SOAR Critical Component: Collecting Medical Evidence

Collecting Medical Evidence

It is important to remember that the DDS examiner rarely meets the applicant and determinations are based solely on the medical evidence gathered.

Advantages of SOAR

SOAR facilitates the gathering of medical records prior to submission of the application packet to SSA. This ensures that DDS receives complete information without duplication of effort and as quickly as possible to assess whether the applicant's physical and mental health problems lead to functional impairments that result in an inability to work at SGA.

When case managers facilitate gathering of medical records, they can:

• Often access medical records faster
• Ensure that records are sent and ensure that the information is relevant and complete, including information that is often overlooked, such as progress notes
• Make an initial assessment about the available information
  • Does it substantiate the health problems?
  • Does it provide documentation of functional abilities?
  • What information is missing, what needs clarification, and what needs further development?

Representative Responsibilities in Collecting Medical Evidence

In addition to the advantages above, when a SOAR provider serves as the applicant’s Appointed Representative using the SSA-1696, his or her duties as a representative include assisting the applicant in gathering and submitting medical evidence to DDS.

• The Representative Rules of Conduct states that a representative must promptly obtain and submit information and evidence to DDS.
• Representatives should make good faith efforts to obtain medical evidence, but if they are unable to do so (e.g. the medical center does not respond to the request or charges a fee that the provider cannot pay), then the representative can inform DDS about the evidence and DDS will reach out to the medical provider.

Five Steps for Collecting Medical Evidence

1. Make List of Treating Sources

Make a list of the places where the person received treatment.

• Use the Disability Report and additional contacts.
• Identify what information might be acquired from each source.
• People often have difficulty recalling all of their treatment history, so be creative in identifying potential sources of information.
• Maintain a spreadsheet of the commonly used facilities and instructions for requesting their records – this may be handy for future applications.

2. Obtain Releases for Medical Information

Have the applicant sign two releases for each treating source.

• Applicants need to sign BOTH an SSA-827: Authorization to Disclose Information to the Social Security Administration AND your agency's release of information form (see a sample) for each treatment source.
  • Signing two releases provides "compound authorization" which enables the case manager to obtain the information and send it on to SSA. This process complies with HIPAA regulations.

3. Send Releases to Medical Records Departments

If acceptable, fax or hand deliver releases for medical information to providers.

• Contact current and past providers to explain the critical importance of obtaining complete information.
• Prepare “request packets” that include a Medical Records Request Cover Letter (see a sample) and the two releases.
• Confirm receipt of fax or delivery, if mailed.
• Specify the type of information needed.
• Ask what you can do to facilitate quick receipt of records.

4. Offer Assistance to Medical Records Departments

Case managers can collaborate with medical records department directors to coordinate the information collection process. Offer assistance to alleviate the burden for busy medical records staff:

• Offer to review records; this ensures that all relevant information is copied.
• Offer to make the copies or bring paper for records to be copied on.
• Offer to pick up the records at a designated place and time.
• Say “hi,” even when no requests are pending.
• Remind staff how critical they are in process.
• Bring flowers, candy, brownies, etc. to show your appreciation.
• Report to higher-ups that staff help the agency receive more Medicaid/Medicare dollars.

5. Follow Up Weekly on Information Not Received

Follow up on records collection on a weekly basis until all information is received.

• Continue to identify new sources of information (new sources may be identified or recalled; new problems may arise that need treatment).
• Maintain ongoing and regular contact with DDS.
• Pass new information on to DDS.
• Inform DDS of sources that did not send information so that DDS can follow up.

Fees for Obtaining Medical Records

Building relationships with medical records departments also helps SOAR providers arrange fee waivers and obtain records free of charge.

• Meet with the medical records department manager or billing supervisor. Make sure you are speaking with someone who has the authority to waive fees.
• Explain that the records are for an individual who is experiencing homelessness, has no income and needs the records to apply for disability benefits; ask that the fees be waived.
• Remind them that when the individual is approved for benefits, the facility could be reimbursed for services provided.
• Read more about state statutes and regulations regarding the collection of fees for medical records.

Organize and Review Records

Organize records chronologically.

• Place the most recent records on top.
• Remember that DDS requires a mental status exam within the past 90 days.
• Note what is missing and what needs clarification.
• Get assistance from a supervisor, the individual’s treatment provider, or a consultant (if needed); make sure to have releases for any reviewers.
• You will incorporate all information into the Medical Summary Report.