The Medical Exam or Consultative Exam for Social Security Disability

If Social Security sets up for a doctor's appointment, make sure you know the who, what, and why of consultative medical exams.

Consultative examinations are medical examinations that Social Security disability and SSI claimants are sometimes sent to in the course of processing a claim for disability benefits.

In cases where a claimant's medical records are "thin" (there is not enough evidence) or where a claimant has not been seen by a doctor for a considerable amount of time, the DDS claims examiner will generally schedule a consultative exam.

Who Performs a Consultative Exam?

Consultative exams (CEs) are not conducted by doctors who work for the Social Security Administration (SSA). The doctors who perform consultative examinations for the SSA are independent physicians who have contracted to perform such services for the SSA.

What Is the Purpose of a Consultative Exam?

Medical exams conducted for Social Security objectives are not for the purpose of delivering medical treatment. Instead, their purpose is to provide a recent snapshot of a claimant's conditions and various limitations. Consultative exams can be physical, psychiatric, or psychological in nature. They can also include ophthalmological exams, blood work, and the taking of x-rays. What happens at the medical examination is at the discretion of the disability examiner ordering the exam. The examiner obtains only what is necessary for a decision to be made.

Are There Problems With Consultative Exams?

Consultative medical examinations are not necessarily the best way to get evidence to decide a disability claim. For one thing, a doctor who conducts a consultative exam has typically never seen a claimant (the disability applicant). And though DDS examiners often send a portion of a claimant's medical records to the physician who will conduct the CE (to inform the doctor of the patient's medical background), some CE doctors don't actually read the file ahead of time.

Additionally, Social Security medical exams tend to be fairly brief. It is a common complaint among claimants who have gone to CEs that the duration of the exam was only five to ten minutes. Sometimes a comprehensive consultative exam won't be scheduled; for example, when the claimant is sent to only have an x-ray or a straight leg raise test.

What Does It Mean if a CE Has Been Scheduled?

Getting an appointment letter for a Social Security medical examination means, at the very least, that a claim is actively being worked on. In some cases, it may be that a claims examiner who is leaning toward making an approval needs to obtain additional evidence, such as an x-ray.

However, a CE appointment can also mean that a claimant has very little in the way of medical records because he or she has not gone to a doctor in a long time, or has been treated by a doctor only sporadically. In such cases, the scheduling of a consultative examination may simply be a technical necessity before a claims examiner denies a claim (examiners are required to obtain "recent" medical evidence on which to base their decisions).

Since you won't know the reason for the exam, don't be overly concerned about having to go to one.

What Happens if You Miss a Social Security Doctor's Appointment?

If you don't go to the consultative exam that Social Security arranged for you, and you don't reschedule it, your disability claim could be decided without medical evidence from the consultative exam. In all likelihood, this means you would be denied for failing to attend a consultative examination, and you would have to appeal to have your case looked at again. At that point, you would either have to pay to go to your own doctor or hope that the administrative law judge (ALJ) would send you to another consultative exam.

If you had a good reason for missing an appointment that you confirmed, the claims examiner will usually allow the exam to be rescheduled. A good reason would be illness, death in the family, or unexpected transportation problems.

To reschedule an appointment, call your disability claims examiner. The notice you received about the consultative examination should include the phone number to call. Write down the day and time you called and who you spoke to, in case Social Security later says that you didn't reschedule the appointment.

What's in a Report from a Consultative Exam?

The consulting doctor who performs your consultative exam will send a written report about the results of the physical examination, positive or negative findings, and the results of any tests you took. The doctor will typically also include a diagnosis and prognosis of your condition and a statement about what you are capable of doing, such as how many hours you can stand or walk and how many pounds you can lift.

The doctor may also include notations on his or her opinion of whether your symptoms are as serious as you say. For instance, the doctor could note that you were able to get out of your vehicle with little or no difficulty, or that the doctor did not feel that you gave your best effort during the examination. Consulting doctors do see some disability claimants who are malingering (faking the severity of their condition), so they will be on the lookout for this. Remember that Social Security doctors are evaluating you from the moment they see you, not just during their physical or mental examination. For more information, see our article on trusting a doctor hired by Social Security.

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