I-2-1-32.Disqualification and Referrals of Medical Experts, Vocational Experts, or Consultative Examiners

Last Update: 7/18/14 (Transmittal I-2-113)

A. Notification of a Disqualification From Disability Determination Services

When the Disability Determination Services (DDS) identifies a medical provider who is disqualified from performing consultative examinations on behalf of the Social Security Administration, DDS may provide formal notice to the Office of Hearings Operations (OHO) and the Office of Appellate Operations (OAO) through the regional consultative examination coordinator (CEC). For a list of CECs, see Regional DDS CEC. In most circumstances, DDS will identify cases pending in OHO and OAO that require further action because the record contains a consultative examination performed by the disqualified consultative examiner.

If the Office of the Chief Administrative Law Judge (OCALJ) is the component notified by DDS, OCALJ will notify the OHO regional office (RO) for each affected region, identify any affected cases pending with servicing hearing offices (HO) in the region, and issue instructions on how to adjudicate the cases. If DDS first notifies the OHO RO of the disqualified consultative examiner, the RO will notify OCALJ before notifying the affected HOs.

B. Claimant Alleges Disqualification

A claimant or appointed representative may allege in the request for hearing or other correspondence that a consultative examiner is not licensed or has otherwise been medically disqualified. In this circumstance, the assigned administrative law judge (ALJ) or other HO personnel must evaluate the allegation of disqualification on a case-by-case basis, relying on the medical evidence of record, and issue a decision after appropriately weighing the evidence. In considering whether a referral is appropriate, the HO will also follow the instructions in the Hearings, Appeals and Litigation Law (HALLEX) manual I-2-1-32 C.1. below.

NOTE:

The ALJ will not rely on or associate evidence of a consultative examiner disqualification submitted by one claimant with a different claimant's file.

If the claimant or appointed representative alleges that a consultative examiner is not licensed in the state where the consultative examination occurred, see Program Operations Manual System DI 39545.175. To be qualified, the consultative examiner must be licensed or certified in the state in which the examination was performed.

C. HO Referrals of Medical Experts (ME), Vocational Experts (VE), or Consultative Examiners

1. Referral to RO

Occasionally, HO personnel may discover potential issues regarding the conduct, qualifications, or performance of an ME, VE, or consultative examiner during case adjudication.

When a referral for further consideration of an ME or VE may be warranted, the person who discovers the issue will complete a Report of Non-Conformance and forward to an HO manager. When a referral for further consideration of a consultative examiner may be warranted, the person who discovers the issue will notify an HO manager. In both situations, the manager will discuss the issue with the ALJ assigned to the case. If the case has not yet been assigned to an ALJ, the manager will discuss the issue with the Hearing Office Chief Administrative Law Judge (HOCALJ).

If the ALJ or HOCALJ agrees that a referral of an ME or VE is appropriate, the ALJ or HOCALJ will direct the manager to send an email to the RO Contracting Officer's Representative (COR) with the subject line “Possible Expert Misconduct Referral.” They will include the complete Report of Non-Conformance. However, while the matter is fully reviewed, the ME or VE is permitted to provide testimony.

If the ALJ or HOCALJ agrees a referral of a consultative examiner is appropriate, the ALJ or HOCALJ will direct the HO manager to notify the appropriate regional DDS CEC and email the RO contact with the subject line “Possible Consultative Examiner Misconduct Referral.”

The content of the email will include the following information:

  • The claimant's name and Social Security number;

  • The name of the ME, VE, or consultative examiner;

  • A brief description of the conduct or possible qualification issue; and

  • The exhibit number or location of the relevant information in the file.

NOTE:

If the case is paper, the appropriate HO personnel will transmit copies of any relevant documents to the DDS and RO via email, fax, or regular mail.

After sending the email, the person making the referral will add the expert conduct case characteristic “EXCN” in the Case Processing and Management System (CPMS).

NOTE:

If HO personnel suspect fraudulent behavior, they need not consult with a manager before referring the matter to the Office of the Inspector General (OIG), as explained in HALLEX I-1-3-9.

2. RO Actions

The RO will review and evaluate each referral on a case-by-case basis. If the RO determines that further investigation of an ME or VE is warranted, it will refer the information to the Division of Finance, Budget and Audit (DFBA) in the Office of Budget, Facilities, and Security (OBFS) at ^OHO DFBA CORS. If the expert is removed, OBFS will notify the RO COR of the disqualification and instruct that the expert be removed from the witness roster and from CPMS and the Hearings and Appeals Case Processing System (HACPS).

The RO will ensure all allegations of an unlicensed consultative examiner have been referred to the regional DDS CEC and will also refer the matter to the Division of Field Procedures in OCALJ at |||OHO OCALJ DFP.