[Federal Register Volume 87, Number 95 (Tuesday, May 17, 2022)]
[Notices]
[Pages 29995-29998]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-10558]
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SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA-2020-0017]
Social Security Ruling 22-1p; Titles II and XVI: Fraud and
Similar Fault Redeterminations Under Sections 205(u) and 1631(e)(7) of
the Social Security Act
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling (SSR).
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SUMMARY: We are providing notice of SSR 22-1p. This ruling rescinds and
replaces SSR 16-1p and explains the revised process we will use to
redetermine an individual's entitlement to benefits or eligibility for
payments under titles II or XVI of the Social Security Act (Act) when
there is reason to believe that fraud or similar fault was involved in
that individual's original application for benefits or payments. We are
revising the evidentiary standard for fraud and similar fault from a
``preponderance of the evidence'' to ``reason to believe'' to align
more closely with the standard provided in the Act. We are also
providing a new procedure at the hearings level of our administrative
review process. The procedure provides that, before we disregard
evidence under the Act at the hearings level of our administrative
review process, we will consider the individual's objection to the
disregarding of that evidence. We expect that these revised procedures
will allow us to implement relevant sections of the Act in a manner
consistent with the decisions of the Courts of Appeals that have
considered legal challenges to the procedures outlined in SSR 16-1p.
DATES: We will apply this notice on May 17, 2022.
FOR FURTHER INFORMATION CONTACT: Mary Quatroche, Office of Disability
Policy, Social Security Administration, 6401 Security Boulevard,
Baltimore, MD 21235-6401, 410-966-4794. For information on eligibility
or filing for benefits, call our national toll-free number 1-800-772-
1213 or visit our internet site, Social Security online, at http://www.socialsecurity.gov.
SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do
not require us to publish this SSR, we are publishing it in accordance
with 20 CFR
[[Page 29996]]
402.35(b)(1). SSRs do not have the same force and effect as statutes or
regulations, but they are binding on all components of the Social
Security Administration. 20 CFR 402.35(b)(1).
We use SSRs to make available to the public precedential decisions
relating to the Federal old-age, survivors, disability, supplemental
security income, and special veterans benefits programs. We may base
SSRs on determinations or decisions made in our administrative review
process, Federal court decisions, decisions of our Commissioner,
opinions from our Office of the General Counsel, or other
interpretations of law and regulations.
This SSR will remain in effect until we publish a notice in the
Federal Register that rescinds it, or we publish a new SSR that
replaces or modifies it.
(Catalog of Federal Domestic Assistance, Programs Nos. 96.001,
Social Security--Disability Insurance; 96.002, Social Security--
Retirement Insurance; 96.004, Social Security--Survivors Insurance;
96.006--Supplementary Security Income.)
The Acting Commissioner of Social Security, Kilolo Kijakazi, having
reviewed and approved this document, is delegating the authority to
electronically sign this document to Faye I. Lipsky, who is the primary
Federal Register Liaison for the Social Security Administration, for
purposes of publication in the Federal Register.
Faye I. Lipsky,
Federal Register Liaison, Office of Legislation and Congressional
Affairs, Social Security Administration.
Policy Interpretation Ruling
SSR 22-1p: Titles II and XVI: Fraud and Similar Fault Redeterminations
Under Sections 205(u) and 1631(e)(7) of the Social Security Act
This Social Security Ruling (SSR) rescinds and replaces SSR 16-1p:
``Titles II and XVI: Fraud and Similar Fault Redeterminations Under
Sections 205(u) and 1631(e)(7) of the Social Security Act.''
Purpose: To explain the process we use to redetermine an
individual's entitlement to benefits or eligibility for payments under
titles II or XVI of the Social Security Act (Act) when there is reason
to believe that fraud or similar fault was involved in that
individual's original application for benefits or payments.\1\
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\1\ Fraud and similar fault redeterminations under sections
205(u) and 1631(e)(7) of the Act are distinct from reopenings as
described in 20 CFR 404.987-404.996 and 20 CFR 416.1487-416.1494.
Fraud and similar fault redeterminations are also distinct from
redeterminations of Supplemental Security Income eligibility under
title XVI of the Act as described in 20 CFR 416.204 and 416.987.
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Citations (Authority): Sections 205(u) and 1631(e)(7) of the Social
Security Act, 42 U.S.C. 405(u) and 1383(e)(7), as amended; 20 CFR
404.704, 404.708, 404.1512, 404.1520, 416.912, 416.920, 416.924, and
422.130.
Dates: We will apply this notice on May 17, 2022.
Introduction
The Social Security Independence and Program Improvements Act of
1994, Public Law 103-296, amended the Act to add provisions addressing
fraud or similar fault. These amendments to sections 205 and 1631 of
the Act require us to immediately redetermine an individual's
entitlement to monthly insurance benefits under title II or eligibility
for payments under title XVI if there is reason to believe that fraud
or similar fault was involved in the individual's application for such
benefits or payments.
The Act further provides that, when we redetermine entitlement or
eligibility, or when we make an initial determination of entitlement or
eligibility, ``we shall disregard any evidence if there is reason to
believe that fraud or similar fault was involved in the providing of
such evidence.'' \2\ If, after redetermining entitlement to benefits or
eligibility for payments, we determine that the evidence does not
support entitlement to benefits or eligibility for payments, we may
terminate such entitlement or eligibility and may treat benefits or
payments paid based on such evidence as overpayments.
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\2\ See 42 U.S.C. 405(u)(1)(B), 1383(e)(7)(A)(ii).
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This ruling explains the standards we use when we determine whether
there is reason to believe that fraud or similar fault was involved in
providing evidence in connection with an application for benefits or
payments. The ruling applies to all applications for benefits under
title II and payments under title XVI of the Act; e.g., claims for old-
age and survivors benefits and disability benefits under title II of
the Act, and applications for Supplemental Security Income payments for
the aged, blind, and disabled under title XVI of the Act.
This ruling also describes the process we use when we redetermine
an individual's entitlement to benefits or eligibility for payments
when there is reason to believe that fraud or similar fault was
involved in that individual's original application for benefits or
payments.
This ruling does not replace or limit other appropriate standards
and criteria for development and evaluation of claims in accordance
with our rules. There may be instances in which we will not disregard
evidence under the statutory provisions discussed in this ruling, but
nevertheless, factors may exist that justify considering the evidence
in question less persuasive or probative than other evidence.
Policy Interpretation
A. General
1. Sections 205(u) and 1631(e)(7) of the Act require us to
immediately redetermine an individual's entitlement to monthly
insurance benefits under title II or eligibility for payments under
title XVI if there is reason to believe that fraud or similar fault was
involved in the individual's application for benefits or payments.
2. The Act requires us to redetermine an individual's entitlement
or eligibility immediately, unless a United States Attorney or other
Department of Justice prosecutor, or equivalent State prosecutor, with
jurisdiction over potential or actual-related criminal cases,
certifies, in writing, that there is a substantial risk that our action
with regard to beneficiaries or recipients in a particular
investigation would jeopardize the criminal prosecution of a person
involved in a suspected fraud.
3. We may discover suspected fraud or similar fault related to a
claim for benefits or payments or in the provision of the evidence in a
variety of ways. Most often, we learn about fraud from our Office of
the Inspector General (OIG). OIG is responsible for investigating fraud
within our programs and must notify us under section 1129(l) of the Act
when it has reason to believe that fraud was involved in an
individual's claim for benefits or payments. We refer to this
notification as a section 1129(l) referral. We may also learn about
fraud from a Federal or State prosecutor during the course of a
criminal investigation or prosecution. With regard to similar fault, as
we administer our programs, we may uncover information that provides a
reason to believe similar fault was involved in the provision of
evidence in an individual's claim for benefits or payments.
4. We may find there is reason to believe fraud or similar fault
was involved in a claim for benefits or payments, or in providing
evidence, based on the actions of any individual whose actions affect
an application for benefits or payments, or the evidence provided in
support of it, even when such an individual has no direct relationship
to the affected claimant, beneficiary, or recipient or acts without
[[Page 29997]]
the affected claimant's, beneficiary's, or recipient's knowledge or
participation. These individuals may include, but are not limited to,
claimants, beneficiaries, auxiliaries, recipients, spouses,
representatives, medical sources, translators, interpreters, and
representative payees. For example, we may have reason to believe a
medical source or a representative provided false information to
support a claim without the knowledge or participation of the
beneficiary or the recipient.
5. When we redetermine an individual's entitlement to benefits or
eligibility for payments under sections 205(u) or 1631(e)(7) of the
Act, we must disregard evidence if there is reason to believe that
fraud or similar fault was involved in providing that evidence.
6. Except for evidence we are required to disregard under the Act,
we will consider all other evidence that relates to the individual's
entitlement or eligibility during the period at issue in the
redetermination, in accordance with our rules. Even if we disregard
evidence, we will evaluate the remaining evidence of record and
determine whether that evidence supports a finding of entitlement to
benefits or eligibility for payments. This includes evidence included
in the record at the time of the original favorable determination or
decision, along with evidence provided during the redetermination
process. When requested, we will help individuals obtain evidence
relevant to the redetermination.
7. If, after redetermining an individual's entitlement to monthly
insurance benefits under title II or eligibility for payments under
title XVI, we determine that the evidence does not support such
entitlement to benefits or eligibility for payments, we may terminate
such entitlement or eligibility and may treat benefits paid or payments
made based on such evidence as overpayments.
8. If an individual disagrees with our finding that the evidence
does not support his or her entitlement or eligibility at the time of
the original favorable determination or decision, that individual may
appeal our determination or decision. Together with such an appeal, an
individual may object to our finding to disregard evidence under the
Act. We will consider any appeal in accordance with our rules for
administrative review.
9. If the individual believes he or she was disabled at any point
after the period at issue in the redetermination, he or she may file a
new application while appealing our determination or decision.\3\
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\3\ SSR 11-1p: Titles II and XVI: Procedures for Handling
Requests to File Subsequent Applications for Disability Benefits
does not apply in the context of fraud or similar fault
redeterminations.
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10. If we assess an overpayment, we will apply the provisions of 20
CFR part 404, subpart F (20 CFR 404.501 et seq.) and 20 CFR part 416,
subpart E (20 CFR 416.501 et seq.). We will consider a request to waive
the overpayment in accordance with our rules.
B. Definitions
1. Fraud. Fraud exists when a person, with the intent to defraud,
either makes or causes to be made, a false statement or
misrepresentation of a material fact for use in determining rights
under the Act; or conceals or fails to disclose a material fact for use
in determining rights under the Act.
2. Similar Fault. Similar fault is involved with respect to a
determination if: ``an incorrect or incomplete statement that is
material to the determination is knowingly made, or information that is
material to the determination is knowingly concealed.'' \4\
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\4\ See 42 U.S.C. 405(u)(2), 1383(e)(7)(B).
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3. Material. Material describes a statement or information, or an
omission from a statement or information that could influence us in
determining entitlement to benefits under title II or eligibility for
payments under title XVI of the Act.
4. Knowingly. Knowingly describes a person's awareness or
understanding regarding the correctness or completeness of the
information he or she provides us, or the materiality of the
information he or she conceals from us.
5. Reason to Believe. Reason to believe means reasonable grounds to
suspect that fraud or similar fault was involved in the application or
in the provision of evidence. The reason to believe standard requires
more than mere suspicion, speculation, or a hunch, but it does not
require a preponderance of evidence.
C. How We Redetermine an Individual's Entitlement to Benefits or
Eligibility for Payments Under Sections 205(u) and 1631(e)(7) of the
Act
1. Under sections 205(u) and 1631(e)(7) of the Act, we will
immediately redetermine an individual's entitlement to benefits or
eligibility for payments when there is reason to believe that fraud or
similar fault was involved in an individual's application for benefits
or payments, including the providing of evidence.
2. We will disregard any evidence if we find there is reason to
believe that fraud or similar fault was involved in the providing of
such evidence. We will consider all evidence in the case record before
determining whether specific evidence must be disregarded. In
determining if there is reason to believe fraud or similar fault was
involved, adjudicators may make reasonable inferences based on the
totality of the circumstances such as facts or case characteristics
common to patterns of known or suspected fraudulent activity. For us to
disregard evidence it is not necessary that the affected beneficiary or
recipient had knowledge of or participated in the fraud or similar
fault. We will fully document the record with the description of the
disregarded evidence and the reasons for disregarding the evidence.
a. We will disregard evidence supplied, prepared, or signed by a
medical source or nonmedical source when there is reason to believe
that the source knowingly (1) provided incorrect or incomplete evidence
material to the determination or decision or (2) concealed or failed to
disclose evidence material to the determination or decision, even if it
includes a report prepared or signed by another source.
b. In certain circumstances, we may disregard evidence provided by
someone who has not committed fraud or similar fault, but whose
evidence relies on other evidence involving fraud or similar fault. For
example, we may disregard parts of a medical source's opinion, which
relies on evidence that we disregarded from another medical source.
Depending on the extent to which the medical source relied on the
disregarded evidence, we may disregard some or all of the medical
source's opinion.
c. Before we disregard evidence pursuant to sections 205(u)(1)(B)
and 1631(e)(7)(A)(ii) of the Act at the hearings level of our
administrative review process, we will consider the individual's
objection to the disregarding of that evidence. After considering any
objections, our adjudicators will decide whether there is reason to
believe that fraud or similar fault was involved in providing evidence
in the individual's case.
d. If we do not find there is reason to believe evidence provided
by a source involved fraud or similar fault, we will consider the
evidence in accordance with our rules, such as our rules regarding
evaluating symptoms and medical evidence. We will adhere to existing
due process and confidentiality requirements during the process of
resolving fraud or similar fault issues.
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3. We will consider the claim only through the date of the final
determination or decision on the beneficiary's or recipient's
application for benefits or payments (i.e., the date of the original
favorable determination or decision).
4. We will consider evidence relevant to the issues we decide
during a redetermination. For example, we will consider evidence that
postdates the original date of the favorable determination or decision
if that evidence relates to the period at issue in the redetermination.
We will not develop evidence about new medical conditions or
impairments arising after the date of the original favorable
determination or decision.
5. Generally, a finding that there is reason to believe fraud or
similar fault was involved in providing evidence does not constitute
complete adjudicative action on the redetermination. Even if we
disregard evidence, we will evaluate the remaining evidence of record
and determine whether that evidence supports a finding of entitlement
to benefits or eligibility for payments.
D. Appeal Rights
1. Our regulations contain examples of administrative actions that
are not initial determinations.\5\ Our initiation of a redetermination
under sections 205(u) and 1631(e)(7) of the Act is not listed as an
example in those regulations. However, the initiation of a
redetermination is similar to the administrative action of starting or
discontinuing a continuing disability review, which is listed as an
example in the regulations of an administrative action that is not an
initial determination.\6\ Therefore, we interpret our regulations to
mean that our initiation of a redetermination under sections 205(u) and
1631(e)(7) of the Act is not an initial determination that is subject
to administrative or judicial review.
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\5\ 20 CFR 404.903 and 416.1403.
\6\ 20 CFR 404.903(z) and 416.1403(a)(24).
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2. After a redetermination, an individual who is dissatisfied with
our determination or decision may request an appeal of our
determination or decision. In conjunction with such an appeal, an
individual may object to our finding to disregard evidence under the
Act. We will consider any appeal in accordance with our rules for
administrative review.
3. An individual may appeal any overpayments we assess, or request
waiver of the overpayment. We will consider any appeal of the
assessment of an overpayment or a request for waiver of our overpayment
in accordance with our rules.\7\
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\7\ 20 CFR part 404.501-404.545 and 20 CFR 416.501-416.590.
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Cross-References: SSR 85-23: Title XVI: Reopening Supplemental
Security Income Determinations at Any Time for ``Similar Fault''; SSR
22-2p: Titles II and XVI: Evaluation of Claims Involving the Issue of
Similar Fault in the Providing of Evidence.
[FR Doc. 2022-10558 Filed 5-16-22; 8:45 am]
BILLING CODE 4191-02-P