A common question we get from our clients is how their medical file is developed. How your medical file is developed and who develops it is affected by what level the appeals process is at – Initial (when you first apply), Reconsideration (appealing an initial denial), or Hearing level (when you see a Judge about your case).
Generally, file development is the same at the Initial and Reconsideration level. At these levels, the claim is assigned to the local Social Security Administration (SSA) Office. This office handles everything from name changes, marriage certificates, initial and reconsideration disability claims and everything else in between. The local SSA office is responsible for gathering information from the claimant and the claimant’s attorney. Typically this results in the claimant receiving forms such as Work History or Adult Function reports or other such forms that provide them the background information they need. Often the claimant will receive the same forms at both the initial and reconsideration level. This is so the SSA can ensure they are getting up to date information. From the information they gather, the adjudicators at the SSA are able to request medical records from the claimant’s medical providers. At this level of the claims process, SSA is responsible for developing the medical file for the claimant; and they do this at no cost.
Specifically in regards to developing the medical file at the Initial and Reconsideration levels, the claimant’s attorney is responsible for getting medical updates from the client and making sure SSA is aware of these updates. The representative should also strive to gain Medical Source Statements from the claimant’s treating doctors. It is very important to keep your representative up to date on all medical information especially if a client receives a new diagnosis or starts seeing a new medical provider. Once the firm receives this new information, the paralegal in charge of the case will report it to SSA, and they will in turn request medical records directly from the new medical provider.
Unfortunately, we have found that oftentimes claims are denied and some medical providers are not even listed on the denial as being reviewed during the decision making process. This is obviously very frustrating to a client who has already been waiting so long for a decision. We don’t always know why this is the case since the SSA doesn’t allow the client or the attorney access to the client’s electronic file at the Initial or Reconsideration level; however, the most common reason is that the SSA requested the medical records, but the medical provider did not provide the records back within the time frame requested and therefore those records weren’t reviewed during the decision making process. It is important to note though, that in our experience, even when SSA has reviewed all of the medical evidence and has received the entire medical file, the claimant’s chances of being denied at the Initial and Reconsideration level are still extremely high given the fact that SSA tends to give a rubber stamp denial to most people at these stages of the claims process.
If the claim is denied at the Reconsideration level, the firm files a request for hearing and the case moves from the local SSA office to the local ODAR (Office of Disability Adjudication and Review). ODAR facilitates the local Social Security Disability Hearings. Once at the hearing level, the law firm can get access to the client’s entire electronic file. This allows the firm to see what medical records have been received and what medical records still need to be obtained. Because ODAR does not request medical records at this level, it is up to the client’s representative to request all the remaining medical records needed to support the client’s claim and submit it as evidence.
Since it can take anywhere from 12-18 months for a hearing to be filed, the law firm may wait several months to order medical records. This done for two main reasons: first, this is to keep the cost of the case low for the claimant; second, the firm wants to submit the most up to date medical information to the ODAR office. As we all know, a lot can change in 12-18 months, for better or for worse, and the most current information is what is relevant to and supportive of a clients claim.
At the end of the day, it is imperative that your representative has the most up to date information about your medical treatment history prior to your hearing. The hearing is the level at which you have the highest chance of winning your case and the Administrative Law Judge really does pay attention to your medical file (unlike the adjudicators at the Initial and Reconsideration level). Also, your attorney will rely on your medical records at the hearing level to prove and argue your case to the Judge.
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Atlanta Divorce Law Group