Two Causes of Claims Denial for Social Security Disability Eligibility

One of the best safety nets for patients who have suffered a long-term or permanent disability is receiving Social Security Disability (SSD) benefits. Millions of Americans apply for disability insurance but only 37% have their claims approved. Furthermore, appealing for SSD is extremely frustrating as it now takes 596 days or almost 20 months for an applicant to get a hearing.

Hospitals are seriously concerned of the lengthy time it takes for SSD application and appeals because it will affect their revenue reimbursement. Here are the two possible factors that can affect Social Security Disability eligibility processing and lead to claims denial.

Existing Stumbling Blocks to Social Security Disability Eligibility

Complex Health Conditions

Some health conditions face a higher risk of claims denial than others because of the difficulty of diagnosis. The NPR article, “Long Waits And Long Odds For Those Who Need Social Security Disability,” describes the plight of Stephani Hashmi, a charge nurse in a Kansas City ICU. She has been reapplying for SSD several times already, but her claims kept on being denied due to her systemic lupus, which is difficult to prove or measure.

Patients with complicated conditions, such as mental illness, multiple sclerosis and lupus, that are complex to determine and which affect patients in many different ways tend to receive a notice of denial from SSA. With additional denials, the backlog for appeals increases as well.

New SSA Rule

A new rule from the “Revisions to Rules Regarding the Evaluation of Medical Evidence” of the Social Security Administration (SSA) reduces the consideration for an applicant’s long-time doctor. The SSA believes that proof from a medical professional who has an enduring treatment relationship with a patient may provide “inconsistencies” in time with regards to understanding the changes in the severity of the latter’s illness.

The new rule suggests that there could be problems in diagnosing the development of diseases when done by long-term healthcare providers. As an implication, for the SSA, a new examiner’s diagnosis can have a bigger weight than the patient’s long-term doctor wherein the former can immediately reject the existence of an applicant’s pre-existing condition, a critical factor that can cause the dismissal of SSD claims as well as subsequent appeals.

Despite these hindrances to SSD benefits, hospitals that want to help their patients shouldn’t despair. If you want to learn more about successful SSD processing, contact a company that can assist with SSD advocacy and representation. They have qualified navigators who are experienced in SSD eligibility processing within the new restrictions and rules, as well as in supporting claims appeals, through their access to diverse technological and network resources.


“Long Waits And Long Odds For Those Who Need Social Security Disability,”
“Wait Time for Federal Disability Benefits Appeal Hits a Record,”

Pete Ash

Pete is the Vice President of Sales & Client Services at DECO Recovery Management. He covers the Mid Atlantic region and specializes in Medicaid related topics. It is DECO’s Mission to maximize reimbursement to our clients by leveraging innovative technology, processes and compassionate advocates to provide exemplary service.

Categories: Social Security Disability Eligibility