Consultative Examination-Annual Onsite Review of Medical Providers, 32845-32846 [2010-14070]

Agencies

• Social Security Administration

[Federal Register Volume 75, Number 111 (Thursday, June 10, 2010)]
[Rules and Regulations]
[Pages 32845-32846]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-14070]



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Federal Register / Vol. 75, No. 111 / Thursday, June 10, 2010 / Rules 
and Regulations

[[Page 32845]]



SOCIAL SECURITY ADMINISTRATION

20 CFR Parts 404 and 416

[Docket No. SSA-2006-0109]
RIN 0960-AH17


Consultative Examination--Annual Onsite Review of Medical 
Providers

AGENCY: Social Security Administration.

ACTION: Final rules.

-----------------------------------------------------------------------

SUMMARY: We are revising the threshold billing amount that triggers 
annual on-site reviews of medical providers who conduct consultative 
examinations (CEs) for our disability programs under titles II and XVI 
of the Social Security Act (Act). The revision will raise the threshold 
amount to reflect the increase in billing amounts since we first 
established the threshold amount in 1991. We expect the revised 
threshold amount will reestablish the level of oversight activity we 
required under our original rules.

DATES: These regulations are effective July 12, 2010.

FOR FURTHER INFORMATION CONTACT: Richard Bresnick, Office of 
Regulations, Social Security Administration, 6401 Security Boulevard, 
Baltimore, MD 21235-6401, (410) 965-1758. For information on 
eligibility or filing for benefits, call our national toll-free number, 
1-800-772-1213 or TTY 1-800-325-0778, or visit our Internet Web site, 
Social Security Online, at https://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION:

Electronic Version

    The electronic file of this document is available on the date of 
publication in the Federal Register at https://www.gpoaccess.gov/fr/.

Why are we revising our rules?

    We are making final the rules we proposed in the notice of proposed 
rulemaking (NPRM) published in the Federal Register on March 20, 2007. 
72 FR 13053. Since 1991, our regulations have required each State 
agency that makes disability determinations for us to provide 
comprehensive oversight management of its CE program with special 
emphasis on key providers. Sections 404.1519s(d) and 416.919s(d). A CE 
is a medical examination or test that we purchase at our expense when 
we need additional information to make a disability determination, and 
we cannot obtain that information from existing medical sources. 
Sections 404.1517, 404.1519, 416.917, and 416.919.
    As part of its oversight management of the CE program, each State 
agency must conduct annual on-site reviews of key providers. Sections 
404.1519s(f)(11) and 416.919s(f)(11). Our regulations define a ``key 
consultative examination provider'' as a provider that meets at least 
one of three specified conditions. Sections 404.1519s(e) and 
416.919s(e). Those conditions are:
    (1) Any CE provider with an estimated annual billing to the Social 
Security disability programs of at least $100,000; or
    (2) Any CE provider with a practice directed primarily towards 
evaluation examinations rather than the treatment of patients; or
    (3) Any CE provider that does not meet the above criteria, but is 
one of the top five CE providers in the State by dollar volume, as 
evidenced by prior year data.
    We are increasing the threshold billing amount in the first of 
these conditions to $150,000, the first change in the threshold since 
we published this provision in 1991. Due to the rise in CE costs since 
1991, many providers who perform relatively few CEs nevertheless meet 
the current $100,000 threshold and are subject to mandatory on-site 
reviews. Raising the threshold amount to $150,000 will allow us to 
focus our limited resources on annual reviews of our largest CE 
providers.
    We set the threshold at $150,000 by multiplying the current 
$100,000 threshold by the percentage increase in the consumer price 
index for urban wage earners and clerical workers from 1991 (134.3) to 
November 2006 (196.8) (the most recent information available at the 
time we proposed the revision). For administrative convenience, we 
rounded the resulting amount ($146,537.60) to $150,000. The CPI was 
211.3 in October 2009, which would correspond to a threshold of 
$157,334. However, we believe that $150,000 remains an appropriate 
threshold for purposes of the on-site review requirement.

Public Comments

    In the NPRM we published on March 20, 2007, we provided the public 
with a 60-day period in which to comment. The comment period ended on 
May 21, 2007.
    We received one comment, from a professional organization 
representing adjudicators of claims for disability. We carefully 
considered the comment. Because the comment was long, we have 
condensed, summarized, and paraphrased it. We have tried to summarize 
the commenter's views accurately and to respond to all of the 
significant issues raised by the commenter that were within the scope 
of these rules.
    Comment: The commenter recognized that the costs for performing CEs 
have risen and that some high volume CE providers may reach the 
$100,000 threshold amount sooner than in previous years. However, the 
commenter believed that raising the threshold amount could lead to some 
key providers furnishing ``less than quality service'' to the 
disability program. The commenter indicated that some of the smaller 
States currently do not have providers that meet the $100,000 threshold 
amount and only do reviews of the top five providers in their States in 
accordance with the current regulations. The commenter also stated that 
its experience has shown that the current regulations allow some high 
volume providers in larger States to not have on-site reviews. The 
commenter believed that more, not fewer, on-site reviews of high volume 
CE providers need to be conducted and increasing the threshold amount 
for performing on-site reviews from $100,000 to $150,000 would take 
away the possibility of reviewing some high volume CE providers in the 
future. The commenter believed that the State agencies need to continue 
to monitor high volume CE providers on a regular basis to maintain the 
quality and consistency of CEs. Thus, it favored expanding, rather than 
limiting, the situations in which State

[[Page 32846]]

agencies review high volume CE providers. The commenter also expressed 
concern that increasing the CE threshold amount may create the 
impression that oversight of CEs is not important.
    Response: We disagree with the commenter's assertions. First, we do 
not believe that raising the threshold amount will lead to some key 
providers furnishing ``less than quality service'' to the disability 
program. Rather, we believe this revision will allow us to fulfill our 
stewardship obligations to the disability programs, while also ensuring 
that we use our scarce administrative resources as efficiently as 
possible. As for the commenter's assertion that the revision will lead 
to fewer on-site reviews of high volume providers in large States, the 
commenter is correct that we will no longer require automatic review of 
CE providers whose billing falls between $100,000 and $149,999. 
However, we will still require States to review all high volume 
providers as we now define that term. In addition, our regulations 
require the State agencies to maintain procedures for handling 
complaints. Sections 404.1519s(f)(9) and 416.919s(f)(9). By reducing 
the number of required reviews, we believe that the State agencies will 
be able to conduct more on-site reviews sooner in situations where 
credible complaints have been lodged against mid-tier and smaller CE 
providers. We can better fulfill our stewardship responsibilities by 
providing the State agencies with the ability to target CE providers 
with documented problems for on-site reviews regardless of their 
volume. Thus, we are not making any changes to the rules we proposed.

Regulatory Procedures

Executive Order 12866

    We have consulted with the Office of Management and Budget (OMB) 
and determined that these final rules meet the criteria for a 
significant regulatory action under Executive Order 12866. Thus, they 
were subject to OMB review.

Regulatory Flexibility Act

    We certify that these final rules will not have a significant 
economic impact on a substantial number of small entities because they 
only directly affect States. Thus, a regulatory flexibility analysis as 
provided in the Regulatory Flexibility Act, as amended, is not 
required.

Paperwork Reduction Act

    These final rules will impose no additional reporting or 
recordkeeping requirements requiring OMB clearance.

Federalism and the Unfunded Mandates Reform Act

    We have reviewed the final rules under the threshold criteria of 
Executive Order 13132 (Federalism) and the Unfunded Mandates Reform Act 
of 1995. These final rules would change the threshold billing amount 
above which the State agencies that make determinations of disability 
for the Commissioner under titles II and XVI of the Act perform an 
annual on-site review of CE providers. Although the State agencies 
perform these reviews, the Social Security Administration fully funds 
the necessary costs of providing this service. We have determined that 
these final rules would not have substantial direct effects on States, 
on the relationship between the Federal Government and the States, or 
on the distribution of power and responsibilities among the various 
levels of government.

(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social 
Security--Disability Insurance; 96.002, Social Security--Retirement 
Insurance; 96.004, Social Security--Survivors Insurance; 96.006, 
Supplemental Security Income.)

List of Subjects

20 CFR Part 404

    Administrative practice and procedure, Blind, Disability benefits, 
Old-Age, Survivors, and Disability Insurance, Reporting and 
recordkeeping requirements, Social Security.

20 CFR Part 416

    Administrative practice and procedure, Aged, Blind, Disability 
benefits, Public assistance programs, Reporting and recordkeeping 
requirements, Supplemental Security Income (SSI).

Michael J. Astrue,
Commissioner of Social Security.


0
For the reasons set out in the preamble, we are amending subpart P of 
part 404 and subpart I of part 416 of chapter III of title 20 of the 
Code of Federal Regulations as set forth below:

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
(1950-)

Subpart P--[Amended]

0
1. The authority citation for subpart P of part 404 is revised to read 
as follows:

    Authority: Secs. 202, 205(a), (b), and (d)-(h), 216(i), 221(a), 
(i) and (j), 222(c), 223, 225, and 702(a)(5) of the Social Security 
Act (42 U.S.C. 402, 405(a), (b), and (d)-(h), 416(i), 421(a), (i) 
and (j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-
193, 110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 
(42 U.S.C. 902 note).


0
2. Revise paragraph (e)(1) of Sec.  404.1519s to read as follows:


Sec.  404.1519s  Authorizing and monitoring the consultative 
examination.

* * * * *
    (e) * * *
    (1) Any consultative examination provider with an estimated annual 
billing to the disability programs we administer of at least $150,000; 
or
* * * * *

PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND 
DISABLED

Subpart I--[Amended]

0
3. The authority citation for subpart I of part 416 continues to read 
as follows:

    Authority: Secs. 221(m), 702(a)(5), 1611, 1614, 1619, 1631(a), 
(c), (d)(1), and (p) and 1633 of the Social Security Act (42 U.S.C. 
421(m), 902(a)(5), 1382, 1382c, 1382h, 1383(a), (c), (d)(1), and 
(p), and 1383b); secs. 4(c) and 5, 6(c)-(e), 14(a), and 15, Pub. L. 
98-460, 98 Stat. 1794, 1801, 1802, and 1808 (42 U.S.C. 421 note, 423 
note, 1382h note).


0
4. Revise paragraph (e)(1) of Sec.  416.919s to read as follows:


Sec.  416.919s  Authorizing and monitoring the consultative 
examination.

* * * * *
    (e) * * *
    (1) Any consultative examination provider with an estimated annual 
billing to the disability programs we administer of at least $150,000; 
or
* * * * *
[FR Doc. 2010-14070 Filed 6-9-10; 8:45 am]
BILLING CODE 4191-02-P