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In this lesson, we introduce
you to the concept of Sequential Analysis and how
this procedure is used in the evaluation of a Social
Security disability case.
Before diving into SA, let’s review the steps
in case processing.
CASE PROCESSING REVIEW
What is
Case Processing?
Case
processing
is a general term used to describe the process of
taking a case through the Social Security
Administration (SSA) procedures that ultimately lead
to an allowance or denial decision. There is
no single correct way to represent a disability
claim. Processing procedures can be very
different for different cases. In this lesson,
we’ll focus on SSA's case processing procedures from
the representative’s standpoint. This training
segment will also discuss at what point a
representative should initially get involved in the
disability case process.
Case processing
essentially involves six steps:
1.
Client
Interview
2.
Case
Assessment
3.
Case
Acceptance
also referred to as Intake
4.
Case
Development
5.
Case Evaluation and Argument
Creation
6.
Receipt
of the SSA Decision
We
will now go through these steps for the first time.
Then we will get into increasing depth on the
steps as we proceed through the lessons.
Step
One: The
Initial Interview
In the
Disability Associates approach to representation,
case assessment starts with a potential client
interview, which is usually done over the phone.
This is an important screening step that was first
introduced to you in Lesson One.
In the interview, look for findings that may destroy the case at a
later time. The following conditions are
examples of cases that probably won’t be successful:
·
The claimant has never seen
a doctor for his/her condition
·
The claimant does not
appear to have a severe impairment
·
The claimant was
incarcerated during his/her impairment
·
The claimant is suspicious
or evasive
·
The case appears weak or
unbelievable
If the claimant is suffering
from a progressive disorder that may worsen, simply
take the claimant’s information and check back in a
few months. We
call this follow-up approach to client management
the Guidance Package. We
will explain this approach later.
Step Two:
Case Assessment
The
purpose of a case assessment is to determine the
chance of winning a case before you accept it for
representation. Under
Social Security's contingency fee rules, you’re only
paid for cases that result in a benefit payment to
the claimant. Therefore, the case assessment
process is really a screening system designed to
increase the number of cases you win.
The more
cases won, the higher your overall income!
A case assessment weighs certain characteristics like the client's
age, education, type of impairment, etc., to
determine the client's chances of winning benefits.
As discussed in Lesson One, it can take years to
develop the skills needed to perform an effective
manual case assessment with any accuracy. That’s
why we created the Olivia 2.0© auto-assessment tool
to give you the benefit of our experience in
evaluating cases.
A Closer
Look at the Case Assessment Process
The determination of a case’s viability is actually never complete
until the case is closed. New issues can come
up at any time during the adjudicative process, and
can increase or decrease your chances of winning the
case.
Disability Associates is generally able to determine viability
early in a case due to our years of experience.
However, even for us, not every case that
looks viable at the start results in an allowance.
We have designed a systematic case assessment
process to increase your chances of accepting only
winnable cases.
Our method is far superior to the
shot-in-the-dark approaches used by many attorneys
and ex-SSA employees who are operating in this
field. We’ll teach you this method later in
the course. For now, our aim is just to ensure
that you recognize
that the
case assessment process is important.
Step Three:
Case Acceptance
Once
you have ascertained that a case is viable, it's
time to for the Intake step.
Accepting a case begins by sending the client
an Information Packet containing your company
information, an instruction sheet and the necessary
Social Security forms, medical release form, fee
contract, fee petition form, etc., for the client’s
signature. The
most important form in the information packet is
the “Authority to Represent” form, also known as SSA
Form 1696.
Once the applicant signs and returns the forms, you will forward
some of them to the applicant’s local Social
Security District Office. This notifies SSA that you
will be the claimant’s Advocate, which begins your
official representation process. These materials
also authorize you to make requests of the SSA and
to inform them of issues later in the case.
If you’re using a fee contract -
and you should! – include
a copy of your signed contract with Form 1696.
SSA will add these two vital documents to the
claimant’s folder. If at a later date you need
to interact with SSA on behalf of your client, these
verify your authority to do so.
Note:
We prefer the fee petition to the fee
contract billing approach.
In the fee petition you will list your work,
making it harder for SSA to deny the total amount of
your fee.
We’ll address this issue in more detail later
in the course.
Once you’ve established yourself as the claimant’s authorized
representative, you’re ready to develop the case.
Step Four:
Case Development
Case development
is a two-phase process in which you gather all
relevant medical and vocational information (Phase
One) in order to construct an argument (Phase
Two). How much case development you need depends upon the case’s
complexities and the case level. If you enter
a case at the
Initial Level, the claimant hasn’t yet submitted an application.
You need to acquire as much medical evidence
as possible to formulate a case strategy prior to
approaching SSA.
If you enter a case on the
Reconsideration or
Administrative Law Judge Level, the claimant has
already applied and been denied. SSA will have
copies of everything used in the prior decision.
Therefore, you can request medical and vocational
evidence directly from SSA. However, there may
be more evidence out there that will be necessary to
win the case.
Because there are so many potential information sources, we
recommend that you always start with the claimant.
Get him/her to supply you with copies of any
evidence in his/her possession as well as with
contact numbers for all doctors and medical
institutions involved. As the Authorized
Representative, you can directly request anything
else you need from SSA or directly from medical
sources.
Case
development is not over until you’ve got enough
evidence to support your argument for a total
disability.
Case Evaluation:
Phase One of Case Development
Case Evaluation
is the process of reviewing a claimant's medical and
vocational records for the purpose of creating a
case argument. As the Advocate, you have both
the power and responsibility to disagree with SSA's
opinion if it would result in a denial decision.
You demonstrate your disagreement with SSA by
pointing out medically supportable signs and
symptoms that appear to further reduce your client’s
ability to perform work. You present your
findings to SSA for consideration as part of the
decision-making process.
Example:
SSA states that your client, a construction worker who is suffering
from heart disease, can still perform less demanding
sitting work. You counter that argument by
pointing out that SSA did not take into account the
client's back condition. You point out this
condition’s effect on the claimant’s ability to
work, and present medical evidence supporting this
alleged limitation. As
a result of severe back pain, the claimant is unable
to sit for more than fifteen minutes without
experiencing increased pain, stiffness and numbness
of the lower extremities. In our example these
findings weren’t taken into account by SSA for
whatever reason, but you can support them with valid
medical evidence.
You conclude that this severely limits the
claimant's ability to adapt to work that requires
sitting.
Upon
receipt of your argument, SSA must decide if the
claimant can perform less demanding work that
requires the ability to sit. As we mentioned
in Lesson One, this is “The Game”, which pits your
ability to create a strong argument for allowance
against SSA’s ability to create a strong argument
for denial.
The object of “The Game” for the Advocate is
to find subtle but important medically supportable
signs and symptoms that further reduce the
claimant's perceived ability to perform work.
Argument Creation:
Phase Two of Case Development
Once
you’ve completed your evaluation of the medical and
vocational evidence, you will create a list of facts
that support the claimant’s alleged limitations.
You then use your documentation to:
·
Establish
the alleged impairment’s existence
·
Describe
its severity
·
Explain
how the impairment limits physical and/or mental
capability
·
Explain how the alleged limitations limit work
The Advocate then boldly asks that the case be
allowed and benefits be paid!
As discussed in Lesson One, the argument is usually
three to six pages in length, and is a critical part
of winning the claimant’s case. To construct
an effective argument you will have access to the
argument development training program within the
Olivia© system: MemoWrite
Composer©.
We suggest that you wait until you’ve
completed all of the basic training lessons before
reading the MemoWrite© information, as it will be
easier to understand at that time.
When you’re ready, you
will access this program by visiting your training
control panel and clicking on the MemoWrite© link.
Step Five:
Argument Submittal
After
evaluating the client’s medical evidence and
creating an argument, you submit your work to SSA,
which must consider your evidence before making a
final decision. The submittal of a trained
professional’s carefully constructed argument will
increase your client's chances of receiving
benefits.
This is how you earn your fee.
Step Six:
Wait for the Decision!
Once SSA has gathered and
reviewed all known evidence including your argument,
they’ll make a decision. At this stage, you’ve
done your best job and can only wait.
Sometimes SSA will contact you and request
additional information. Cooperate to the max!
Having said this, remember you’re not obligated or
required to perform actions that would hurt your
client's case - with the exception of providing
requested evidence.
Do not
withhold evidence even if it hurts your client’s
case.
However, you are not required to point out
anything that you feel is harmful to the case – just
supply it without comment.
Depending on the detail and location, SSA may
never notice it anyway and you’re not obligated to
bring it to their attention.
The Decision
If the decision is a
denial, you will either drop the case or begin the
appeal process, depending on the individual case
circumstances. We’ll discuss both dropping and
appealing a case later in the course.
For now, it is time to get
to the main topic of this lesson:
Sequential Analysis.
Sequential
Analysis:
SSA’s Application Review Process
A
disability application usually begins at the Social
Security District Office (DO). The DO is
responsible for determining
the applicant's non-medical eligibility to
apply for benefits. The DO staff may also
initiate the request for copies of the applicant’s
medical evidence. Once the DO determines the
applicant is eligible to apply, the case is
transferred to a State or Federal Disability
Determination Section. Transferral usually
takes about two or three weeks.
When a case first arrives at the DDS, it is assigned
to a Claims Examiner.
The Examiner begins the case development
process by requesting any medical and vocational
records that have not arrived as a result of a DO
request. The records are used to determine
impairment severity.
As
discussed in Lessons One and Two, the Examiner
reviews the claimant's medical documentation
applying a special internal process called
Sequential
Analysis (SA). SA is a flow chart
procedure that clearly defines the point in the
evaluation process at which the denial or allowance
decision is made. (View Sequential Analysis
Chart).
It is a systematic tool that removes the emotional
element from the review of a claimant’s medical
documentation.
Understanding the SA process is important to
your future effectiveness as a Disability Advocate.
In its most
basic form, SA is a series of steps driven by a
series of questions which are answered in the case’s
medical documentation.
The process is outlined below.
Step One/Question One:
Does the claimant have a medically determinable impairment?
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Note:
The
answers to the SA questions determine the
reason for allowance or denial of a case.
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If the
answer is
no, the DDS Examiner will write a denial decision based on the
reasoning that there is no significant impairment
that reduces the claimant's ability to perform work.
If the answer to the first question is
yes, the
Examiner will move to Question 2 in the SA process.
As a
Disability Advocate, follow the SA steps just as the
DDS Examiner does.
You can then effectively counter the
Examiner’s opinion using a more favorable
interpretation of the same facts.
You can also add other supportive evidence
that may not have been considered by the Examiner.
Sequential Analysis tells us how the DDS Examiner
made his/her denial decision. It’s a lot
easier to develop an argument for reversal when you
understand specifically why the case was denied in
the first place.
Step Two/Question Two:
Is the Impairment severe?
A
no answer
results in a denial of the case. If the answer
is yes,
the DDS Examiner moves to next step.
Step Three/Question Three:
Will the impairment last for twelve continuous months?
If the
answer is no,
the case is denied based on
duration.
SSA’s definition of a total disability is that the
impairment will last or be expected to last for
twelve continuous months. A
yes
answer moves the DDS Examiner to Step Four.
Step Four/Question Four:
Does the impairment meet or equal the medical listing?
The medical listing is a
book used by SSA Examiners to determine the degree
of impairment. If a claimant’s condition
meets or equals this listing, the case will merit an immediate
allowance.
This
happens in about 10-15% of disability claims.
If the
impairment
does not meet or equal the listing, the DDS
Examiner moves to Step Five.
Step Five/Question Five:
Can the claimant still do his/her past work?
If the
answer to this SA question is
yes, then
the case is denied. If the answer is
no, the
DDS Examiner moves to the final step.
Step Six/Question Six:
Can the claimant perform
other less demanding work?
If the
answer is yes,
the case will be denied. If the answer is
no, the
case will be allowed based on the claimant’s
inability to perform even less demanding types of
work.
The
majority of adult disability cases are allowed or
denied based on SA Step Five or Step Six.
Determining the Reason for a Denial
The SA
process makes it fairly easy to determine why a case
is denied. However, there are other ways.
Let’s say a claimant has just received word from the
DO that her initial application was denied.
She is eligible for a Reconsideration Appeal and has
come to you for help with her case. You're
entering the case at the Reconsideration Level and
you're wondering why the case was denied at the
Initial Level.
You
receive your new client's medical and vocational
reports from various sources including the SSA
office. Now ask yourself:
On what basis
was the client denied? Or to put it
another way,
what was the issue used by SSA to deny the claimant
benefits at the Initial case level?
The answer can be determined in either one of two
very simple ways.
Method One:
The Personalized Denial Notice
The
first method you can use to determine why SSA denied
a case is to review the claimant’s
Personalized
Denial Notice (PDN), which explains the basis
for denial. Request
a copy of the PDN when you take the case, either
from the claimant or directly from SSA.
Method Two: The
Technical Rationale
The
Technical Rationale is a formal version of the PDN.
The only difference between a PDN and a Technical
Rationale is that a PDN uses everyday language and a
Technical Rational uses technical language.
Because it is a technical paper, the Technical
Rational also provides a more in depth explanation
of the decision.
Our
Technical Rational example below contains most of
the information you need to determine why the
claimant involved was denied benefits. Once you have
determined at what point in the SA process the case
was denied, you're ready to begin creating a
strategy to counter SSA’s opinion.
Sample
Technical Rationale:
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The claimant is a 34-year-old individual
who has alleged disability due to a back
disorder. The medical evidence
shows a significant impairment that does
not meet or equal the listing. The
evidence also shows that despite
impairment, the claimant is still
capable of performing work at a medium
Residual Functional Capacity. It
appears that the claimant is capable of
returning to the duties of his past work
as a truck driver. In making this
decision, the SSA considered the
claimant's age, education and the
required physical and mental duties of
his past work and found him capable of
performing his past work.
Accordingly, he is found
not disabled as defined by law.
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Review of sample Technical Rationale:
Let’s
identify the pertinent information in the above
Technical Rationale.
We know that:
1. The
claimant is 34 years old
2. He has
alleged that a back disorder prevents him from
performing work
3. He has a
significant impairment (his impairment is serious
enough to cause a physical restriction)
4. His
condition does not meet or equal the listings.
5. The
claimant has a Residual Functional Capacity rating.
This is SSA’s opinion of the claimant’s
remaining capabilities, taking into consideration
the limiting impact of the impairment.
The fact that SSA applied an RFC rating to
the case suggests that the claimant may actually be
suffering from a severe impairment that is indeed
causing physical limitation.
Another
Method:
The SA Chart Tells All
You can
find out why a case was denied without the PDN or
Technical Rationale. How? You let the
client tell you the reason for the denial. He/she
will usually say something like, "SSA
told me that I’m still able to do my past work.”
You would then look at the SA chart. Comparing
the information that you got from the client with
the SA flow chart, you will find that the general
reason for the denial decision was either in Step
Five or Step Six. SA Step Five indicates that
the claimant can still perform his/her
past work
with consideration of the limiting affects of
his/her impairment.
If the denial took place at Step Six of the
SA process, the indication is that he/she cannot
perform his/her past work, but is able to perform
other less
demanding work.
Residual Functional Capacity
As you recall from Lesson
Two, Residual Functional Capacity (RFC) is
the remaining
ability to function that a claimant possesses
despite his/her impairments. It
is a
subjective determination that SSA makes
based on the medical evidence.
If SSA’s
RFC results in a denial, you have the right and the
responsibility to argue for a lower or more
restrictive RFC that would result in an allowance.
If your position on the RFC issue is supported by
the claimant's medical evidence, SSA may accept your
argument.
To Your Client's Advantage
Because
the SSA’s adjudicative staff must rigidly follow the
SA process, you’ll always know exactly what SSA was
thinking in formulating a denial decision.
This gives you a tremendous advantage in arguing a
case. By following the SA process yourself,
you know exactly where to focus your argument
against the denial.
This is like being told your enemy’s battle
plans by the General who was responsible for
creating them!
The
quality of your argument will almost always rest on
your ability to prove to SSA that limitations
suffered by the claimant have resulted in an
inability to perform any type of work. You must
clearly demonstrate in your argument that SSA did
not consider all of the claimant's physical or
mental limitations or that a severe impairment has
been overlooked in making the denial decision.
You must bring to the
SSA’s attention any impairment that they have
overlooked or that has developed since the decision.
You must explain and document how this new or
ignored impairment limits the claimant’s ability to
perform work. This
is the key to winning a Social Security disability
case.
An Informed Client is a
Happy Client
Make
your client aware up front that he/she may lose the
case at the Initial or Reconsideration Level.
This will reduce the claimant’s anxiety if the case
is denied. It’s also a good idea to inform the
claimant at the outset about the appeal process and
what to expect from each appeal level.
In most cases, the ALJ Appeal is your best chance to win.
This is because an ALJ can take into consideration
certain medical findings and physical restrictions
that cannot be considered by a DDS Examiner.
As a result, decisions at the ALJ Level are often
more favorable to the claimant. However, at
all levels it is important that to bring out all
physical or mental impairments that are causing
restrictions in the claimant's ability to perform
work.
IMPORTANT:
Whole Body Principle
The term “Whole Body”
refers to a little known policy within the SSA
rules. This policy essentially states that SSA
must consider the effects of all alleged severe
impairments in determining the claimant’s final RFC.
However, SSA will only consider impairments that are
brought to their attention.
It’s your job as a Disability Advocate to
make sure all
serious impairments are considered.
This is critical to winning or losing your
case.
The main reason Disability
Associates Advocates
win up to 90%
of the cases they represent is because of our usage
of the Whole Body principle.
Each alleged impairment condition
results in one or more limitations.
When all limitations are added together, the
result is a more limited individual. The more
limited the individual, the less capable he/she will
be of performing work. Therefore,
use the Whole
Body Principle in every case to create more
limiting RFCs than those originally considered by
SSA.
Using the Whole Body Principle, identify all severe impairments in
the claimant’s medical evidence. Then consider
each condition individually and identify all its
limitations. Add all the limitations together
to formulate an RFC and present this data in your
formal argument. Any decision that involves an
RFC will be allowed or denied based on
Medical-Vocational factors.
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Important:
Always begin your argument at whichever
SA step that SSA used to deny the case.
With a few exceptions, this will be Step
Five or Step Six.
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What is Medical-Vocational
Basis?
Any case that SSA decides
based on the work issues of SA Steps Five and Six is
said to be based on
Medical-Vocational factors. This means
that, in view of the findings in the claimant's
medical and work history, SSA feels the claimant can
neither do his past work nor other less demanding
work.
The Vocational Analysis process is a cumbersome and time consuming
one. Disability Associates addresses it in two
unique ways. We have created a process called
Common
Sense
Vocational
Analysis© that enables you to bypass some of the
laborious research typically required. We also
created a software program that does much of the
analysis for you. If you're an Olivia© account
holder, you have access to our new
Voc RFC
Analyzer©.
It's the job of the DDS
Examiner to logically argue that a claimant is
not
disabled based on his/her ability to do either
his/her past work or other less demanding work.
It’s your job as the claimant's representative to
logically argue that closer analysis of the
claimant's evidence demonstrates that the claimant
cannot perform any type of work.
The secret to winning an SSA disability case
lies in your ability to create medically-based
arguments that a claimant is not capable of
performing any type of work. In future lessons
we’ll show you how to use medical and vocational
evidence to win a disability claim.
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Note:
In the online Program Syllabus,
we provide a link to the medical
listings and other important reference
materials used in Vocational Analysis.
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Summary
Sequential Analysis (SA)
is a systematic method used by SSA to evaluate each
disability case. SA enables both the DDS
Examiner and the Disability Advocate to quickly
determine the reason why a case should be allowed or
denied. SA also allows an Advocate to quickly
determine where to begin when creating an appeal
argument.
Lesson Four Preview
Lesson
Four teaches you how to use medical evidence in the
evaluation of a Social Security disability claim:
Phase One of
Case Development.
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