What is a Consultative Exam?

What is a Consultative Exam?

In order to receive disability benefits, claimants must provide certain information to the Social Security Administration (SSA). In some cases, the SSA will request that the claimant undergo a consultative examination. This occurs when the SSA does not have sufficient information to make a determination of whether the claimant is disabled.

Gathering More Information

A consultative exam will provide more information to the SSA, enabling it to make a disability determination. A consultative exam may be required because of the following:

  1. More evidence is needed because the evidence on file is not sufficient to make the disability determination
  2. To gather more detailed medical findings of the impairment(s)
  3. To gather technical or specialized medical information
  4. To resolve conflicts or differences of the medical evidence on file
  5. If the claimant is an adult, to determine that person’s ability to perform the substantial gainful activity; or, if the claimant is a child under the age of 18, to determine that child’s ability to function like other children the same age who do not have any impairments

Under most circumstances, the claimant’s treating healthcare provider (the “treating source”) is the preferred person to perform the consultative exam. The treating source must be qualified, equipped, and willing to perform the exam. However, in some cases, the SSA will request that the exam is performed by another medical source. An independent source may be used if:

  1. The treating source does not want to perform the exam
  2. There are conflicts or inconsistencies in the claimant’s file that cannot be resolved by using the treating source
  3. The claimant prefers that a different source is used and has a good reason for this
  4. Based on prior experience, the treating source may not be a productive source

If an independent source is used, it may be possible to obtain payment from the SSA for the travel expenses related to the exam.

Reporting the Results

The SSA has specific reporting requirements for the consultative exam. For example, the report should have the claimant’s claim number and a physical description of the claimant. These help to ensure that the person examined is actually the claimant. Further, the Disability Determination Service (DDS) must be able to understand the nature, duration, and severity of the health condition. In the case of adult claimants, the report should include an assessment of the claimant’s ability to perform work-related functions. However, the report should not include an opinion on whether the claimant is disabled.

If the consultative exam report contains sufficient information for the SSA, the disability determination will be made. In the event that the claimant refuses to undergo a consultative exam, the determination will be based on the evidence on file. Whether refusing to submit to the exam is in the claimant’s best interests varies with each individual’s particular situation. Often, discussing this issue with an attorney is helpful.

If you would like more information on the process of applying for and obtaining disability benefits, speak with an experienced attorney today. At the Klok Law Firm LLC, we proudly utilize our knowledge and experience to help individuals secure these often much-needed benefits. We look forward to hearing from you.

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