Identification Number:
GN 04440 TN 37
Intended Audience:See Transmittal Sheet
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Determinations
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part GN – General
Chapter 044 – Quality Appraisal
Subchapter 40 – Federal Quality Review of Disability Determinations
Transmittal No. 37, 01/24/2019

Audience

PSC: DE, DEC;
OCO-OEIO: FDE;
DQB: DE, PL;
OCO-ODO: DE, DEC, DS, RECONE;

Originating Component

OQR

Effective Date

Upon Receipt

Background

This is a QAT- no change to or introduction of new policy or procedure.

Summary of Changes

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

Subsection A:

  • We changed Disability Determination Services (DDS) to adjudicating components and added field offices

  • We added “all employees, including” to the last sentence to emphasize quality reviewers’ roles in the process

Subsection D:

  • We replaced DDS with adjudicating component

  • We made additional language changes to make it active and improve clarity

Subsection E:

  • We replaced DDS with adjudicating component

  • We made additional language changes to make it active and improve clarity

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

A. Background

In most cases, field offices and adjudicating components identify fraud or similar fault (FSF) issues during the adjudication process. However, the agency personnel are 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 all employees, including 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 an adjudicating component identifies FSF in a claim, the adjudicator is required to evaluate and disregard evidence as necessary, per DI 23025.025, when making the determination.

  1. 1. 

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

  2. 2. 

    The adjudicating component is required, in most cases, to hold the case until the investigation for FSF is complete. If you receive a claim with an open FSF investigation, returned to the adjudicating component. There are two exceptions per DI 23025.020B.1.2.

    1. a. 

      If there is sufficent evidence in file to make a denial determination, the adjudicating component can make the determination. The investigatior stops his or her investigation and provides any existing documentation. The adjudicator add the available evidence to the claims file.

    2. b. 

      If the evidence in file supports an allowance determination based on other impairments than those suspected for FSF, the adjudicating component can make the determination.

IMPORTANT NOTE: If an ROI or any other investigatory information is received during the quality review, 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 differs from the adjudicative process. If you identify a potential FSF during review, refer via an e8551, (the referral of a potential fraud violation).

  1. 1. 

    If you are returning the case for a deficiency correction, instruct the in your return document, instruct the adjudicating component to refer the case for FSF investigation per guidelines in DI 23025.015.

  2. 2. 

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

    1. a. 

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

    2. b. 

      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. c. 

      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:


GN 04440 TN 37 - Federal Quality Review of Disability Determinations - 1/24/2019