	SSA Lacks a Formal and Systematic Approach for Identifying CAL Conditions

SSA has in recent years relied on advocates for individuals with certain  diseases and disorders to bring potential CAL conditions to its attention. In our  August 2017 report, we recommended that SSA develop a formal and  systematic approach to gathering information to identify potential  conditions for the CAL list, including sharing information through SSA’s  website on how to propose conditions for the list and using research that  is directly applicable to identifying CAL conditions. Our review also found that SSA has not developed or communicated  clear, consistent criteria for deciding which potential conditions will be  included on the CAL list. Further, SSA officials have cited  different reasons for not designating conditions as CAL in  communications with those who proposed conditions, which led to  confusion regarding CAL condition criteria for staff from some advocacy  organizations we interviewed. SSA agreed with this  recommendation. SSA’s Procedures Do Not Ensure All Claims are Accurately Identified for Expedited CAL Processing

To identify disability claims for expedited CAL processing, SSA primarily  relies on software that searches for key words in claims. However,  because text provided by claimants may be ambiguous, incomplete,  inaccurate, or misspelled, the software is hindered in its ability to flag all  claimants with CAL conditions and may also flag claimants for CAL  processing that should not be flagged. We also found that DDS offices play an important role in helping to  ensure that claims are accurately flagged for CAL by manually correcting  flagging errors made by the software, but SSA’s guidance on how to  make such corrections does not address when they should occur. We concluded that 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 and  accurate tracking of CAL claims. Such variance could  result in some claimants who assert a CAL condition not receiving  expedited processing because their claims were not flagged for CAL by  the selection software or DDS examiners. SSA Takes Some Steps to Ensure Accurate and Consistent CAL Decisions But Does Not Regularly Update Condition Descriptions or Leverage Data

In our August 2017 report, we found that 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, but has not regularly updated the summaries. These summaries suggest specific medical evidence for the DDS  examiner to obtain to verify the claimant’s asserted CAL condition and  help examiners make decisions about whether to allow or deny a claim. However, we found that because SSA has not regularly updated the  impairment summaries, nearly one-third are 5 or more years old. 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. We concluded that given the pace of  medical research for certain CAL conditions, in the absence of a  systematic and regular mechanism to update CAL impairment  summaries, SSA potentially faces the risk of making inaccurate and  inconsistent disability determinations based on outdated information. SSA agreed with this  recommendation. We also found that SSA does not leverage data it collects to identify  potential challenges to accurate and consistent decision-making on CAL  claims. We concluded that without regular analyses of available data,  SSA is missing an opportunity to ensure the accuracy and consistency of  CAL decision-making. In our August 2017 report, we recommended that  SSA develop a plan to regularly review and use available data to assess  the accuracy and consistency of CAL decision-making.
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.
This testimony summarizes the information contained in GAO's August 2017 report entitled SSA's Compassionate Allowance Initiative: Improvements Needed to Make Expedited Processing of Disability Claims More Consistent and Accurate , GAO-17-625 . It examines the extent to which 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.
For its August 2017 report, 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, representatives from patient advocacy groups, 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 through the disability determination process claimants who are likely to be approved because they have certain eligible medical conditions. SSA has in recent years relied on advocates for individuals with certain diseases and disorders to bring conditions to its attention for potential inclusion in CAL. However, by relying on advocates, SSA may overlook disabling conditions that 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. Without clear guidance on when to make manual changes, DDS examiners may not take timely actions and may hinder expedited processing for appropriate 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 to reduce the risk of SSA making disability determinations using medically outdated information. In addition, GAO found that SSA does not leverage data it collects to identify potential challenges to accurate and consistent decision-making on CAL claims. Without regular analyses of available data, SSA is missing an opportunity to ensure the accuracy and consistency of CAL decision-making.

What GAO Recommends

In its August 2017 report, GAO made 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 all of GAO's recommendations.