The Role of the State Agency Doctor and Why You Might Want to Get an Independent Medical Exam

Welcome to Season 1, Episode 40 of Winning Isn't Easy: Navigating Your Social Security Disability Claim. In this episode, we'll dive into the complicated topic of "The Role of the State Agency Doctor and Why You Might Want to Get an Independent Medical Exam."

Most people don’t realize that the first “medical decision-makers” in a Social Security Disability claim are doctors who never examine you. These state agency physicians review your records from a desk and issue opinions about the severity of your condition, the credibility of your symptoms, and the work you can still do - and their views often carry more weight early on than your own doctor’s. In this episode of Winning Isn’t Easy, Nancy L. Cavey explains the real influence these agency doctors have and why their assessments can shape, or even derail, your claim. She breaks down how their opinions fit into the evaluation process, what happens when their conclusions don’t match your limitations, and the red flags that suggest their review may be incomplete. We also explore Independent Medical Examinations (IMEs): what they are, when they help, and how they can counter flawed agency opinions. Nancy outlines the benefits and risks of obtaining your own consultative exam, what a strong IME should include, and how attorneys use these reports to strengthen the medical evidence on appeal. You’ll learn which medical opinions matter most, how to build a record that reflects your true limitations, and the strategies that ensure the right evidence is working for your claim. Winning isn’t easy, but understanding the role of these doctors can make all the difference. Let’s get started.

In this episode, we'll cover the following topics:

One - Why a State Agency Doctor’s Opinion Can Make or Break Your Social Security Disability Claim

Two - Independent Medical Examinations (IMEs) and Their Role in Disability Claims

Three - Should I or My Lawyer Hire a Consultative Doctor in My Social Security Disability Claim?

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Long-Term Disability ERISA Claims. Give it a listen: https://wiedisabilitypodcast.buzzsprout.com


Resources Mentioned In This Episode:

LINK TO YOUR RIGHTS TO SOCIAL SECURITY DISABILITY: https://mailchi.mp/caveylaw/your-rights-to-social-security-disability-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Nancy Cavey [00:00:00]:
 Foreign. Welcome back to Winning Isn't Easy Social Security Disability Benefits this is a podcast where we break down everything you need to know about navigating the Social Security disability claims process. I'm your host, Nancy Cavey. Before we get started, I've got to give you that blasted legal disclaimer. This podcast is not legal advice. The Florida Bar association says I've got to tell you this, and now that I've done that, nothing will prevent me from giving you an easy to understand overview of the Social Security disability claims process, the games that are played during it, and what you need to know to get the disability benefits you deserve. So off we go. Now, today I'm going to be jumping in to a discussion about the role of a state agency doctor and when it makes sense to potentially get your own independent medical exam in your claim.
 
 Nancy Cavey [00:01:03]:
 Most people are surprised to learn that the very first doctors who decide their Social Security claims may never meet them and quite frankly, may never even be qualified to evaluate their specific medical condition. These state agency doctors review your records from behind a desk and they issue an opinion about whether your condition is severe enough, whether your symptoms are believable, and your restrictions and limitations. Ultimately, of course, these opinions carry enormous weight at the early stages of your claim because Social Security will take this opinion and then determine whether at step four you can do your past work and at step five, whether you can do other work in the mythical hypothetical, not real world national economy. These opinions carry enormous weight at this stage, even more than your own doctor's records, because quite frankly, Social Security doesn't always have your complete medical chart and even worse, they don't always send the agency peer review doctor all your medical records. So what happens when the agency peer review doesn't match your real limitations and your records? That's where maybe having a consultative exam come in, or even going so far as to get your own independent medical evaluation. These evaluations can provide an in person detailed medical evidence that your claim may be missing or that your doctor just doesn't want to address because they don't do disability claims. So in this episode I'm going to unpack why state agency opinions can make or break your claim, what an IME is, how it might work, and when it makes sense for you or your lawyer to consider getting an ime. Now, what I want you to understand by the end of this podcast is the hidden power that these medical opinions hold, not only at the initial stage, but at the end, and how they can be used at a hearing by a judge in formulating a hypothetical about whether you can do your past work or other work, and that hypothetical will make or break your case.
 
 Nancy Cavey [00:03:09]:
 Got it. So let's get started. I'm going to talk about three things. Number one, why a state agency doctor's opinion can make or break your Social Security claim. Two, IMEs and their role in a disability claim and three, should I or my lawyer hire a consultative doctor in my Social Security claim? Before we get started, let's take a quick break.
 
 Speaker B [00:03:32]:
 Are you considering filing for Social Security Disability or has your claim been denied already? Either way, you require a copy of your rights to Social Security disability benefits, which will cover everything you need to know about the Social Security disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:04:07]:
 Welcome back to Winning Isn't Easy why a state agency doctor's opinion can make or break your Social Security disability claim now, when you apply for Social Security benefits, your application is initially processed and at a field office which verifies non medical eligibility requirements such as work credits and income levels. Now, once that step is completed, the field office is going to forward your case to a state agency called Disability Determination Services dds. DDS is responsible for developing the medical evidence in your file and making the initial determination about whether you are disabled under Social Security regulations. When you fill out this initial application, you're telling the doctor, I'm sorry, you're telling Social Security, hopefully about all the doctors and medical providers and facilities you have seen. DDS is going to write those providers and ask for a copy of the records. Unfortunately, not all doctors or providers will reply and supply the records. Not all of them will supply the complete chart. DDS doesn't always review the entire chart, nor do they not necessarily review them carefully.
 
 Nancy Cavey [00:05:18]:
 Wow. Isn't that a problem if those records are unavailable, incomplete or insufficient, DDS is going to rely on the opinions of state agency doctors and quite frankly I will tell you that is most of the time the state agency doctors are not typically specialists in your specific condition. So I have had cases where the person might have Parkinson's disease and the claim is reviewed by an OB gyn. Yeah, I understand that, don't you? Now they are going to be performing what is essentially a paper review of your medical file and rendering opinion on medical and psychological issues in your claim. They can address questions about the existence and severity of your impairment, the existence and severity of your symptoms, whether your impairment meets or equals a listing at step three, your residual functional capacity and the level of work that you can do despite Your disability, whether your impairment is expected to last at least 12 months, whether you fail to follow prescribed treatment and how that impacts your claim, and in cases involving substance abuse or use, whether that drug or alcohol addiction is material to your disability. Okay, well, this is. The process is important because why? Well, after March 27, 2017, there's no such thing as a treating physician rule. Social Security doesn't automatically defer to the opinion of any medical source.
 
 Nancy Cavey [00:06:47]:
 But I will tell you, in the real world, DDS and sometimes even judges will place greater weight on the opinions of the state agency doctors. And certainly that's true during the initial and reconsideration stages. Remember, state agency doctors will never have examined you. They often rely heavily on diagnostic studies like MRI, CT scans. And they'll overlook, in my view, detailed examination findings and functional observations of your doctors. That's a huge disconnect and it can create lots of problems for you. Now, DDS claims examiners are supposed to provide a written analysis explaining why they found each medical opinion persuasive, the DDS claims examiner, as opposed to evaluate whether the medical evidence is consistent and supported by the record. But the reality is they're overworked and underpaid.
 
 Nancy Cavey [00:07:39]:
 And certainly in these days, with the reduction in staff, they don't have the time really to do the job they're supposed to. And unfortunately, that means that their explanations are often superficial or incomplete. And what's amazing to me is that the examiners aren't even required to address other factors such as the length and nature of the treating relationship you have with your doctor, the medical provider's specialization, their familiarity with the full evidence in your file. And what amazes me is whether new medical evidence that's submitted after the state agency's doctor's opinion is rendered actually makes your treating doctor's opinion stronger. So it might be a new MRI or a new CT scan or some new medical evidence that obviously the state agency doctor didn't have to consider because it didn't exist. But they aren't sending it back to them to say, well, you know, wait a second, there's something's changed. What do you think? This really, in my view, creates an uneven playing field. That's why one of the first things that we do when we have access to your file is to look at the electronic case file, DDS medical consultant opinions and the examiner's analysis.
 
 Nancy Cavey [00:08:56]:
 This review explains why your claim was denied and shows us what evidence needs to be added to counter the state agency conclusions. And so that's a crucial piece of evidence for us that we're looking at. When we are looking at the claim, of course, we look at the, you know, the claim denial letter, which, you know, sometimes doesn't make sense. And then we're looking at what's in the file, that and including the opinion of the DDS medical consultant. The to try to put together the breadcrumbs that will tell us why it is they claim, deny the claim. And then more importantly, it tells us what the weaknesses of this claim are and gives us an idea of what it is we need to do in terms of evidence, including medical evidence, residual functional capacity forms or maybe evaluations to establish that you meet the five step sequential evaluation. And we're going to talk more about how the opinion of the DDS medical consultant can make or break your case at later stages of the case. But we've just laid the framework for the role of the DDS provider.
 
 Nancy Cavey [00:10:03]:
 Now in our next segment, I'm going to talk about the potential use of IMEs in a Social Security disability claim. But let's take a break first. Okay. Foreign. Welcome back to Winning Isn't Easy. Independent Medical examinations and their Role in Disability Claims. Now let's talk about what an IME is. And then I'm going to back myself, if you will, into the answer to this question about their role in disability claims.
 
 Nancy Cavey [00:10:43]:
 An independent medical evaluation. An IME is a medical evaluation performed by a physician who's not involved in your regular treatment and has no prior relationship with you. Now, they're often used in workers compensation cases, in personal injury cases and disability cases, ERISA or individual disability cases. It's not uncommon that when I'm handling a disability claim, a ERISA disability claim, that I may be getting an independent medical evaluation to address, to address issues to rebut the disability carrier's IME doctor It might be that we've had a claimant who's come to us who got treatment in a context of a workers comp case where liar for hire IMEs are used widely. Same way in a personal injury case. Let me tell you, the word independent has nothing to do with an ime. I call them liar for higher evaluations unless I hire the doctor. And generally the doctors I hire, I would say 99% of the time are doctors who I believe in.
 
 Nancy Cavey [00:11:49]:
 I'm not sending my client to get an opinion that I know is going to be favorable. Now, not all lawyers are like that, but I want to make sure that the judges who see these IMEs understand not only my credibility, but the credibility of the IME doctor. Now, unlike state agency doctors, IME physicians normally will meet with you. They'll take a history, perform an exam, they, they may even conduct additional testing and that can provide a more complete picture of your health and functional limitations. I will tell you that the benefits of an IME can include that detailed in person assessment rather than paper only review. An opportunity to get another opinion about an issue that might arise in the work comp case, the ERISA case, the Social Security case. Because a lot of these issues will cross these types of boundaries. We want them to address symptoms or limitations overlooked by the DDS doctor and we will obviously want to create challenges to the validity of the state consulting physician.
 
 Nancy Cavey [00:12:54]:
 So in that case, fibromyalgia, where the DDS doctor was a obgyn, I might want to get an IME by a fibromyalgia specialist. Clearly, I want to go after the qualifications of the DDS doctor, but I will tell you that IMEs can have limitations. Now, Social Security does use exams. They call them consultive exams. And I find them not to be particularly helpful. And there was a long pause there. What I find is this. If the Social Security administration doesn't think there's sufficient information, they may ask for a consultive exam.
 
 Nancy Cavey [00:13:42]:
 I try to substitute, with Social Security's approval, the treating physician for the ce, assuming that the treating physician is going to answer the questions that Social Security wants answered. If my client doesn't have a lot of medical treatment, I may ask for a cell. But ultimately the CE is going to be not necessarily qualified and they are from a stable of doctors who've made themselves available to Social Security. That's a problem in my view, because they make a living or supplement their income by doing these ces. Do you think they're necessarily going to say something that would get them kicked off of the list? I don't think so. Now, let's talk about two other things here. Under the Social Security rules, we have an obligation to submit all evidence whether it's favorable or not. That means that if you have a personal injury claim, a worker's comp claim, the records of the treating physicians are going to go in and that can include doctors that have been picked by the disability carrier or by the or comp carrier.
 
 Nancy Cavey [00:14:54]:
 And it's going to include IMEs, even if they're favorable or not. So it's going to come in. Now, I have seen certain judges view IME opinions with skepticism. Assuming that there is a bias in favor of the of the claimant. And my Response to that is, look, we have to submit all of this evidence. The ERISA disability carrier may have had an ime, the work comp carrier has had an ime. Do you think that those are, are not biased opinions? They can be just as quote, unquote biased as the IME gotten by the claimant. So, you know, either it's all in or it's all not in.
 
 Nancy Cavey [00:15:34]:
 And either there's bias or there's not bias. So don't sort of paper coat my IME with a veneer of bias and then look at the work comp IME and say, oh, well, I'm going to accept that. That I think is a problem and certainly something that we lawyers attack when it comes to the quality of the evidence and the rationale that the judge is given or not given for accepting IMEs. But if we're going to have a CE or even an IME, we are going to look at several factors. One is the physician's specialty, what's the quality and thoroughness of the report, and how well do the findings align with the overall medical record. So when done correctly, a CE or an IME can add significant weight to the case by filling in gaps and providing evidence. But because of these complexities, it's often advisable to discuss with your lawyer whether the IME will strengthen your case. More often than not.
 
 Nancy Cavey [00:16:35]:
 If I have a personal injury case and I don't do personal injury, but it's a referral from a personal injury lawyer, I'm on the phone with that personal injury lawyer saying, are you going to get an IME for this personal injury case? Because if you are, can you have them ask these questions in the context of my Social Security case so we can use this IME in both cases? Or if I'm going to get an evaluation, maybe like a functional capacity evaluation, I'm on the phone with the work comp attorney if it's a work comp case, or the PI attorney if it's a PI case saying, I want to go get an fce. This is what I want to know. Do you agree? Not agree. What do you want to know? So again, the multiple lawyers, if you will, are sharing this information to maximize the benefits. But clearly a well chosen IME can make the difference between a denial and approval. And we want to make sure that we're maximizing your benefits. Got it. Let's take a break.
 
 Speaker B [00:17:32]:
 Struggling with your Social Security disability case. The right attorney can make all the difference. Get our booklet. The key to hiring a great attorney for your Social Security disability case. Discover how to find an experienced attorney who will fight for your rights and navigate the process with ease. Don't leave your future to chance. Request your free copy@kvlaw.com today and ensure you have the expert support you deserve.
 
 Nancy Cavey [00:18:13]:
 Welcome back to Winning Isn't Easy. Now, in our last session we talked about an independent medical evaluation, but let's talk about whether you or your lawyer should hire a consultative exam on your Social Security disability claim. And I don't have a straight answer for you. It's maybe each one of these cases are unique, but what's important to me is getting a detailed residual functional capacity form or a narrative report addressing a person's functional restrictions and limitations. How long can you sit? Stand? Stoop? Walk? Bend? Do you have problems with bilateral manual dexterity? Do you need to take breaks? Would you be off task? Would you be absent? Would you have any issues with concentration, pace, duration? Getting along with others? Those are the kinds of questions that are important in a Social Security case. It can be obtained by getting a RFC form as opposed to an IME or even a consultative exam. Remember, let's talk about the difference here between a consultive exam. Normally consultive exams are used by Social Security.
 
 Nancy Cavey [00:19:23]:
 After DDS has examined the claim and there's not enough medical evidence to address a person's restrictions and limitations, they may go order a consultative exam. Under the Social Security rules, you basically have to attend unless you can get Social Security to accept your treating physicians opinions and records in lieu of the ce. Now that can work, but it also can't work if your records just simply don't address what needs to be addressed. So in those situations, I generally don't have a problem with with Social Security bringing in a consultative exam. What I want them to do is to corroborate and strengthen the conclusions of your physician or clarify issues in complex or poorly understood cases like pots, chronic fatigue syndrome, long haul Covid or rare disease, and to provide that information when your physician is unwilling or unable to complete the forms. Now, there are times when I do use IMEs, but I'm using them in the context of other cases. Again, as I've alluded to, we may get a referral from a work comp attorney or a personal injury attorney. The IMEs are widely used in those cases by both sides the defense, the insurance company, the work comp carrier, and by the plaintiff's attorney.
 
 Nancy Cavey [00:20:42]:
 And so there already might be an IME that I want to use and quite frankly I have to disclose it under the Social Security rules. But we also do ERISA disability work. And many times in our ERISA disability claims, we are representing people who are pursuing both. And we have valuable medical evidence in the ERISA claim that we also want to expand on because we're attacking the disability carrier's denial and they're doing it based on Liar for Hire paper reviews. So we want to go back to the treating physician, have them do an examination to address these issues, or there are times when we actually have an ime. But it's there for a reason. It's to address the particular problems with the ERISA claim, the Liar for hire doctors. And as an adjunct, I want them to address the issues in the Social Security case, be it the functional restrictions and limitations.
 
 Nancy Cavey [00:21:41]:
 So I'm doing this purposefully in conjunction with other lawyers who may be involved in the personal injury or work comp case or in conjunction with my strategy in my ERISA disability claims. As I commented, sometimes Social Security judges will give little weight to medical opinions obtained by claimants or their attorneys, regardless of the doctor's expertise. That is not truly allowed by the regulations. But in practical reality it occurs. And I think that's bull because many judges will lean heavily on the opinions of state agency doctors, even though those doctors may have never examined the client at all. So under the Social Security rules and regulations, all medical opinions, regardless of where they come from, have to be evaluated under the same standards of supportability and consistency. So we attack when appropriate that the consultative exam or that they're using is not according to qualified specialist. They haven't reviewed all the relevant medical information and they haven't provided an opinion that's consistent with the medical evidence.
 
 Nancy Cavey [00:22:44]:
 So their opinion should not be given substantial weight. Again, the decision to have IME CES really depends on the particular case. Now, I did allude to talking about why the DDS evaluator, the doctor's opinion, the state agency doctors can make or break your case, particularly at the end of the case, if you're in front of a judge, the judge is going to be giving a hypothetical at step four and five of the five step sequential evaluation to address it. Step four, whether you can go back to the lightest job you held in the five years before your claim was adjudicated and then at step five, whether there's other work you can do in the mythical hypothetical, not real world national economy in view of your age, education and skills. Well, the first hypothetical that the judge is going to give during the course of a hearing to the vocational evaluator is going to be based on that initial DDS Dr. Opinion. And so as part of my memorandum of law that I'm giving to the Social Security judge, I am attacking the basis of that DDS doctor's opinion, that state agency doctor, on the basis of their qualifications, the records they had, problems with their report, to argue to the judge that that opinion is not valid, or more importantly, that other additional information has been developed because of new MRIs or diagnostic studies or surgeries, so that that opinion is worthless. And I'm also arguing in the hypothetical, if you will, that the state agency doctor's opinion does not consider all the factors such as absenteeism, off task and other relevant factors.
 
 Nancy Cavey [00:24:30]:
 So I may take that state agency doctor's opinion, which was the basis of the original denial and the denial at the recon stage, and then start supplementing it with the hypothetical I want to give based on the residual functional capacity form our doctors have filled out, or the consultative exam reports or the IME reports. Ultimately, all these reports are tools, in my view, to expand a hypothetical to show that the person, the client, can't do their past work or other work. So I just see these as tools and adjuncts. The decision to use them is going to be made on a case by case basis based on the strength of the medical, the nature of the medical condition, and the opinion of the DDS state agency doctor. You can see that this is not necessarily an easy topic. Again, it's really case specific. So today we've looked at how state agency doctors, independent exams and consultative exams and opinions can shape the claim. I've covered how these early opinions matter, how consultative exams or IMEs can fill in the gaps, and when it might make sense to hire your consultative doctor or IME doctor.
 
 Nancy Cavey [00:25:49]:
 Remember, if those opinions exist in the context of other cases, be it the workers comp case, motor vehicle case, we have to produce them, we cannot hide them. And as a result, we may have to deal with the problems caused by those reports. These cases are tricky because it's not just proving you're sick. It's showing that your limitations are real and well documented. The right medical evidence presented in the right manner, together with the right legal strategy is going to make all the difference. I hope you've enjoyed today's episode and remember that you don't have to go this alone. An experienced disability attorney can help you gather the right evidence, challenge these opinions, and present your case in the strongest possible way. So with the right guidance, you can give yourself the best chance to win.
 
 Nancy Cavey [00:26:38]:
 If you found this episode helpful. Take a moment to like our page, leave a review, share it, and please subscribe to this podcast. Please also join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening.