Social Security Disability Insurance (SSD or SSDI) is a payroll tax-funded federal insurance program of the United States government. It is managed by the Social Security Administration and designed to provide monthly benefits to people who have a medically determinable disability (physical or mental) that restricts their ability to be employed.
SSDI does not provide partial or temporary benefits but instead pays only full benefits and only pays benefits in cases where the disability is “expected to last at least one year or result in death.” Relative to disability programs in other countries in the Organisation for Economic Co-operation and Development (OECD), the SSDI program in the United States has strict requirements regarding eligibility. A legitimately disabled person (a finding based on legal and medical justification) of any income level can receive SSDI. (‘Disability’ under SSDI is measured by a different standard than under the Americans with Disabilities Act.)
Trends
At the end of 2020, there were 9.7 million Americans receiving benefits from theSSDI program. This included 8.2 million disabled workers, 1.4 million childrenof disabled workers, and 0.1 million spouses of disabled workers. Children andspouses are sometimes referred to as auxiliary beneficiaries because theyreceive benefits based on their relationship to a disabled worker, not becausethey are necessarily disabled.
The number of beneficiaries multiplied between 1990 and 2010 before leveling offand then declining in recent years. Two schools of thought developed to explainthe rapid growth in the program during the 1990s and early 2000s.
According to David Autor and Mark Duggan, policy changes and earnings patternswere responsible for the growth. About policy, Autor and Duggan argue an SSDIreform act loosened the disability screening process, leading to more SSDIawards and shifting their composition towards claimants with low-mortalitydisorders such as mental illness and back pain.
About earnings patterns, Autor and Duggan argue SSDI benefits rose in valuerelative to what recipients would have earned from employment, prompting moresignificant numbers of individuals to seek blessings.
The second school of thought on program growth in the 1990s and early 2000semphasized demographic factors such as population growth, aging of the baby boomgeneration into their disability-prone years, growth in women’s labor forceparticipation, and the increase in Social Security’s full retirement age from 65to 66.
The number of disabled workers peaked in 2014 at 9.0 million and has declinedeach year since, reaching 8.2 million individuals in 2020.
Determination of disability –
The disability decision is based on a sequential evaluation of medical and otherevidence. The sequence for adults is:
- Is the applicant performing a substantially gainful activity? If yes, deny.If no, continue to the next series
- Is the applicant’s impairment severe? If no, deny. If yes, continue tofollow the line
- Does the impairment meet or equal the severity of impairments in the Listingof Impairments? If yes, allow the claim. If no, continue to the followingsequence
- Is the applicant able to perform past work? If yes, deny; if no, continue tothe following sequence
- Is the applicant able to perform any work in the economy? If yes, deny; ifno, allow the claim
Medical evidence that demonstrates the applicant’s inability to work is required.The DDS may require the applicant to visit a third-party physician for medicaldocumentation, often to supplement the evidence treating sources do not supply.
Appeals and Denials
In the fiscal year 2020, state DDSs denied 61 percent of initial claims. SSAprovides for three levels of administrative appeal if an applicant is initiallyrejected by a state DDS. At the first level, the applicant may request areconsideration of the initial decision.
In the reconsideration, a different DDS examiner will review the case. Finally,if the claim is denied at this stage, the applicant can request a hearing beforean Administrative Law Judge (ALJ).
ALJs are not state employees but rather federal employees of the Social SecurityAdministration. If the claim is denied at this stage, the applicant can requesta review of the case by the Appeals Council of the Social SecurityAdministration. Administrative appeals are non-adversarial and new evidence canbe submitted by the applicant.
After an applicant has exhausted the administrative appeals process, theindividual may appeal the case to the federal courts. Federal court findings maypertain to the individual case. Still, they may also result in required changesin SSA’s policies and procedures if the court concludes those policies andpractices do not conform to federal law or the U.S. Constitution.
One study found that 12.4 million Americans, or about 6.2 percent of the U.S.population ages 18-66, are denied SSDI applicants. The study also found theseindividuals had high rates of health problems and a high hospitalization ratecompared to the general population.
About 52 percent of denied applicants reported difficulty standing for one hourcompared to about 5 percent for the general population. About 21 percent ofdenied applicants were hospitalized during the year compared to about 6 percentfor the general population. Denied applicants had a high poverty rate (38percent) and a high rate of material hardship (43 percent). Material hardshipwas measured as having low or very low food security or an inability to payutility or housing costs.
A baseline study of denied SSDI and SSI applicants who sought benefits on thebasis of mental impairments found denied applicants had low income and had“multiple mental health and general medical conditions, low quality of life, andlow functional ability.” The baseline population is composed of individuals whoare part of the Social Security Administration’s Supported EmploymentDemonstration. The goal of the demonstration is to test whether employmentsupport and health interventions can improve outcomes for denied applicants.
iMAGNUM can support you with your SSDI claims
We at iMagnum are outfitted with the best medical coding and billing experts,hand-picked for their ability in the area. These experts are constantly enrolledthrough consistent staff education initiatives to have the most exceptionalknowledge of the billing and coding guidelines. In addition, we have experts inthe complex requirements of the Social Security Administration’s programs. Theyassist patients through the entire application process, including hearings andappeals.
iMagnum maintains a database of such endorsed combinations by various insuranceagencies and is cutting-edge on something very similar. We work with theexisting data and our industry experts’ help; we provide solutions for most ofthe challenges faced by hospitals, medical facilities-related businesses. Someof those are listed below:
- Lost revenue in expected collections due to lack of appeals for deniedclaims
- Payer claims and rejections
- Lack of resource bandwidth to accomplish tasks to recover lost revenue ondenied claims
- Failure to request assistance from key stakeholders like physicians orpatients, within the process
- Vendor performance
Our Denial Management services include:
- Identify and correct root causes of denials. All denials are routed to thedenial analysis department. Denials are segregated into line items andcomplete denials
- We work with all federal and commercial payers and have strong knowledge oftheir payment mechanisms
- Streamline workflows for greater efficiency, faster appeals, and improvedcash flow.
- Our denial management and reporting app gives you real-time insights
- All claims are categorized into different follow-up groupings
- Redundant processes are automated. This cuts back on cycle times. Recovermoney faster.
- Software that identifies, isolates, quantifies, and categorizes denials tohelp you lower your denial rate and spot revenue leakage sources
- Help improve revenue cycle management and financial performance
There may be varied reasons for a claim’s rejection, it may be a modifier that isout of place or a combination of codes not allowed under the CCI edits, or itjust could be that appropriate pre-authorization for the particular procedure,as mandated by the patient’s carrier was not obtained at the first instance ofthe patient coming in. For multiple challenges you face, we are the one-stopsolution provider.
