Africa. Why is this important. Because divot-heads will still chant that there are long wait times in Canada and England, but that is only true in elective surgery. In ER's in those countries you are seen ASAP and you don't get a "sell my house" bill for it. AND they do it for less than half of what we spend per person.

Go America. Were number 47. Were number 47. Were number 47. It doesn't have the same ring to it as number 1, does it?

[Laelth]

14. Welcome to DU!

I handle workers' compensation cases, for workers against employers, and my experience comports with yours. IMEs are performed, usually, by paid hacks, and the results are usually the same ... no injury here, nothing to see, insurance coverage denied.

This system is broken.

:dem:

-Laelth

[happyslug]

11. Chiropractor are NOT a medical source according to SSA.

So Social Security should NEVER send you to a chiropractor. Instead SSA should sent you to an orthopedic surgeon. The problem is most such surgeons want to be paid more money then SSA is willing to pay, so it is difficult to get such a review.

Now, SSA will review any records a Chiropractor has on your condition to give the Administrative Law Judge (ALJ) a better idea on how bad is your condition, but only SOAP notes prepared by the Chiropractor who had been treating the claimant. You will still need notes from a orthopedic surgeon as Medical evidence that you have something wrong with you. The SOAP notes only go to issue of how bad is the underlying condition affecting you. Thus the Chiropractor will be treated like your own testimony and any one else' testimony on how your medical condition affects you, up to the ALJ to decide how much weight to give to the reports, NOT to the issue if you have an underlying medical problem.

[Laelth]

16. I have to send some of my Clients to a chiropractor.

When they're injured, and the company they worked for has fired them (because they got injured), and all medical treatment has been denied because nobody's willing to pay for it, I have to send my clients to a chiropractor who will at least diagnose the injury (via x-ray and/or MRI, usually) so that I will then have some medical records to take to the Court to prove that my client is actually injured. These doctors work for free on the promise that, if I win in Court, they can get the bills for their services paid.

However, without me as an attorney, promising to pay them out of what my client may recover, these people would have no medical treatment at all.

While I've never been to a chiropractor, I have a soft spot for the ones who work with me toward the ultimate goal of vindicating the rights of my clients to receive at least some medical attention when they're injured.

-Laelth

[happyslug]

21. My local office is very anti-Chiropractor, and is supported by the Federal courts in this.

Under Pennsylvania law a person who is applying for Social Security can get Public Welfare (On the Condition he agrees to pay DPW back if he wins) and with that Grant he gets a medical card (Which many, but not all, doctors take). Now DPW will pay for Chiropractor visits, but given SSA hostility to them, generally a waste of time. There are 1-2 Orthopedic Surgeons in the area who will review such cases locally so I send my clients to them (Or I wait for Social Security to sent my client to them for an consultative exam, SSA pays more then DPW will).

[Laelth]

23. If we had that option in Georgia ...

... I'd be sending my clients to DPW. Then they could go to a doctor of their choice, as opposed to the doctor of last resort. Wish I lived in a civilized state.

Of course, if we had a single-payer health care system, we wouldn't even be having this discussion.

:dem:

-Laelth

[fed-up]

18. he is listed as a "orthopedist" and SS is paying for the exam-what are SOAP notes?

He also happens to have been trained by my former, now deceased chiropractor from Sonora.

I am also recently diagnosed bipolar, 49, speak English and have an AA. Can I pm you later with my questions?

[happyslug]

19. SOAP Notes are the records Chiropractor keep

I forget what SOAP stands for, I have just seen them in the SS medical records. I should say that is what my local Chiropractors call their medical records.

As to bi-polar, the issue is what HOW does it prevent you from working, generally if it makes you miss 2-3 days per month you are unemployable, but this will NOT come out till the ALJ hearing. In the ALJ hearing, in my area anyway, a Vocational Expert (VE) is always present and he testifies as to what jobs with with certain limitations can do. I have to advise my clients to listen to the Question of the ALJ to the VE, for the VE is answering that question NOT what my client is capable of doing. Some ALJ start out with "A hypothetical Claimant with the age, education and Work Experience of the Claimant,what jobs can such a person do". Notice NO LIMITATION IN THAT QUES ION. The VE will report all types of jobs for such a person. The ALJ then will slowly add restrictions till the VE says "There are no jobs that exist in substantial numbers in the National Economy" and stop the questioning. Notice I said SOME ALJs, most go to the heart of the issue and add restrictions from Question one, but the VE is only answering the question NOT saying what my client can do.

In Bi-Polar cases, the issue is how many days will you be off task. The Vocational Experts (VE) always say if you will miss more than one day a month constantly, you are unemployable. The issue when it comes to any psychological problem is HOW BAD IS IT? If mild, will not prevent you from working. Winston Churchill, England's WWII Prime Minister, was a known Manic-Depression (Using the term of the time for what we now call "bi-polar"). He puled some dumb moves when depressed (His Ordering the Royal Navy to sink the French Fleet as France was taken over by the Nazis is the best known), but overall he did his job and thus would have been ruled "Not Disabled" by SSA.

My point is SSA is concern more about how the disability affects your ability to work then what the disability is (Through both are related).

As to contacting me, I have no problem with you doing so, just remember it may take me a few days to respond.

[loves_dulcinea]

22. soap notes

subjective: what the patient complains of

objective: what you notice when you examine the patient

assessment: your idea of what is exactly wrong with the patient

plan: your idea of what it will take to alleviate the patient's condition.

iirc

[jonnyra]

7. In America

its profit over people
religion over reason
aggression trumps compassion

Immorality is the reality and the republican party is responsible.

[melm00se]

9. if you dig into numbers

you will see some scary trends:

70% of disability claims are denied on the 1st pass
That number is even higher when claims are reconsidered (1st appeal) ~85%

these 2 numbers alone indicate that it will take quite a bit of time from application to approval for SSI benefits.

that is truly sad and is one of my biggest fears with health care: overworked, understaffed faceless bureaucrats making decisions from their cubes.

[cap]

10. my husband's cousin was denied...

flat on his back with a ruptured heart... surgeon couldn't close the wound for months... so the poor man was flat on his back with all kinds of tubes sticking out of him with his heart open for all the world to see.

His wife kept going to the SSDI office to wait for her answer and finally, after a big delay, it was denied.

She then called me and I told her the system is broken...find some one who knows somebody and it will go through. Finally hit on the right judge, sent the pictures and medical report in. It was approved within a week.

[melm00se]

20. and from what I understand

(and remember from my days in banking as the manager of collections dept) your husband's cousin is not alone.

If we are not very careful, we may end up exchanging one bureaucracy for another...equally unresponsive and capricious in it's decision making.

[rodeodance]

12. so so sickening

[JPZenger]

13. Merck Miracle Drug

There was a story on public radio yesterday about Merck's fake miracle drug. They said that a medical organization had recommended that doctors try to get certain patient's colestoral levels down to 70. Many doctors realized that no current drug could do that. 13 days later Merck announced its new drug. It turned out that almost all of the doctors on the board of that organization had financial ties to Merck and the other drug company that was involved.

---
The CBS news report was interesting in that the Social Security Admin. chief admitted that the system was completely screwed up, and didn't try to make any excuses.

[eShirl]

15. k&r

[Delphinus]

24. Kick.

Everyone needs to read this.

[Tansy_Gold]

25. Kick, with a story from the other side

Details are too depressing to go into, but briefly:

When my husband's cancer rendered him disabled in June 2005, I helped him fill out the paperwork to apply for SSDI. We did not know at the time how far the disease had spread; we did know that if he was approved for disability, payments would not commence until January 06. We were notified only that his application had been received, was being reviewed, and we would be contacted if SSA needed additional information.

He died in July 2005, long before SSDI payments would have commenced. I received no further communication from SSA on his application.

In October 2007 I learned, to my total shock, that monthly SSDI payments had been deposited to MY checking account beginning in January 06. I immediately contacted SSA to make arrangements to return the overpayment. I heard nothing from them until two "special investigators" showed up at my front gate one day last week to interrogate me about how could I possibly not know the money was in the account.

The system is broken, and broken in ways that most people won't even look at. Sometimes it's the hidden breaks that can cause the most ultimate damage.

(Don't even get me started on the mortgage industry. . . . . . . .I have an appointment with a lawyer for next Tuesday to try to deal with the screw-ups on what should have been a simply mortgage pay-off. . . . . . .)

Tansy Gold, disgusted