Quality Assurance Systems in the Adjudication of Claims of Entitlement to Benefits or Compensation

The federal government is engaged in either the direct administration or the funding of a substantial number of programs which involve the adjudication of claims of entitlement to benefits or compensation. Examples include veterans’ benefits; the basic Social Security (OASDI) programs; Medicare and Medicaid; public employee retirement benefits; federal employees’ and longshoremen’s and harbor workers’ compensation programs; and programs of categorical public assistance for the aged, blind and disabled and for dependent children.

In many of these programs the number of claims per year is very large while at the same time the determinations of fact and law involved in adjudicating an individual claim may be quite complex and difficult. Moreover, claimants under these programs often lack the personal resources or access to technical assistance necessary to prepare claims material adequately and to pursue hearing or administrative appeal procedures should their claims be denied. These factors give rise to a particular concern with the quality of the adjudication process and product at all levels of the administrative process in programs which make determinations concerning large numbers of claims of entitlement to individual benefits or compensation.

As a part of a continuous effort to provide the highest possible degree of accuracy, timeliness and fairness in the adjudication of claims, the following recommendation should be adopted by agencies which directly administer benefit and compensation programs and by agencies which have a capacity and a responsibility to assure the quality of claims adjudication by grantees of federal funds.

Recommendation

1. Positive caseload management should be recognized as essential to the accurate, timely and fair adjudication of claims of entitlement to benefits or compensation. A positive caseload management system should include three connected operations: (1) the development of standards and methods for measuring the accuracy, timeliness and fairness of agency adjudications; (2) the continuous evaluation of agency adjudications through the application of those standards and methods; and (3) the use of the information gathered in the course of such evaluation to identify needed improvements in adjudicative performance.

2. As part of their positive caseload management program, agencies should begin immediately to explore, develop and implement statistical quality assurance reporting systems that will indicate the accuracy, timeliness and fairness of claims processing. In designing such systems, agencies should consider the need for information of a type that:

(a) Reflects differences in the types of cases and types of issues adjudicated and the stages of the administrative process involved;

(b) Identifies the management unit or, where appropriate, the individual adjudicator involved in order that effective action may be taken to reinforce success and to improve performance;

(c) Permits separate evaluation of (1) substantive decisionmaking, (2) case development effort and (3) procedural regularity;

(d) Enables separate evaluation of particular functions of the decision process (e.g., issue statement or evaluation of evidence in substantive decisionmaking).

3. Agencies should employ such other techniques for gathering information on their adjudication process, including field investigations and special studies, as are required for the evaluation of accuracy, timeliness and fairness. Agencies should be particularly sensitive to the need for better information on the extent to which claimants’ personal resources, social status and access to representation or other assistance may affect the adjudication of claims.

4. The positive caseload management program should facilitate not only objective evaluation of the agency’s case processing operation, but also the effective utilization of quality assurance information in policy formation and operational control.

 

Citations:

38 FR 16840 (June 27, 1973)

3 ACUS 21

Citation:

Mashaw, Jerry L.  Quality Assurance Systems in the Adjudication of Claims of Entitlement to Benefits or Compensation.  3 ACUS 160 (1975).