Why Do Claims Get Denied?

Why do claims get denied?

All denial letters start the same way: “Based upon the evidence we have. . .” you are either 1) not medically disabled, or 2) even though you cannot do your past work, there is other work you can do.

That sums up the entire decision making analysis.

Note the phrase “medical evidence we have.” That does not mean that they have everything they needed.

Similarly, they may not have understood what your past work was; or, how your age, education and experience will affect what other work you could do.

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Email Inquiry Response:

Dear Ms. D.,

I write to respond to the inquiry you placed on the internet concerning disability benefits. I pasted your inquiry below. If you did not do this, or if you were not actually interested in Social Security Disability, please let me know. The short answer is: I don’t have enough information to give you a real opinion. But, I have enough experience with blindness cases to give you the following information. (Understand, sending you this does not create a lawyer/client relationship and I am happy to give you more information if you contact me.)

Description:
 I have glaucoma. my eye doctor has me using eye drops to bring the pressure down it was 50 pressure in my right eye.. and 45 in my left eye. know it is 25 in my right eye and 24 in my left eye, my eye doctor said he is probably going to half to do surgery on my eyes

AIDS AND THE HOMELESS; A STRUGGLE FOR HELP, DIGNITY

AIDS and the homeless; a struggle for help, dignity - By Irma Widjojo/Times-Herald staff writer/     Posted: 03/18/2014 01:07:48 AM PDT


John Carter, a homeless man with AIDS sleeping outside the Vallejo public library, takes a sip from a drink supplied by a friend as he talks recently about his problems finding medical assistance in the county. Carter had just visited a local emergency room, having had a health crisis. He has now found temporary inside lodging, waiting for a medical appointment. (Mike Jory/Times-Herald)
John Carter was covered in his own excrement and too weak to speak when a few people found him about a month ago asleep on the concrete outside a Vallejo library.
With their help, Carter, 44, is now on medication and in transitional housing.
Carter was diagnosed HIV positive in 1989, and has been homeless for the past few years. Last year, his HIV developed into full-blown AIDS.
He said without the help of Good Samaritans, who brought him food, clothing and even took him to doctor appointments, he likely would have died.
Although a much healthier looking man today, Carter still has a basic question from when he was found in front of that library: Where was the help?
County and hospital officials said there are resources, but Carter and his supporters say they are difficult for those who are down and out to access.
"The system is broken," Solano AIDS Coalition's Izzy Drumgoole said. "I know (Carter), but literally this can be anybody. If you don't have insurance, you are poor, and you don't have access to resources. Is this what you deserve? No, it's wrong."
When Mario Saucedo, also of Solano AIDS Coalition, found Carter on Valentine's Day, he took him to the emergency room at Sutter Solano Medical Center.
However, Saucedo said Carter was given a blood transfusion, and was released hours later in the middle of the night, with no warning to Saucedo who was going to pick him up. He walked out with papers listing phone numbers and websites to available resources.
But Carter had no money, and said he wondered, "How am I supposed to call? I don't have a phone."
The Solano County AIDS Community Education Program's number to enroll in its Ryan White program requires a call-back number.
The program is available for those who "have no other option," said Cara Drake, the senior health education specialist.
If eligible, clients are provided a case manager, who arranges housing, food, transportation, health and other services for them. To be eligible for the program, prospective clients must have a letter of diagnosis, which is also problematic for someone in Carter's situation who may not keep documentation. The county, however, does provide free testing twice a month at its Vallejo clinic, 365 Tuolumne St.
Drake said each week many people try to get into the program, but there's only so much state funding. According to the state Office of AIDS website, Solano receives $136,220 for HIV Care Programs from July 1, 2013 until the end of March.
Saucedo said there's a breakdown in communication, and more outreach is required so potential clients like Carter don't fall through the cracks.
"They live on the streets," Saucedo said. "The county needs to go to the streets to look for these people, to tell them that the resources are here."
Drake said the program outreach must come from its community partners.
"I think the reason people are not calling is because they don't know about the services," Drake said. "We rely on the community to spread the word. If there's one person along the way who's willing to help, you're more likely to get care."
At Sutter Solano Medical Center, Carter said he spoke with a hospital social worker, but was unable to be immediately placed in transitional housing. The hospital offers Transitional Care Program in partnership with various community organizations.
Hospital spokeswoman Liz Madison said patients are treated and released "when they are medically safe."
"Upon discharge, the additional resources that are given to the patient ... we are really hopeful that they take the initiative to pursue them," Madison said. "There's only so much we can do in the hospital. It's important and appropriate for the hospital (and community organizations) to work on that end."
Through assistance from, and phone calls by Saucedo, Planned Parenthood paid for Carter to stay at a local motel for three weeks, plus meals. Carter also receives medication through the California AIDS Drug Assistance Program, and is applying for Medi-Cal.
"I was lost," Carter said when he first spoke to a reporter nearly a month ago. "I want people to get services that they need. I want people to get treated with dignity. I want people to be OK to be sick."
Saucedo said he knows there are many like Carter living on the street with HIV, or AIDS.
"We can't tolerate this," Saucedo said. "We are in 2014, and this is happening? Why does it take me to scream for things to happen?"
As for Carter, he said he's focused on getting healthy, and planning on helping Saucedo help others living with HIV.
"I feel supported," Carter said. "I don't want to go back to the street. I'm surprised I didn't die. ... I'd like to see people like me blend in, with no stigma. Treat us like a person. I am normal."
Contact staff writer Irma Widjojo at (707) 553-6835 or iwidjojo@timesheraldonline.com. Follow her on Twitter @IrmaVTH.

(Kay's note:  He came in to my office on March 19th.  We filed that day and he was approved and received his first check on about April 15th.  He’s gained 25 pounds (having lost 60 in 3 months) and his T Cell count is working it’s way up.)

http://www.timesheraldonline.com/news/ci_25364704/aids-and-homeless-struggle-help-dignity
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What are the Chances of Winning?

What are the chances of winning?

Obviously, this depends upon your medical conditions.

There are three levels in the application process. 1) The Initial Application; if that is denied; 2) An appeal called "Reconsideration;" if that is denied, 3) an appeal to an Administrative Law Judge. (There are appeals after that – but, it’s too complicated for this discussion.)

At the Initial Application Level, the approval rate in 2010 was 35%. Remember that this 35% includes people who have terminal illnesses; organ transplants; have lost limbs and are blind. The statistics for a "typical case" (low back problems; purely mental illnesses; cancer in remission etc.) are unknown. I’d guess 10 – 15%, but that’s just a guess.

At the next stage, Reconsideration, only 10% of the people who did appeal were approved. Remember here, that many people just give up after the first denial – particularly if they’ve tried to do it themselves. They are either too tired to go on, or they figure that the "government knows what it’s doing" and wouldn’t deny a good claim.

At the Administrative Law Judge Stage, about 70% of those who appeal go on to have their claims approved – this varies greatly region to region. One third to one half of that 70% are not represented.

You can find out about your region, and specific judges at the Social Security Official Website:
http://www.socialsecurity.gov/appeals/DataSets/03_ALJ_Disposition_Data.html

As a general rule, the younger you are, the less likely your chances of winning.






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Who Qualifies and What are the Benefits?

Who Qualifies and What are the Benefits? Financial 1
There are two basic Social Security programs: Social Security Disability Insurance (SSDI) which is what it says: Insurance - If you qualify, so do minor children you support.

A typical benefit is $1,100 per month, and additional amounts for minor children in your household who you support. If you win, you can get benefits as far back as a year before the date you first filed. But, every case is different.

Whether you qualify for SSDI or not depends upon how long you worked and when. You can ask your local Social Security Field Office – but be skeptical of their answer.

You need to know what your “Date Last Insured” is.

Just like with car insurance, when you stop paying the premium, your coverage will stop.

Say your coverage ended in January, but you had an accident in November of the preceding year. You could still go to your insurance company about the claim even if you are no longer covered.

The same is true in SSDI cases.

Say you were employed full time, and got hurt in 2004 and stopped working. But, you didn’t file a claim until 2013. You would not be covered in 2013 – but, you probably would have been covered up to December 31, 2010.

So you would be covered, if Social Security Agency finds your disability started any time before December 31, 2010 – but not after.

This happens all the time in Workers Compensation cases when people live off of their WC payments and so aren’t working. When that money is gone, they decide to file for SSDI. The Social Security Field Office could very well tell you when you call that you are not eligible. That is true – but only if your condition happened after December 31, 2010.

So, you need to know 1) Were you ever covered; and, 2) When did coverage stop.

Financial 2:

Supplemental Security Income (SSI) provides a very small amount of money (less than $850 per month) to people who live at or below the poverty level. If you win, you do get paid for the time you have been waiting to get your case heard, but not for any time prior to that.

Prior Claims: How far back the government will pay you could depend on whether you filed prior claims – too complicated to explain here.

Medical: Once you know your financial status, there are five steps to a determination.

Step 1. Are you working? You don't have to be bed-ridden to qualify. This is why so many people who get Social Security benefits may not look like they should qualify if you see them on the street. Only you know how you feel and what you can do. Don't give up hope just because someone else doesn't believe you.

Step 2. Do you have a medical impairment? Basically this means a diagnosis of something that limits your ability to work. Here, unlike Workers Compensation cases, they don't look at just one injury, illness or consequence. Everything counts. Does pain or pain medication limit your ability to concentrate? Are unscheduled breaks necessary for you? Are you out of breath or fatigued because you can't sleep? It is the combination of things and what a medical professional says about them that matter.

Step 3 Listed Impairments: There are special rules for some conditions (blindness, some cancer, some heart conditions, etc.). These cases may be processed more quickly. There is a long list of these conditions. Every case is different.

Step 4: Past Work. Can you do the easiest job you have done in the past 15 years? They don't just look at the most recent job you have had. If you have had a sit-down job in the past 15 years, it is legally significant even if you have done heavy labor for the past 10 years.

Step 5: Other Work If you can't do your past job, other factors (age, education, job skills and difficulty with English) will make it harder for you to go back into the work force. It does not matter whether you could actually find a job. It is your "vocational profile" and what the medical professionals say your maximum physical capacity that count.

CASE EXAMPLE: The young man with diabetes I mentioned earlier. He could easily lift 50 pounds. He could sit, stand and walk on an unlimited basis. So, why was he disabled? He was denied at the first two levels because the decision makers at that point did not look at the ravages of the disease.

He was approved by the Judge because we proved he could not do those things on a competitive and sustained basis long enough to maintain full time employment. In his case, the Agency will do a medical review in about a year. Hopefully, he will get the right medication and be better enough that he can go back to work – which he really wants to do. His benefits will end at that point.

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