Problems with Establishing a Mental Health Disability in Today’s Managed Care Environment

In order to establish a claim for Social Security disability insurance (SSDI) benefits or Supplemental Security Income (SSI) benefits, it’s necessary that you prove you are likely to remain totally disabled from all forms of gainful employment despite prescribed treatment for a year or longer.  With the state of managed care through one’s own health insurance coverage, not to mention the state of the current Social Security regulations and the availability of treatment providers, it has become increasingly more difficult to prove a mental health disability claim.

The Social Security regulations require, as an initial manner of proof, that a claimant show that they have been diagnosed with a severe medically determinable impairment.  In order to establish that such a severe impairment exists, it must be through the evaluation and treatment of what is deemed to be a “treating source” or “acceptable medical source,” who are defined as: licensed physicians (medical or osteopathic doctors) and licensed or certified psychologists.   For those individuals receiving Mass Health in the State of Massachusetts, Medicaid out of New Hampshire or Mainecare out of Maine, it is virtually impossible to find a licensed psychiatrist or psychologist who is willing to treat a patient given the low level of reimbursement provided by these forms of health insurance.  For those who are fortunate enough to have private health insurance, it remains quite difficult to locate psychologists/ and/or psychiatrists who are accepting insurance.   Thus, in establishing a medically diagnosed severe impairment, we are many times reliant on hospitalizations or treatment through one’s primary care physician to establish the working diagnosis.  The problem, however, is that the Social Security Administration will not provide much weight to the opinions of a primary care physician.  Referrals from a primary care physician are likely to take place to a mental health center that is now providing services by way of a psychiatric nurse practitioner (who is the provider serving as the medication management provider) and through counselors.

Once the diagnosis has been established, it then becomes necessary for one to prove the extent to which the mental health conditions impact their residual functional capacity: that is to say, their ability to function in a work environment.   The Social Security regulations provide that treating source opinions are generally provided more weight “since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations.”  In fact, Social Security Ruling 96-2P provides that “if a treating source’s medical opinion is well-supported and not inconsistent with the other substantial evidence in the case record, it must be given controlling weight.”

Thus, if at all possible, obtaining opinions about the nature and severity of one’s mental health condition and the extent to which it impacts one’s residual functional capacity from a psychologist or psychiatrist can make all of the difference in one’s case.   While one can certainly obtain a medical opinion from a primary care physician, the concern is that the Social Security Administration will discount it as not coming from a specialist, and, ordinarily, such opinions are not ordinarily supported by the primary are physician’s treatment record: certainly, their practice does not focus on the treatment of mental health concerns and the records do not ordinarily provide the objective findings the Social Security regulations call for.

The Social Security regulations do allow for the consideration of other source opinions, such as would include opinions from nurse practitioners, physician assistants, and licensed clinical social workers.   As Social Security Ruling 96-3P makes clear, these “‘other sources’ cannot establish the existence of a medical determinable impairment.  Instead, there must be evidence from an ‘acceptable medical source’ for this purpose.”  The ruling suggests that the opinions of these “other sources….may provide insight into the severity of the impairment(s) and how it affects the individual’s ability to function.”

Given the provisions of the Social Security regulations and rules, it can not be emphasized how much of a difference the longer term treatment and care provided by a psychologist and/or psychiatrist can make in compelling SSA to provide a favorable decision.   If you or someone you care for is suffering from severe mental health difficulties and require an expert in Social Security disability law to assist in proving their care, contact the Law Offices of Russell J. Goldsmith at 1-800-773-8622 so we may provide you with the benefit of our 26 years of experience.