Section 840.90  Consultative Examination Oversight Plan

a)         The Bureau will conduct a consultative examination oversight following the specifications set forth in the Code of Federal Regulations 20 CFR 404.1519s, 404.1519t, 416.919s, and 416.919t as amended August 1, 1991, and POMS DI E39545.400 - .425 as revised August 1991.

b)         The Bureau also uses the following procedures with regard to establishment of a consultative examination oversight plan:

1)         The following steps will be taken with regard to recruitment of the consultative panel:

A)        The Bureau will undertake active recruitment of the consultative panel by contacting county medical societies, medical schools, Department field offices, physicians, clinics and various other medical sources in the community by mail, telephone and in person indicating Bureau needs and explaining the consultative examination process.

B)        After a potential consultant has agreed to accept the Bureau's medical fees, perform examinations and testing according to the Bureau's requirements and submit examination reports per the Bureau's criteria concerning substance, quality and timeliness, a curriculum vitae will be requested.

C)        The curriculum vitae will be reviewed and approved or disapproved by the Chief Medical Consultant.  If the curriculum vitae is not approved, the consultant will be notified and will be informed or the reason(s) for disapproval and what, if any, actions can be taken to correct the problems.

D)        After review and approval of the curriculum vitae, the following actions will be taken:

i)          The medical board of a physician consultant's speciality will be contacted to verify certification or eligibility for certification for the particular specialty (e.g., internal medicine, psychiatry, neurology, etc.).

ii)         The Illinois Department of Registration and Education will be contacted to verify that the consultant is licensed and to determine if any disciplinary action has been taken or is pending against the consultant.

iii)        The State of Illinois Comptroller's office will be contacted if the consultant indicates employment by another State agency.  If the consultant is employed full-time by another State agency, then the Bureau will request that the consultant obtain a waiver from the Governor's office to perform consultative examinations and submit it to the Bureau.

iv)        If it is determined that the consultant is not board certified or eligible for certification (except if the consultant is the claimant's treating physician or psychologist), is not licensed or has had disciplinary action taken or is pending, or has not or refuses to sign a waiver as described in Section 840.90(b) (1) (D) (iii) then the consultant will be given written notification that the Bureau will not accept his or her application to perform consultative examinations.  He or she will be informed of the reasons for nonacceptance.  The Bureau will indicate that, if the situation is rectified at a later time, the consultant  can reapply.

E)        According to the Code of Federal Regulations 20 CFR 404.1519s and 416.919s, orientation will be conducted before a consultant receives any referrals for examinations.  The consultant will be given an orientation packet consisting of information on the Social Security disability program, medical evidence and consultative examination report requirements, consultative examination procedures, teledictation service, and condfidentiality of records.  He or she will also be given a copy of the Privacy Act of 1974 (5 U.S.C. 552a and 552a note), Handbook for Physicians, the Bureau's fee schedule, sample examination reports and sample information.  The consultant will provide information for completion of a Consultative Panel Information Form which contains informaton about the consultant's practice and x-ray, laboratory and testing procedures. The consultant will sign a Medical Disclosure Acknowledgement Form which explains that the consultant is prohibited from unauthorized disclosure of information obtained in conjunction with the Social Security disability program.

2)         According to the Code of Federal Regulations 20 CFR 404.1519s and 416.919s as amended August 1, 1991, the Bureau will undertake a program of systematic, onsite reviews of key providers that will include annual onsite reviews of such providers when claimants are present for examinations.  The Bureau will use the review protocol for onsite review as specified in POMS DI E39545.445 and E39545.900 as revised August 1991.

3)         The following situations are subject to investigation and shall result in removal of a consultative examination provider from the consultative panel, if the situation is not resolved:

A)        claimant complaints

B)        conflict of interest as described in Code of Federal Regulations 20 CFR 404.1519a and 416.919a as amended August 1, 1991

C)        evidence of fraud in report preparation

D)        facility in which exams are performed is unacceptable (e.g., inaccessible by persons with disabilities; the location, facility, equipment, or staff are not hygienic; improper use of equipment or equipment unacceptable per disability program requirements; license not displayed)

E)        unacceptable reports (e.g., objective evidence not provided, use of decisional comments, brevity to the point that completeness of exam is questionable)

F)         late reports

G)        license revoked or suspended

H)        fees which are above the usual and customary fees requested by other consultants in the area where the consultant is located

I)         American Medical Association complaints

J)         any other situation which is detrimental to the claimant or the claimant's determination of disability or blindness

K)        death, retirement, request to be removed from panel.

4)         The consultant will be given the opportunity to submit evidence on his or her behalf and to correct the problems when possible.  Referrals to the consultant may be suspended pending the outcome of an investigation.

(Source:  Amended at 16 Ill. Reg. 10301, effective June 15, 1992)