Can I Appeal a Social Security Quality Assurance Review Decision?

Social Security's Office of Quality Performance (OQP) uses a program called the Quality Review system (QR) to review disability decisions. The QR system randomly reviews both denials and awards after the disability claims examiner enters the initial decision but before the decision is sent to the applicant.

The purpose of the QR is to make sure that claims examiners' decisions are made in accordance with proper Social Security procedures and disability guidelines. Proposed benefit amounts and other non-disability factors are also reviewed for accuracy. In the past, the QR system has also been used to identify and compensate SSI recipients who had been underpaid.

What Benefits Are Subject to Review?

Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), retirement, survivor, and railroad disability cases are all subject to review.

The Office of Quality Performance can select decisions on the initial application, cases that are scheduled for hearings, and attorney adviser opinions.

What Kind of Mistakes Does the Reviewer Look For?

A QR reviewer looks for any errors that could have resulted in an incorrect award or denial of benefits. These errors are called deficiencies. Deficiencies are classified into two groups.

Group I deficiencies. Group 1 deficiencies can affect the basic disability decision that allowed, denied, continued, or ceased disability benefits. There are two types of Group 1 deficiencies:

  • where the decision-maker should have made a different finding of disability, or
  • where more medical evidence is needed to make an accurate determination of disability.

Group 1 deficiencies happen when a finding of disability is based on certain incorrect determinations about such factors like the severity of a medical condition, the expected duration of the condition, whether the claimant (applicant) has been compliant with treatment, or whether the claimant is working above the substantial gainful activity (SGA) level.

Group II deficiencies. Group II deficiencies affect only the onset date of disability, end date, or cessation date. There are two categories of group II deficiencies:

  • where a different period of disability should have been established, and
  • where more medical evidence is needed to decide the correct period of disability.

What Happens if the Reviewer Finds a Deficiency?

Even if the reviewer finds a deficiency, the case is sent back to the original decision maker only if correcting the error would:

  • change the disability decision, or
  • change the period of disability.

If the original decision-maker agrees with the findings of the Office of Quality Performance (OQP), the disability decision will be changed accordingly. However, the department that made the original disability determination does not have to accept the OQP's deficiency findings, but instead can file a "rebuttal." In these cases, Social Security creates a team to review the claim collectively and resolve any areas of disagreement.

Can an ALJ's Decision Be Pulled for Review?

An Administrative Law Judge's (ALJ) decision can also be pulled for review by the Social Security Appeals Council; this includes both favorable and unfavorable decisions (approvals and denials).

In 2010, reviewers of ALJ decisions reviewed just unfavorable decisions and agreed with the ALJs the vast majority of the time. In 2011, the Appeals Council began to review, at random, favorable and partially favorable decisions as well; however, the statistics are not yet available on these reviews.

Can I Appeal My Case if it is Overturned By the Reviewer?

You may not even be aware that your case has been selected for quality review. You will be notified of your award or denial the same way as a claim that was not selected for review. If your claim is denied and you want to appeal the decision, you must follow the Social Security rules for doing so. For more information, see our section on appealing disability denials.

If My Case Is Reviewed Will It Take Longer to Get a Decision?

Yes, even if no deficiencies are found in the decision being reviewed, it takes longer for the claimant to be notified of the outcome of his or her case. Social Security will not inform you if your claim has been pulled for review, but if you contact Social Security, the agency should inform you if your claim has been selected for review.

If your case is taking longer than expected, you can contact Social Security to get the status of your case and ask if it has been selected for quality review.

by: , Contributing Author