SSA began CAL in October 2008 with the stated goal of providing  expedited benefit processing to those with certain medical conditions  whose claims are likely to be approved. Certain expedited processing  rules apply to claims that are flagged for CAL. Since 2011, SSA has also relied on advocates for individuals with certain  diseases and disorders to bring conditions to the agency’s attention,  rather than proactively and systematically reviewing conditions to identify  potential additions to the CAL list. Federal internal control standards state that  agencies should use quality information to achieve their objectives. Absent clear guidance to advocates on how to make suggestions through  its CAL webpage, SSA is missing an opportunity to gather quality  information to inform its selection of CAL conditions. SSA Does Not Have Clear, Consistent Criteria for Designating CAL Conditions or a Formal Process for Documenting Its Decisions

SSA has generally described CAL conditions as those that “invariably  qualify as allowances under the  Listing of Impairments based  on minimal objective medical evidence,” according to SSA officials. However, SSA has not developed or communicated clear, consistent  criteria for designating conditions as CAL conditions. Because some claimants misspell words describing their conditions, the  selection software may also omit a CAL flag on claims that should be  flagged. Without clear guidance  on when to make manual changes, DDS examiners may continue to take  actions that are not timely and may hinder expedited processing for  appropriate claims and accurate tracking of CAL claims. SSA Takes Some Steps to Ensure Accurate and Consistent CAL Decisions But Does Not Regularly Update CAL Condition Descriptions or Leverage Available Data

		SSA Has Procedures to Ensure Accurate and Consistent Claim Decisions But Does Not Regularly Update CAL Condition Descriptions

SSA has various procedures in place, including the use of detailed CAL  condition descriptions, to help ensure the accuracy and consistency of  CAL claims decisions. Although CAL impairment summaries are a key tool used by examiners to  make a decision on whether to allow or deny a CAL claim, SSA has not  regularly updated the impairment summaries. This is because SSA does  not have a process for regularly updating all of these summaries. As a  result, since the initiative’s inception in fiscal year 2009, about two-thirds  of the summaries have not been updated. 5). Several advocates (4 of 6) and medical experts (2 of 3) we interviewed  suggested that the impairment summaries should be updated every 1 to 3  years because medical research and advancements may have  implications for disability determinations. Develop a plan to regularly review and use available data to assess  the accuracy and consistency of CAL decision-making. In its  written comments, reproduced in appendix IV, SSA agreed with our eight  recommendations. This report examines the extent to which the  Social Security Administration (SSA) has procedures for (1) identifying  conditions for the CAL list; (2) identifying claims for CAL processing; and  (3) ensuring the accuracy and consistency of CAL decisions. Management Information Data

We analyzed SSA data on CAL from SSA’s Management Information  Disability database, including the number of allowance (approval) and  denial decisions for disability claims identified with CAL conditions from  fiscal year 2009, when CAL was implemented, through fiscal year 2016. Interviews with SSA and DDS Staff

To gather information on how SSA identifies conditions for the CAL list,  identifies claims for CAL processing, and ensures the accuracy and  consistency of CAL decisions, we conducted interviews with staff from  SSA headquarters and select DDS offices. Claim File Review

We conducted a non-generalizable review of 74 claim files with fiscal year  2016 initial determinations to confirm our understanding of how claims are  identified as CAL by the selection software and manually by DDS officials  and to assess the reliability of CAL management data.
Why GAO Did This Study

SSA in October 2008 implemented CAL to fast track individuals with certain conditions through the disability determination process by prioritizing their disability benefit claims. Since then, SSA has expanded its list of CAL conditions from 50 to 225. GAO was asked to review SSA's implementation of CAL.
This report examines the extent to which SSA has procedures for (1) designating CAL conditions, (2) identifying claims for CAL processing, and (3) ensuring the accuracy and consistency of CAL decisions. GAO reviewed relevant federal laws, regulations, and guidance; analyzed SSA data on disability decisions for CAL claims from fiscal years 2009 through 2016 and on CAL claims with manual actions in fiscal year 2016; reviewed a nongeneralizable sample of 74 claim files with fiscal year 2016 initial determinations; and interviewed medical experts, patient advocates, and SSA officials in headquarters and six DDS offices selected for geographic dispersion and varied CAL caseloads.

What GAO Found

The Social Security Administration (SSA) does not have a formal or systematic approach for designating certain medical conditions for the Compassionate Allowance initiative (CAL). CAL was established in 2008 to fast track claimants through the disability determination process who are likely to be approved because they have certain eligible medical conditions. In lieu of a formal process for identifying conditions for the list of CAL conditions, SSA has in recent years relied on advocates for individuals with certain diseases and disorders to bring conditions to its attention. However, by relying on advocates, SSA may overlook disabling conditions for individuals who have no advocates, potentially resulting in individuals with these conditions not receiving expedited processing. Further, SSA does not have clear, consistent criteria for designating conditions for potential CAL inclusion, which is inconsistent with federal internal control standards. As a result, external stakeholders lack key information about how to recommend conditions for inclusion on the CAL list.
To identify disability claims for expedited CAL processing, SSA primarily relies on software that searches for key words in claims. However, if claimants include incorrect or misspelled information in their claims the software is hindered in its ability to flag all claimants with CAL conditions or may flag claimants for CAL processing that should not be flagged. SSA has guidance for disability determination services (DDS) staff on how to manually correct errors made by the software, but the guidance does not address when such corrections should occur (see figure). Without clear guidance on when to make manual changes, DDS examiners may continue to take actions that are not timely and may hinder expedited processing for appropriate claims, and this can also impact the accurate tracking of CAL claims.
SSA has taken some steps to ensure the accuracy and consistency of decisions on CAL claims, including developing detailed descriptions of CAL conditions, known as impairment summaries. These summaries help examiners make decisions about whether to allow or deny a claim. However, nearly one-third of the summaries are 5 or more years old. Experts and advocates that GAO spoke to suggested that summaries should be updated every 1 to 3 years. This leaves SSA at risk of making disability determinations using medically outdated information. In addition, GAO found that SSA does not leverage data it collects to assess the accuracy and consistency of CAL adjudication decisions. Without regular analyses of available data SSA is missing an opportunity to ensure the accuracy and consistency of CAL decision-making.

What GAO Recommends

GAO is making eight recommendations including that SSA develop a process to systematically gather information on potential CAL conditions, communicate criteria for designating CAL conditions, clarify guidance for manual corrections on CAL claims, update CAL impairment summaries, and use available data to ensure accurate, consistent decision-making. SSA agreed with GAO's recommendations.