When applying for disability benefits, such as Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), the claim process relies heavily on medical evidence. The Social Security Administration (SSA) requires objective evidence from acceptable medical sources to establish a medically determinable impairment. While claimants submit their own medical records, the state-level Disability Determination Services (DDS) may find this evidence insufficient. In these cases, the DDS arranges an independent medical evaluation to gather necessary additional information.
Understanding the Consultative Examination
The independent medical evaluation ordered by the DDS is formally known as a Consultative Examination (CE). The agency arranges and pays for this examination when the claimant’s existing medical records are outdated, incomplete, or contradictory. The CE provides a current, objective snapshot of the claimant’s condition and functional limitations to help the agency make an informed decision.
CE Requirements
A CE is a one-time assessment and is not a form of ongoing medical treatment. The doctor focuses on specific medical questions related to the claimant’s ability to perform work-related activities. Failure to attend this scheduled appointment can result in the denial of the disability claim. Although the claimant’s treating doctor is the preferred source, the DDS will arrange a CE with an independent physician if the treating doctor is unable or unwilling to perform the required assessment.
Medical Professionals Conducting Physical Assessments
For claims involving physical impairments, the Consultative Examination is performed by licensed physicians, either Medical Doctors (MDs) or Doctors of Osteopathic Medicine (DOs). These doctors perform a focused examination and report their findings to the SSA. The CE doctor reviews the claimant’s medical history, performs a physical examination, and may order diagnostic tests like X-rays or blood work to support their findings.
Specialist Utilization
The physician conducting the physical CE is often a general practitioner, but specialists are utilized for specific conditions. For instance, an orthopedic injury claim might require an orthopedist, or a neurological disorder claim might necessitate a neurologist. In some states, the DDS may use other licensed health professionals, such as Nurse Practitioners (NPs) or Physician Assistants (PAs), who work under the supervision of an MD or DO. The selection depends on the professional’s qualifications and experience relevant to the impairment being assessed.
Mental Health Professionals Conducting Assessments
When a disability claim is based on a mental health condition, a psychological or psychiatric Consultative Examination is scheduled. These CEs assess the claimant’s cognitive function, mood, and behavioral limitations. They are conducted by licensed psychologists or by psychiatrists, who are physicians specializing in mental health. Both professionals are considered acceptable medical sources by the SSA for providing opinions on mental impairments.
Roles of Psychiatrists and Psychologists
A psychiatrist, as a medical doctor, can diagnose, treat, and prescribe medication, offering a medical perspective on the disorder. A psychologist focuses on administering standardized psychological testing, assessing intellectual capacity, memory, and concentration. The resulting report, often called a Mental Status Examination, details how the mental impairment affects the ability to function in a work setting.
The Distinction Between Treating and Examining Doctors
A key difference exists between the claimant’s treating physician and the CE examining doctor in the disability determination process. The treating physician provides ongoing care, has an established relationship with the claimant, and possesses long-term knowledge of the condition. The examining doctor is an independent contractor who conducts a single, brief evaluation solely to provide an objective report to the disability agency. This CE doctor is bound to the agency, not the claimant, and does not establish a doctor-patient relationship or provide treatment.
Weight of Evidence
The SSA evaluates all medical opinions based on their supportability and consistency with the rest of the evidence, known as the “weight of evidence.” For claims filed after March 27, 2017, the treating physician’s opinion is no longer automatically given more weight than the CE doctor’s opinion. Instead, the persuasiveness of any medical opinion depends on how well it is supported by objective medical evidence, such as test results, and its consistency with other evidence in the record. The treating physician’s long-term knowledge remains influential, provided the opinion is well-supported with clinical findings.