I-3-2-31.Allegations of Improperly Completed or Deficient Consultative Examination Reports or Misconduct by Consultative Examination Providers

1. Reporting Allegations of CE Provider Misconduct, Fraud or Similar Fault, or Lack of Qualifications

If a claimant or representative alleges CE provider misconduct with the request for review, including allegations of fraud or similar fault, lack of qualifications, or patterns of deficient CEs and reports, OAO staff and adjudicators will report the allegation to the Executive Director's Office in an email with the subject line, “Claimant Allegation of Consultative Examination Provider Misconduct.”

Reports detailing claimant or representative allegations should include the following:

• The claimant's name and Social Security number;

• The name of the CE provider;

• The verbatim allegation(s) (when possible); and

• The exhibit number or location of the allegation(s) in the claim(s) file.

2. Handling Information Related to Another Party Intentionally Submitted to Support Allegations of Patterns of Misconduct or Fraud or Similar Fault

OAO staff must not associate information relating to non-parties with the claimant's record.

If a claimant submits a CE report prepared for an individual who is not a party to the hearing, the AC will acknowledge the allegation and handle the evidence following the procedures in HALLEX I-3-2-24 C.1..

OAO staff and adjudicators will refer allegations relying on evidence involving a non-party to OAO management consistent with the instructions in subsection B.1.

1. CE Report Requirements

Under agency regulations, all CE reports obtained in connection with a claim(s) must comply with the following requirements:

• The CE report must be complete enough to help determine the nature, severity, and duration of the claimant's impairment(s) and the claimant's residual functional capacity (20 CFR 404.1519n(b) and 416.919n(b)).

• A complete CE involves an examination with all the elements of a standard examination in the applicable medical specialty (20 CFR 404.1519n(c) and 416.919n(c)). A complete CE is only necessary when dictated by the particular facts of the case (20 CFR 404.1519n(d) and 416.919n(d)).

• When a complete CE is involved, the report includes the elements identified in the regulations (20 CFR 404.1519n(c) and 416.919n(c)). If the evidence the agency needs does not require a complete CE, the CE report need not contain all of these elements identified in the regulations (20 CFR 404.1519n(d) and 416.919n(d)).

• All CE reports must be personally reviewed and signed by the medical source who actually performed the CE (20 CFR 404.1519n(e) and 416.919n(e)). A rubber stamp signature of a medical source or the medical source's signature entered by any other person is not acceptable (20 CFR 404.1519n(e) and 416.919n(e)).

• The agency will not use an unsigned or improperly signed CE report in denials, cessations, or allowances with closed periods of disability or later onsets (20 CFR 404.1519o and 416.919o).

2. Issues of CE Report Deficiencies at the AC Level

If a CE report does not meet the requirements provided in subsection D.1, the AC will consider whether a grant review action is appropriate to resolve the deficiencies.

• If a less than fully favorable ALJ decision relies upon an improperly signed CE report, the AC will generally grant review based on an “error of law” and remand the case for further actions consistent with 20 CFR 404.1519o and/or 416.919o and HALLEX I-2-5-20.

• If a fully favorable hearing level decision relies upon an improperly signed CE report, OAO staff and adjudicators should check if the hearing office has an outstanding development request to obtain the signature with the DDS. If a development request has not been initiated by the hearing office, OAO staff should consult their manager for appropriate action.

• If the CE report is inadequate or incomplete for a reason other than a missing signature, the AC will evaluate whether the decision is supported by substantial evidence. See HALLEX I-3-3-4. As necessary and appropriate, the AC may grant review to request that the ALJ undertake additional development pursuant to HALLEX I-2-1-33 D. 2.

3. Evaluating Allegations that a CE Provider is Unqualified

If a claimant or representative alleges a CE provider is not licensed or has been disqualified, the AC must evaluate the allegation on a case-by-case basis, relying on the medical evidence of record. See HALLEX I-3-2-30 B.

If the claimant or representative alleged at the hearing level that a CE provider was not licensed or has been disqualified, OAO adjudicators will evaluate whether the hearing level adjudicator processed the allegation in accordance with HALLEX I-2-1-32 B and I-2-1-33 D.

OAO staff and adjudicators will report all new allegations that a CE provider is unqualified per the instructions in subsection B.1. In addition, the AC will consider whether a referral is appropriate under HALLEX I-3-2-30 B and C.