BASIC (10-16)

DI 23060.040 Referring Non-Compliant Excluded Medical Sources of Evidence to the Social Security Administration’s Office of the Inspector General (SSA’s OIG)

Citations:

Soc. Sec. Act as amended in 2015, Secs. 223(d)(5)(C), 1614(a)(3)(H)(i), 42 U.S.C. §§ 423(d)(5)(C), 1382c(a)(3)(H)(i); P.L. 114-74, § 812; 20 CFR §§ 404.1503b, 416.903b

A. Referring excluded medical sources of evidence to SSA’s OIG

1. When to refer

Refer an excluded medical source(s) of evidence to SSA’s OIG if the source does not include a written statement of exclusion with furnished evidence.

EXAMPLE: An excluded medical source of evidence submits evidence without including a written statement of exclusion. The adjudicator receives clear documentation (e.g., an email from the administrator or professional relations officer) that the source is an excluded medical source of evidence. Refer the source to SSA’s OIG.

2. How to refer

Use the electronic SSA e8551, Reporting Form for Programmatic Fraud (e8551): (http://electronic8551.ssahost.ba.ssa.gov/(S(3oghkqtjmznkrapfwvd1dsac))/forms/e8551.aspx or GN 04124.001).

Follow GN 04111.065 to fill out the electronic e8551, except as follows:

  • In “Section II – Subject,” for “Allegation 1,” select “FRAUDULENT MEDICAL EVIDENCE” from the drop-down box;

    NOTE: The current e8551 form does not offer the option to choose an allegation related to an excluded medical source of evidence who fails to provide a written statement of exclusion. Without such an option, adjudicators are directed to choose the “FRAUDULENT MEDICAL EVIDENCE” selection and provide a summary of the allegations as discussed below. If an adjudicator has reason to believe that the evidence itself was obtained through fraud or similar fault (FSF), the adjudicator must follow our FSF policies and refer the case to SSA’s OIG as appropriate. See DI 23025.000 for instructions on FSF.

  • In “Section II – Subject,” for “Subject Type,” select “ATTORNEY/MEDICAL PROVIDER” from the drop-down box;

  • Do not complete “Section IV – Victim”;

  • In “Section V – Summary,” for “Description” write

[Insert Name(s) of Excluded Medical Source(s) of Evidence], an excluded medical source(s) of evidence under 42 U.S.C. 423(d)(5)(C) and 1382c(a)(3)(H)(i), did not comply with the reporting requirements of 20 C.F.R. 404.1503b(c) or 416.903b(c) when submitting evidence on [Insert date(s)] that related to [Insert Claimant’s Name(s) and SSN(s)] claim(s) for initial or continuing [Insert claim type]. We believe that [Insert Name(s) of Excluded Medical Source(s) of Evidence] is an excluded medical source(s) of evidence because [Insert Brief Explanation]. [Insert Name of Excluded Medical Source(s) of Evidence]’s failure to provide a written statement as required by 20 C.F.R. 404.1503b(c) or 416.903b(c) could have caused SSA to rely on evidence that it may not consider under the Social Security Act.

  • In “Section V – Summary,” for the mandatory question, “Potential Administrative Sanctions Case,” click the “No” radio button.

B. The referral does not delay case development or adjudication

Referring an excluded medical source of evidence to SSA’s OIG for not providing a written statement of exclusion does not delay case development or adjudication. Unless otherwise instructed by SSA’s OIG, continue to develop and adjudicate the case using normal procedures.

NOTE: Do not consider evidence furnished by an excluded medical source of evidence referred to SSA’s OIG unless there is sufficient information in the folder to apply a good cause exception(s).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423060040