This section provides background information on certain cases
processed under Hearings, Appeals, and Litigation Law (HALLEX) manual
I-1-3-25. This
instruction relates to a referral under section 1129(l) of the Social Security Act (Act)
from the Office of Inspector General (OIG) of the Social Security
Administration (SSA), stating that the OIG has reason to believe fraud
was involved in the applications of certain individuals seen by Americo
Oms-Rivera, M.D. (Dr. Oms-Rivera).
I. Background
In 2016, after an extensive investigation by SSA's OIG and the
Department of Justice, a Federal grand jury in Puerto Rico indicted
Dr. Oms-Rivera, his assistant Mayte González-Muñoz
(González-Muñoz), and non-attorney representatives Samuel
Pérez-Rivera (Pérez-Rivera) and Francisco Cabrera-Alvarado
(Cabrera-Alvarado), for creating and submitting fraudulent
evidence in support of individuals' applications for Social Security
benefits. Dr. Oms-Rivera later pleaded guilty to conspiracy to commit
wire fraud related to the transmission of fraudulent medical reports to
SSA. González-Muñoz and Cabrera-Alvarado pleaded guilty to
conspiracy to defraud the United States, and Pérez-Rivera pleaded
guilty to conspiracy to commit wire fraud related to the transmission
of fraudulent medical reports to SSA. A copy of each plea agreement is
available under Attachment 1.
SSA disqualified Cabrera-Alvarado and
Pérez-Rivera from representing claimants before SSA on February 5,
2018 and June 8, 2021, respectively.
Under section 1129(l) of the Act, as soon as OIG has reason
to believe that fraud was involved in an individual's application for
monthly insurance benefits under title II or for payments under title
VIII or XVI, OIG will generally make available information identifying
the individual(s) to SSA and general information about the conduct at
issue.
On November 8, 2021, OIG notified SSA that it had reason to
believe fraud was involved in the application for Social Security
disability benefits of individuals seen by Dr. Oms-Rivera and
referred specific cases to SSA under section 1129(l) of the Act. See Attachment
3 for a copy of OIG's section 1129(l) referral memorandum.
Based on the referral from OIG, as well as the plea agreements from
Dr. Oms-Rivera, González-Muñoz, Pérez-Rivera, and
Cabrera-Alvarado, SSA is required under section 205(u) of the Act to take action in the cases
identified by OIG.
SSA must redetermine the identified closed favorable cases,
and disregard evidence signed by Dr. Oms-Rivera if there is reason
to believe that fraud or similar fault was involved in the provision
of that evidence. Before SSA disregards evidence pursuant to section
205(u)(1)(B) of
the Act at the hearings level of the administrative review process,
it will consider the individual's objection to the disregarding of
the evidence. See Social
Security 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 and SSR 22-2p: Titles
II and XVI: Evaluation of Claims Involving the Issue of Similar Fault
in the Providing of Evidence.