I-3-2-30.Disqualification and Referrals of Medical Experts, Vocational Experts, or Consultative Examiners

Last Update: 2/23/15 (Transmittal I-3-98)

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 Office of Analytics, Review and Oversight (OARO) through the regional consultative examination coordinator (CEC). For a list of CECs, see the Regional DDS CEC. In most circumstances, DDS will identify cases pending in OHO and OARO that require further action because the record contains a consultative examination performed by the disqualified consultative examiner.

When the Office of Appellate Operations (OAO) receives notification of a disqualified consultative examiner, the Executive Director's Office (EDO) will identify the affected cases pending with the Appeals Council (AC) and issue instructions on how to adjudicate the cases.

B. Claimant Alleges Disqualification in Request for Review

A claimant or appointed representative may allege in the request for review that the consultative examiner is not licensed or has otherwise been medically disqualified. In this circumstance, the AC must evaluate the allegation of disqualification on a case-by-case basis, relying on the medical evidence of record, and take the appropriate course of action after appropriately weighing the evidence (e.g., grant review if a basis for granting review under the Hearings, Appeals and Litigation Law (HALLEX) manual I-3-3-1 is present). In considering whether a referral is appropriate, the AC will also follow the instructions in HALLEX I-3-2-30 C.1. below.

NOTE:

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

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

1. Referral to EDO

Occasionally, the AC may discover potential conduct issues of an ME, VE, or consultative examiner during case adjudication. When a referral for further consideration may be warranted, the analyst will discuss the situation with an administrative appeals judge (AAJ). If the AAJ agrees a referral is appropriate, the analyst will send an email to EDO at ^DCARO OAO with the subject line “Expert conduct 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 issue;

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

  • The name of the AAJ agreeing that referral is appropriate.

NOTE:

If the case is paper, staff will also forward copies of any relevant documents to EDO via a scanned attachment or, when more appropriate, forward hard copies of the documents.

After sending the email, the analyst will add the expert conduct case characteristic “EXCN” in the Appeals Review Processing System (ARPS). The case characteristic is located in the “Other” folder in ARPS.

NOTE:

If the analyst suspects fraudulent behavior, the analyst need not consult with an adjudicator before referring the matter to the Office of the Inspector General, as explained in HALLEX I-1-3-9.

2. EDO Actions

EDO will review and evaluate each referral. EDO will refer allegations that a consultative examiner is unlicensed or has engaged in misconduct to the Regional DDS CEC. If EDO determines that further investigation of an ME or VE is warranted, it will refer the information to the Division of Field Procedures (DFP) in the Office of the Chief Administrative Law Judge (OCALJ) at ¦¦¦OHO OCALJ DFP. EDO may send other referrals to the Executive Review Board to consider whether a focused review by the Division of Quality may be appropriate.