New Disability Rules on Weight Given to Treating Doctors and Acceptable Medical Sources

Social Security has made significant rule changes in how it evaluates and weighs the opinions of an applicant's doctor, nurse practictioner, or other medical provider.

In January 2017, the Social Security Administration (SSA) enacted new regulations dealing with the evaluation of treating physicians' opinions and which medical professionals qualify as acceptable medical sources. Highlights of the new rules are discussed below.

Treating Physician Rule Eliminated

Under the new regulations, Social Security will no longer give special weight to the opinions of a disability claimant's treating physician. Instead, all medical opinions—from treating providers, Social Security's consultative examiners (doctors paid by Social Security), and independent medical examiners—will be evaluated on an equal basis for "persuasiveness." The key factors a disability adjudicator will consider in evaluating the persuasiveness of an opinion are supportability and consistency.

A well-supported medical opinion is one that is backed up by the claimant's reported symptoms, observable medical signs, and laboratory findings such as EKGs, blood tests, or medical imaging. Consistency refers to how the medical opinion stands up to the rest of the evidence in the file, including other medical opinions, the claimant's medical records, and the claimant's own statements. For instance, if a physician offers an opinion that the claimant can sit in a chair for only 30 minutes at a time but the claimant reports sitting on the sofa and watching movies on a regular basis, this could be seen as inconsistent. If there is an innocent explanation for this apparent inconsistencyfor example, the claimant stands up or lies down every 15 minutesthe doctor should explain this in his or her opinion.

If the file contains opinions from two or more sources that are equally well-supported and consistent with the record, Social Security will then consider the length and purpose of the patient's relationship with the doctor or other provider and the specialization of the medical provider. The provider's understanding of Social Security policy and familiarity with the claimant's file will also be considered, two factors that are likely to weigh in favor of Social Security's consultative examiners.

While Social Security has explained that the elimination of the treating physician rule change is a result of the "changing nature of healthcare delivery," namely that individuals less frequently develop a long-term relationship with one treating doctor, many disability advocates worry that the rule change will cause many more deserving claims to be denied.

This new rule generally applies to disability applications filed on or after March 27, 2017 and is covered in 20 CFR 404.1520c.

List of Acceptable Medical Sources Expanded

One rule change that might prove favorable for disability claimants is that physician assistants (PAs), advanced registered nurse practitioners (ARNPs) (known as advanced practice registered nurses (APRNs) in some states), and licensed audiologists and optometrists are now generally classified as acceptable medical sources by Social Security.

An acceptable medical source (AMS) is defined by Social Security as a medical provider who can provide evidence to establish the existence of a "medically determinable impairment." (A medically determinable impairment is one that results from "anatomical, physiological, or psychological abnormalities" that can be shown by "medically acceptable clinical and laboratory diagnostic techniques," and thus a diagnosis of such an impairment must be made by someone with high-level medical training. Social Security recognizes that primary care is increasingly being provided by physician assistants and nurse practitioners, and that these medical professionals have the training required to diagnose the existence of an impairment.

In its decisions, Social Security must explain how it how the agency considered the persuasiveness of a medical provider's opinion when the provider is an AMS.

Note that registered nurses, chiropractors, and licensed social workers are still not considered to be acceptable medical sources. But Social Security may use information from these sources in evaluating the severity of applicants' impairments and how the impairments affect their ability to work. Social Security, however, is not required to explain how the agency considered evidence from nonmedical sources about an individual's functional abilities and limitations.

This new rule generally applies to disability applications filed on or after March 27, 2017 and is covered in 20 CFR 404.1513.