TN 26 (03-15)

GN 04440.009 Fraud or Similar Fault (FSF) Procedures for Quality Reviewers

A. Background

In most cases, Disability Determination Services (DDS) identify fraud or similar fault (FSF) issues during the adjudication process. However, the agency is responsible for identifying FSF at every level of the adjudication process. Preserving the public’s trust in the Social Security Administration’s (SSA) disability program and reducing improper payments are critical elements in what quality reviewers do.

B. Identifying Fraud during the Quality Review Process

For a definition of fraud, please see GN 04105.005B.

C. Identifying Similar Fault during the Quality Review Process

For a definition of similar fault, please see GN 04105.005B.

D. Performing Quality Reviews on Cases involving FSF

If the DDS has identified FSF in a claim, the adjudicator is required to evaluate the evidence and disregard evidence as necessary, per DI 23025.025, when making the determination.

1. If the investigation unit (IU) (i.e., the Office of the Inspector General (OIG) or the Cooperative Disability Investigations Unit (CDIU)) completed an investigation, consider the report of investigation (ROI) or any additional documentation received. Evidence in the case file may be discarded based on findings outlined in the ROI report. If there is an ROI or any other investigative information in file when you receive the case for quality review, ensure that the DDS weighed the evidence carefully and followed direction per DI 23025.025B.

2. The DDS is required, in most cases, to hold the case until the investigation for FSF is complete. If the quality review component receives a claim with an open FSF investigation, the case must be returned to the DDS. There are two exceptions per DI 23025.020B.1.2.

   1. If there is evidence in file that is sufficient to make a denial determination, the DDS can make a determination. The investigation will stop, provide existing documentation, and add it to the claims file.

   2. If the evidence in file supports an allowance determination based on other impairments than those suspected for FSF.

IMPORTANT NOTE: If an ROI or any other investigatory information is received during the quality review, the reviewer will treat it as trailer mail (see DI 22520.000).

E. Referring cases for FSF in the review component

The process of referring a case in the quality review component is different from the DDS. If potential FSF is identified during review, the reviewer will refer via an e8551, (the referral of a potential fraud violation).

NOTE: In section V.C of the e8551, quality reviewers leave the section blank.

1. If the case needs to be returned for a deficiency, instruct the DDS to refer the case for FSF investigation per guidelines in DI 23025.015.

2. If there is no returnable deficiency present, follow these steps:

   1. Consult with a member of management to ensure appropriateness and completeness of the referral.

   2. Effectuate the claim and send the appropriate personalized notices (if applicable) to the claimant and any representatives. NOTE: If the IU decides to accept the case for investigation, clearing the case from the legacy system will not cease the process.

   3. Forward the case to the appropriate office (field office or payment center) with an alert in the file explaining that there is a pending referral.

NOTE: Do not hold the case in the quality review component after making a fraud referral.

References:

• See GN 04124.001 for access to the form

• For further instructions on preparing the e8551, see GN 04111.065

• See potential high-risk FSF indicators per DI 23025.005.