To Exam or Not to Exam...

A consultative exam (CE) is an appointment set for a disability claimant by SSA for the purpose of having that claimant undergo a medical evaluation.  The doctor, referred to by SSA as the “examiner," tests and observes either physical or mental/emotional disabilities, depending on the nature of the disability claim. The examiner then summarizes his or her findings in a report that is submitted to SSA. These tests are paid for by SSA and the examiners involved are physicians with their own practices contracted to do this work for SSA.

There are a few different reasons why SSA orders these exams, but it may not always be necessary and may even damage a disability claim. When a disability claimant has a representative, he or she can best determine as to whether the CE is necessary and can object to it if need be.  To the contrary, sometimes a representative may encourage SSA to order a CE when the medical evidence is incomplete or a representative believes there is an undiagnosed impairment.  This is often the case with mental limitations where remote school records suggest possible mental retardation.  In that case, SSA would have the ability to request IQ testing.

The foremost reason why CEs are ordered is when a claimant’s medical evidence of record (MER) is “thin,” meaning there is not enough information from the claimant’s treating sources to make a determination. Another reason is if the MER in the file is old and updated information on the claimant’s current condition is needed. There are also reasons beyond the claimant’s control, such as lack of cooperation from the treating source to release the records or pertinent, objective information such as diagnostic imaging or lab results are not included in the treating source’s records.

While this information could potentially help SSA find a claimant disabled, there is the possibility that it could also do the exact opposite. Because the examiner sees the claimant only one time, from a few minutes to possibly up to one hour, it is difficult to see the “whole picture” of a person’s disability and create an accurate report.

For example, a claimant suffering from back pain may be asked by the examiner to stoop, bend, crouch, etc. The examiner then records how well the claimant can do these things as well as for how long. If the claimant happens to do “well” on the exam (i.e: able to stoop, bend and crouch with little to no difficulty), the examiner will, of course, report same to SSA.

However, if the MER from the claimant’s treating providers shows that the claimant has been complaining to his doctor that he can no longer weed his garden or pick up his grandson due to back pain, this creates a conflict of information in the claimant’s file that SSA must sort out. Disability examiners must decide how much “weight” they can place on the examiner’s report compared to the MER already in the file. Typically, more weight is usually given to the treating providers’ opinions over that of the CE examiner, but it is a conflict of information nonetheless. If the claimant has a representative, he or she can object to a CE if it is felt that this sort of conflict would be created by the CE examiner’s findings.

Generally, people do not like to attend consultative exams and that is understandable. SSA tries to schedule the exam as close to where the claimant lives as possible, but sometimes that can still be quite a drive depending on where the claimant lives. Claimants are usually given a little under a month’s notice to make arrangements to attend the exam. Attending is vital, because if a claimant does not show, it is considered failure to cooperate by SSA and the claim can be turned down for that reason alone (unless the CE is objected to).

Because the issue of “to exam or not to exam” can be complicated, it is advisable for a disability claimant to obtain representation so he or she can determine whether or not a consultative exam would help or hurt the claim.

Written by Anna Westfall & edited by Attorney Andrew November


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