Is SSDI Quality Review Good or Bad? What It Means for You
The answer is that it depends. The Social Security Administration (SSA) conducts random quality reviews to check if your state's Disability Determination Services (DDS) office adhered to accepted procedures when deciding your claim.
If your disability case was denied and the SSA notifies you that they're reviewing the initial decision, that could be good because they might decide in your favor this time.
On the other hand, if they already approved you for Social Security Disability benefits, a review could mean a reversal of the decision.
How Does the Quality Review Process Work?
Even though the federal government funds each state's DDS office, DDS claims examiners aren't directly supervised by the SSA.
To ensure that every claim examiner adheres to federal guidelines when making disability decisions, the SSA conducts random quality reviews.
A quality review is a double-check of the original disability benefits decision. During one, claims examiners ensure that the decision was made accurately and fairly. They'll also make sure that all required medical documentation is on file and that it supports the original decision.
Your disability application's chances of being selected for a quality review are small because only about 1% of all claims are chosen for one.
Once the SSA completes its review, one of three things will happen:
The decision stands: If the examiners agree with the decision, your claim will continue to be processed.
The decision is reversed or modified: If the examiners disagree with the decision, they may reverse or modify it.
Further review: They send it back for additional review.
The Appeals Process
If the claim examiners reverse the decision, it's not the end of the world because you have the right to appeal. There are four stages to the appeal process, and each one must be done within 60 days of receiving notice that you were denied at an earlier stage:
Reconsideration
During reconsideration, an examiner who wasn't involved with the original decision reviews your claim. They go over the evidence you already submitted and any new evidence you want to provide, such as recent medical records, test results, or physician statements. The approval rate for reconsideration requests is less than 15%.
Hearing Before an Administrative Law Judge
If your claim was denied at the reconsideration phase, you have the right to request a hearing before an Administrative Law Judge (ALJ). ALJs serve as decision-makers in disputes between government agencies and individuals.
You'll be able to speak to the ALJ, so being an energetic self-advocate is essential. If you want to ensure that you present the most compelling argument as to why you should be approved for disability, consider hiring a disability law attorney. They can help you practice answering questions that typically arise during these kinds of hearings.
Approximately 50% of unfavorable rulings are overturned at this stage.
Appeals Council Review
If the ALJ rejects your claim, you can request a review by the Appeals Council. If the Council believes that the ALJ made the right decision, they'll most likely deny your request.
Suppose the ALJ made critical errors in deciding your case, such as failing to consider all the medical evidence or misrepresenting your work or medical history. In that case, they'll either decide your case themselves or remand (return) it to an ALJ and have them revisit their original decision. About 22% of cases reviewed by the Appeals Council are remanded.
Federal Court Review
The last stage of the appeals process is filing a lawsuit in a federal district court. You have the right to do this if you disagree with the Council's decision or they decide not to consider your case. A federal judge will review the decision to ensure that no legal errors were made.
Because this is a complex legal proceeding, you'll need to have a disability attorney handle this part of the process for you. They'll file a brief on your behalf. This legal document explains why you believe the SSA made the wrong decision.
About one out of every three cases result in a favorable decision at this stage.
Boost Your Claim with Additional Evidence
There are four stages to the appeals process. This means you have four chances to strengthen your case by providing additional evidence. And the more evidence you can provide to bolster your claim, the greater the chance the SSA will decide in your favor.
The evidence you provided initially to the state agency, such as medical records and work history, might not fully capture the extent of your disability.
Suppose you don't bolster your claim with additional evidence. In that case, disability examiners will use the same information that led to your case being denied to make a decision. This means it's highly probable that your case will be dismissed again.
You want to present the most compelling argument possible when making your case. So, double-check to see if anything more can be added instead of merely including the documentation you provided earlier. If unsure, have a disability benefits attorney identify any gaps in the evidence.
Remember, months will likely have elapsed between appeals, so it's essential to keep medical records current, including any new health problems. Updated records are crucial if your medical condition deteriorates in the intervening months.
Statements from your friends, family, and colleagues describing how your disability interferes with your ability to carry out routine tasks can be powerful, highly personalized complements to objective medical reports.
Remember to submit additional evidence promptly. Otherwise, you risk having your case dismissed.
Conclusion: Is an SSDI Quality Review Good or Bad?
A Social Security Disability Insurance or Supplemental Security Income quality review could be good if your claim was initially denied. Examiners might discover that whoever originally looked at your claim made errors when deciding.
On the other hand, it might be bad if your Social Security benefits claim was already approved because there's a chance that the decision could now be overturned. The good news is that you can appeal the decision.
Keep one thing in mind when making your appeal: Social Security disability law is maddeningly complex. To boost your chances of a favorable outcome, having someone on your side with a comprehensive understanding of this highly specialized field is a good idea.
A Social Security disability lawyer can use information from the quality review to strengthen your SSDI or SSI claim should an appeal become necessary.