In this section, see examples of sanction determinations when we decide to impose
a sanction and not to impose a sanction. These are examples of how to document a sanction
determination, not when to sanction a case.
EXAMPLE 1: decision to impose a sanction
Issue:
Did John Doe Jones (SSN 000-00-0000), willfully and knowingly provide false or misleading
information to SSA by denying work activity, concealing earnings and concealing a
marriage, which could create an overpayment from April 2014 through May 2016?
Per 20 CFR 416.1340, the purpose of this determination is to address whether SSA should
impose an administrative sanction against John Doe Jones based on concealing earnings,
marriage, and work activity.
Facts:
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1.
FO XXX referred this Title XVI case to the OIG for potential sanction.
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2.
This case includes a Category 2 CMP factor.
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3.
Unscheduled redetermination (RZ) initiated 06/01/2016 when John Doe Jones visited
FO XXX for a benefit verification letter.
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4.
During the RZ interview, two years of earnings present on new hire query despite SSI
records showing the recipient was not currently working and hadn't worked since 2011.
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5.
Employer, ABC Staffing, Inc. (EIN # XX-XXXXXXX), listed on the new hire query, has
never been included on John Doe Jones' detailed earnings query.
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6.
Claimant was evasive and defensive when asked about working for ABC Staffing.
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7.
Contact made with ABC Staffing and employer provided verification of earnings on L4201
dated XX/XX/XXXX.
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8.
Medical continuing disability review (CDR) initiated per the OIG's request 07/01/16.
Medical continuance issued 09/10/16.
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9.
Additional allegation referred to the OIG by DDS for uncooperative and evasive behavior
during consultative exams.
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10.
Concealment of marital status revealed during medical consultative exam, which is
being addressed in the current RZ; marriage date 03/06/14.
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11.
John Doe Jones and employer made multiple attempts to revise original report of wages.
All reports are inconsistent.
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12.
ROI confirmed marriage date.
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13.
OIG included the closing memorandum.
Determination:
John Doe Jones made conflicting statements on multiple occasions in multiple field
offices regarding work activity and marital status. All statements appear potentially
fraudulent. No evidence shows that Mr. Jones did not understand what they were reporting.
Therefore, it is determined they knowingly made these false and misleading statements.
Decision to impose an administrative sanction based on ongoing concealment, evasiveness,
manipulation of information, and conflicting statements made to SSA and authorities
with the intention to defraud the programs in place. Overpayment for $18,962.97 created
by false claims and concealment of information. This is Mr. Jones' second occurrence.
The sanction period is 12 months.
Authority:
Social Security Act, as amended in 2004 (P.L. 108-203), §1129A [42 U.S.C. 1320a–8a];
Regulations 20 CFR 404.459 and 416.1340
Signature:
Determination Made By: (Name), Claims Specialist, Date: XX/XX/XXXX
Approved By: (Name), Claims Technical Expert, Date: XX/XX/XXXX
EXAMPLE 2: decision not impose a sanction
Issue:
Did Jane Doe Jones (000-00-0000), representative payee for Supplemental Security Income
(SSI) recipient Frank Doe Jones (000-00-0000), willfully and knowingly withhold information
about his incarceration from Social Security and continue to receive their benefits
from July 2014 through November 2017, totaling $30,003.00?
Per 20 CFR 416.1340, the purpose of this determination is to address whether SSA should
impose an administrative sanctions against Jane Doe Jones based on their failure to
report changes that affect Frank Doe Jones' SSI eligibility and payment.
Facts:
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1.
FO XXX referred this Title XVI case to OIG.
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2.
This case includes a combination of Category 2 and 3 CMP factors.
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3.
SSA did not receive a PUPS alert for Frank Doe Jones.
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4.
Jane Doe Jones has been Frank Doe Jones' payee since 08/14/2006.
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5.
Frank Doe Jones was previously overpaid $14,499.00 due to incarceration from 09/2009-11/2011.
SSA collected the overpayment in full.
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6.
Payee provided a personal bank statement, from 02/22/2018-03/20/2018 showing a balance
of $31,686.47. It appears to be a joint account. Frank Doe Jones' SSI benefits were
being deposited into the same account. The account title is in Frank Doe Jones' name
only; $30,003.00 was returned to SSA on 05/14/2018.
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7.
The Claims File User (CFUI) document 09/08/2014 from Jane Doe Jones dated 07/19/2014
requesting SSA to stop Frank's checks due to an incarceration. The release date unknown.
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8.
CFUI 12/22/2014 scanned document received from Frank Doe Jones. In the document, they
states that they were incarcerated and requests that SSA stop their checks.
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9.
SSA received a letter from Frank Doe Jones from jail 12/16/2014, scanned to CFUI 01/01/2015.
Letter requested that SSA stop the SSI benefits.
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10.
Representative payee completed representative payee accounting forms. Payee stated
that there were no conserved funds 09/01/2014-08/31/2016 and only $812 is being saved
for 09/01/2016-08/31/2017. There was no mention of Frank’s incarceration on the accounting
forms.
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11.
Payee accounting forms indicates that the only money that has been saved was $812.
However, claimant's bank account statement has $31,686.47.
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Determination:
SSA imposes a sanction when a person makes (or causes to be made) a statement or representation
of a material fact for use in determining any initial or continuing right to, or the
amount of, monthly insurance benefits under Title II or benefits or payments under
Title XVI, if:
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•
The statement or representation is false, misleading or omits a material fact which
makes it false or misleading; and
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•
They know or should know the statement or representation is false, misleading, or
omit a fact that the they know or should know is material and know or should know
that the omission of the fact makes the statement misleading, or they make such a
statement or representation with a knowing disregard for the truth.
After reviewing the evidence in file and the reasonable inferences that can be drawn,
there is insufficient evidence that Jane Doe Jones or Frank Doe Jones knowingly omitted
facts that were material for Frank Doe Jones' SSI benefits. Both parties reported
the incarceration to the agency. No administrative sanctions imposed. Advised payee
to change direct deposit to an account with an acceptable account title. Also, advised
payee that, in the future, use the remarks section of the rep payee accounting form
to report any changes that would affect Mr. Jones' eligibility for benefits, or the
payment amount.
Authority:
Section 201 of the Social Security Protection Act of 2004 (P.L. 108-203) broadened
the range of actions that cause a sanction to include failure to report an event that
is material to the eligibility or benefit amount if the person knows or should know
that failure to report is misleading.
Signature:
Determination Made By: (Name), Claims Specialist, Date: XX/XX/XXXX
Approved By: (Name), Regional Sanctions Coordinator, Date: XX/XX/XXXX