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.)
At the end of 2020, there were 9.7 million Americans receiving benefits from the SSDI program. This included 8.2 million disabled workers, 1.4 million children of disabled workers, and 0.1 million spouses of disabled workers. Children and spouses are sometimes referred to as auxiliary beneficiaries because they receive benefits based on their relationship to a disabled worker, not because they are necessarily disabled.
The number of beneficiaries multiplied between 1990 and 2010 before leveling off and then declining in recent years. Two schools of thought developed to explain the rapid growth in the program during the 1990s and early 2000s.
According to David Autor and Mark Duggan, policy changes and earnings patterns were responsible for the growth. About policy, Autor and Duggan argue an SSDI reform act loosened the disability screening process, leading to more SSDI awards and shifting their composition towards claimants with low-mortality disorders such as mental illness and back pain.
About earnings patterns, Autor and Duggan argue SSDI benefits rose in value relative to what recipients would have earned from employment, prompting more significant numbers of individuals to seek blessings.
The second school of thought on program growth in the 1990s and early 2000s emphasized demographic factors such as population growth, aging of the baby boom generation into their disability-prone years, growth in women’s labor force participation, and the increase in Social Security’s full retirement age from 65 to 66.
The number of disabled workers peaked in 2014 at 9.0 million and has declined each year since, reaching 8.2 million individuals in 2020.
Determination of disability –
The disability decision is based on a sequential evaluation of medical and other evidence. 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 to follow the line
- Does the impairment meet or equal the severity of impairments in the Listing of Impairments? If yes, allow the claim. If no, continue to the following sequence
- Is the applicant able to perform past work? If yes, deny; if no, continue to the following sequence
- Is the applicant able to perform any work in the economy? If yes, deny; if no, 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 medical documentation, 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. SSA provides for three levels of administrative appeal if an applicant is initially rejected by a state DDS. At the first level, the applicant may request a reconsideration 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 before an Administrative Law Judge (ALJ).
ALJs are not state employees but rather federal employees of the Social Security Administration. If the claim is denied at this stage, the applicant can request a review of the case by the Appeals Council of the Social Security Administration. Administrative appeals are non-adversarial and new evidence can be submitted by the applicant.
After an applicant has exhausted the administrative appeals process, the individual may appeal the case to the federal courts. Federal court findings may pertain to the individual case. Still, they may also result in required changes in SSA’s policies and procedures if the court concludes those policies and practices 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 these individuals had high rates of health problems and a high hospitalization rate compared to the general population.
About 52 percent of denied applicants reported difficulty standing for one hour compared to about 5 percent for the general population. About 21 percent of denied applicants were hospitalized during the year compared to about 6 percent for the general population. Denied applicants had a high poverty rate (38 percent) and a high rate of material hardship (43 percent). Material hardship was measured as having low or very low food security or an inability to pay utility or housing costs.
A baseline study of denied SSDI and SSI applicants who sought benefits on the basis of mental impairments found denied applicants had low income and had “multiple mental health and general medical conditions, low quality of life, and low functional ability.” The baseline population is composed of individuals who are part of the Social Security Administration’s Supported Employment Demonstration. The goal of the demonstration is to test whether employment support 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 enrolled through consistent staff education initiatives to have the most exceptional knowledge of the billing and coding guidelines. In addition, we have experts in the complex requirements of the Social Security Administration’s programs. They assist patients through the entire application process, including hearings and appeals.
iMagnum maintains a database of such endorsed combinations by various insurance agencies and is cutting-edge on something very similar. We work with the existing data and our industry experts’ help; we provide solutions for most of the challenges faced by hospitals, medical facilities-related businesses. Some of those are listed below:
- Lost revenue in expected collections due to lack of appeals for denied claims
- Payer claims and rejections
- Lack of resource bandwidth to accomplish tasks to recover lost revenue on denied claims
- Failure to request assistance from key stakeholders like physicians or patients, within the process
- Vendor performance
Our Denial Management services include:
- Identify and correct root causes of denials. All denials are routed to the denial analysis department. Denials are segregated into line items and complete denials
- We work with all federal and commercial payers and have strong knowledge of their payment mechanisms
- Streamline workflows for greater efficiency, faster appeals, and improved cash 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. Recover money faster.
- Software that identifies, isolates, quantifies, and categorizes denials to help 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 is out of place or a combination of codes not allowed under the CCI edits, or it just could be that appropriate pre-authorization for the particular procedure, as mandated by the patient’s carrier was not obtained at the first instance of the patient coming in. For multiple challenges you face, we are the one-stop solution provider.
To know more details, please visit – https://imagnumhealthcare.com/