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Two New Fraud SSRS Published

Empire Justice March 28, 2016

On March 14, 2016, the Social Security Administration (SSA) issued two Social Security Rulings (SSRs). SSR 16-1p: Fraud and Similar Fault Redeterminations, provides guidance on redeterminations of entitlement to and eligibility for benefits if there is reason to believe fraud or similar fault was involved in an application for benefits. It sets forth the procedures used for redeterminations. According to the SSR, if fraud or similar fault was involved in providing evidence, that evidence must be disregarded when redetermining entitlement or eligibility.  A beneficiary may appeal a determination that the individual was not eligible at the time of original allowance. And a beneficiary who believes he or she is currently disabled may file a new application for benefits while the appeal is pending.  https://www.federalregister.gov/articles/2016/03/14/2016-05661/titles-ii-and-xvi-fraud-and-similar-fault-redeterminations-under-sections-205u-and-1631e7-of-the.

SSR 16-2p: Evaluation of Claims Involving Similar Fault in the Providing of Evidence, supersedes and replaces SSR 00-2p.  It governs the evaluation and adjudication of claims when there is reason to believe similar fault was involved in providing evidence in support of the claim. https://www.federalregister.gov/articles/2016/03/14/2016-05660/social-security-ruling-ssr-16-2p-titles-ii-and-xvi-evaluation-of-claims-involving-similar-fault-in.

Both SSRs “clarify” that SSA may find any individual or entity has committed fraud or similar fault, and that it may disregard evidence submitted by any individual or entity that has been found to have committed fraud or similar fault.  Examples of the new term “individual or entity” include a claimant, beneficiary, auxiliary, recipient, spouse, representative, medical source, translator, interpreter, and representative payee. Both add a definition of fault, which includes intent to defraud, as compared to “similar fault”: (A) an incorrect or incomplete statement that is material to the determination is knowingly made; or (B) information that is material to the determination is knowingly concealed.”

SSR 16-1p states that in some circumstances, SSA 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.  It sets forth an example of disregarding parts of a physician’s report that relies on evidence from another source that has been disregarded.  It also will consider evidence relied on in a different claim to determine fraud or similar fault in another claim.

Both SSRs allow for the termination of benefits after a determination of entitlement to or redetermination of eligibility for benefits, if SSA determines that without the disregarded evidence, the evidence does not support entitlement or eligibility.  Benefits paid on such evidence will be considered overpayments.

SSR 16-2p emphasizes that a “finding of similar fault does not constitute complete adjudicative action in any claim.  A person may still be found entitled to, or eligible for, monthly benefits despite the fact that some evidence in the case record has been disregarded based on similar fault.”  But a finding of similar fault may constitute evidence to be considered in determining whether similar fault was involved with respect to other evidence provided by the same source. Under SSR 16-1p, SSA will consider evidence provided absent fraud or similar fault during the redetermination, even if not presented previously. But if the evidence does not support eligibility, benefits may be terminated and payments made may be treated as overpayments.

Finally, the new SSRs “refine” the definition of the preponderance of evidence that must be applied in determinations of similar fault: such relevant evidence that as a whole shows that the existence of a fact to be proven is more likely than not.

Both SSRs became effective on March 14, 2016.