TN 9 (01-04)
DI 23025.010 Identifying Cases That May Be High Risk for Fraud or Similar Fault (FSF)
A. PREVIEW
The DDS adjudicator must be alert to circumstances that may indicate FSF. Suspected violations may involve interpreters, representatives, medical sources or other third parties, as well as the claimant. This section describes situations that could be high risk for FSF, but is not all-inclusive.
B. POLICY
Past experience has shown that cases identified as high risk have characteristics that increase the probability of FSF. This category of cases should be examined carefully. This identifier simply indicates that the case is in a category in which there is a greater probability of FSF, but it is not a predictor of FSF in any individual case. We must consider all evidence in the record including any physical, mental, educational, or linguistic limitations (including any lack of facility with the English language) which a claimant might have at that time. Only the careful evaluation of individual case evidence and circumstances will determine if an FSF finding is appropriate.
If there is sufficient evidence (other than evidence from a questionable source) to make a determination on the disability issue, the DDS will not initiate further development solely to resolve possible FSF. (See DI 23025.020A.) Questionable matters should be referred after adjudication as explained in DI 23025.030.
C. PROCEDURE
Consider that any case showing one or more of the characteristics described in subsections DI 23025.010D. through DI 23025.010H. may be high risk for FSF. Identify such cases for special handling, as explained in DI 23025.015.
CAUTION: Exercise the same sensitivity and discretion in dealing with claimants whose cases fall into a high risk category as you would with any claimant.
D. LIST OF GENERAL HIGH RISK FACTORS
Several general factors may indicate the possibility of FSF. Consider whether a case is high risk if any of the following factors are present:
1. FO Alerts
The FO prepared a fraud alert to the DDS for the possibility of FSF. This alert should be based on information pertinent to the DDS decision making process and/or adjudication of the claim, which is obtained at the interview or present in the file.
The FO noted observations on the SSA-3367, Disability Report–Field Office, or on a record of contact that raise questions about the credibility of the individual’s statements or the evidence.
2. Work
There is evidence of recent unreported work or long patterns of unreported work in file. It is important to attempt to determine why work has not been reported, when there is no explanation for the unposted wages. Possible reasons include mere claimant oversight, a misunderstanding of reporting responsibilities by the claimant, or a delay by the employer in reporting wages. (See DI 24001.020C. for DDS responsibilities concerning work.)
3. Education
The claimant alleges illiteracy or no education, which appears to be inconsistent with his/her daily activities, past relevant work, or the claimant’s documented educational level. Lack of education in itself does not indicate FSF.
4. Similar Claims
The DDS receives numerous claims for different individuals over relatively short periods of time showing similar medical histories.
5. Other Family or Household Members Receiving Disability
Other members of the family or household receive disability benefits. Although we recognize that some disabilities can be inherited or may occur in more than one member of a family or household for other reasons, past experience has shown this to be an area we must consider as possible high risk for FSF. The family or household information is often already part of the current file, e.g., a family member files to be representative payee for the current claim and queries show that person is receiving disability benefits.
6. Frequent Reapplications
A denied claimant frequently reapplies for Social Security benefits and there are not readily apparent reasons for doing so, such as state or local assistance requiring the claimant to reapply before any public assistance benefits can be paid.
7. Conflicting Evidence/Information
A medical provider or other source furnishes information that conflicts with the claimant’s allegations or evidence submitted. Any discrepancies should be developed and resolved. If after further development there is no explanation for the conflicting information, consider this a high risk factor for FSF.
E. DESCRIPTION OF SUSPICIOUS “MIDDLEMAN” SITUATIONS
The term “middleman” applies to third parties who involve themselves in the claims process. Middlemen may seek to control interviews and limit direct access to claimants. Middlemen frequently appear at interviews or consultative examinations (CE) for many different claimants and charge claimants a fee for the service.
NOTE: The presence of a middleman or a third party does not in itself indicate FSF.
The term “middleman” is not intended to apply to parents or guardians of children under age 18. However, if the parent or guardian is reluctant or unable to provide basic information about education, medical/psychological treatment, etc., or the parent or guardian appears to exaggerate the child’s condition or limitations, the case may be considered high risk for FSF.
The term is also not intended to apply to state or local agencies that assist a clientele with a particular disability (e.g., the State agency for the blind, deaf, or mentally retarded.)
The term does not apply to attorney and authorized representatives.
In the following situations, the presence of a middleman could be considered high risk for FSF:
1. Coaching
The claimant's reported behavior (or unusual appearance suggesting an impairment) is similar to that of others assisted by the middleman and suggests coaching. For example, the claimant may refuse to speak or may cry throughout an interview.
2. Similar Allegations
The claimant's allegations are similar or identical to those of others assisted by the middleman. Common allegations are post-traumatic stress disorder, anxiety, and depression. The allegations may match published requirements of a listed impairment category.
3. Same Medical Source(s)-Similar/Identical Findings
Medical reports provided by the middleman are from the same source(s) as for others assisted by the middleman, AND findings are similar or identical.
4. Poor Cooperation
The claimant cooperates poorly during an interview, testing, or evaluation with no indication of a physical or mental impairment-related reason that could account for the behavior. The claimant may appear to be totally detached from the surroundings and have no interest in the application process.
5. Failure to Appear at CE
The claimant fails to appear for a CE scheduled with a source other than that desired by the middleman. The claimant does not contact the DDS or CE provider to explain why he/she could not attend the exam, or to reschedule the CE for a later date.
F. DESCRIPTION OF SUSPICIOUS INTERPRETER SITUATIONS
The high risk situations described above for middlemen apply to interpreters as well. See GN 00203.011 and DI 23040.001 for policy on providing interpreters. In addition, the following characteristics suggest high risk for FSF when an interpreter for a non-English speaking claimant is involved:
1. Personal Knowledge
An interpreter who is not a friend or relative alleges personal knowledge of the claimant's history, current functioning, etc.
2. Responses Not Parallel
The length of the claimant's response is markedly different from the length of the interpreter's response, e.g., the claimant appears to be giving a lengthy answer to the question but the interpreter answers in one or two words, or the claimant responds in a few words and the interpreter gives a lengthy response.
The interpreter provides responses after little or no communication with the claimant.
3. Failure to Appear
The claimant fails to appear for appointments when an independent interpreter is scheduled to be present and provides no explanation for his/her failure to appear.
G. DESCRIPTION OF QUESTIONABLE REPORTS
Claimants are encouraged to secure medical evidence from treating sources to help expedite the disability decision. Since this evidence is a critical part of the decision, it should be looked at carefully. Medical or lay evidence in FSF claims often exhibits one or more of the following characteristics. Cases containing such questionable reports should be evaluated for the possibility of FSF.
1. Altered Report
A report appears to be altered. Examples include different inks or typefaces, or photocopied forms on which the typed portion is clearer than pre-printed items.
2. Same Handwriting
Reports, allegedly from different sources, appear to have the same handwriting.
3. Uncertain Identity
Descriptive evidence suggests that someone other than the claimant attended a CE (see DI 22510.015A.7.b.)
Reports from different sources provide conflicting descriptions of the claimant's physical appearance.
Reports from different sources show illogically different test results.
4. Conflicting Nonmedical Information
Nonmedical information on a report (family history, a relative’s assessment of the claimant’s capabilities, educational level, the date a doctor first saw the claimant, etc.) is significantly different from other information in the case file.
5. Same Address/Name
A report shows the same address or last name for the medical practitioner as for the claimant.
6. Copy to Third Party
The claimant submits a medical report that is addressed to a third party, other than the claimant's authorized representative or treating physician. The claimant should be asked to explain why the report is addressed to a third party. A closer review should also occur when the claimant submits a recent medical report that is addressed to the claimant at a different address than the one we have on file (e.g., outside the service area), and there has been no report of a recent move.
7. Outside Geographical Area
The medical provider is not located in the same geographical area as the claimant, and there is no logical reason for the choice (such as obtaining specialty treatment or the claimant’s longstanding relationship with that provider.)
8. Identical Reports
Similar or identical medical reports are provided for different claimants.
9. Inappropriate Tests
Diagnosis is based on one of the following:
Inappropriate psychological tests for the claimant's language ability or cultural background.
Inappropriate tests based on the claimant's alleged medical condition.
H. DESCRIPTION OF PREVALENT ALLEGED IMPAIRMENTS IN FSF CLAIMS
Certain impairments have been found to be particularly prevalent in FSF claims. Generally, these are impairments in which self-serving statements by an applicant may play a more important role in evaluating severity than in other conditions.
The following impairments represent a large portion of the disability workload. Most will not involve FSF and should not be labeled as high risk. However, when associated with the characteristics shown below, these impairments may be high risk for FSF.
1. Mental Impairments
There is an allegation of mental retardation, with any of the following conditions:
A history of semi-skilled/skilled work activity.
Available school records show no history of special education.
Early school/medical records are unavailable with no reasonable explanation or the records lack any indication of significant problems. The records do not necessarily have to show a diagnosis of mental retardation in order to indicate significant problems.
Poor cooperation on psychological or intelligence tests, with no indication of another physical or mental impairment, including educational or linguistic limitations that could account for the behavior.
Absent, unreliable, or conflicting information concerning activities of daily living (ADL).
NOTE: In certain mental disorders, ADLs may be inconsistent and variable. A person with severe mental disorders, because of the intermittent nature of the disorder or its symptoms, may at times function normally and at other times function quite poorly.
A mental impairment other than mental retardation is alleged, with any of the following conditions:
There is no history of treatment, or only very recent outpatient treatment, and there is no valid reason or explanation as to why treatment has not been sought or has only started recently.
There is a suspicious situation involving a third party providing information, e.g., a third party provides all answers to questions even when the claimant appears capable of doing so, or the third party frequently interrupts or contradicts the claimant.
Highly unusual or bizarre claimant behavior is reported by the FO or at a CE, and does not appear to be related to a psychotic or other alleged mental disorder. It is important to consider the degree of consistency with other evidence in the file regarding the claimant’s behavior.
Absent, unreliable, or conflicting information concerning activities of daily living (ADL).
NOTE: In certain mental disorders, ADLs may be inconsistent and variable. A person with severe mental disorders, because of the intermittent nature of the disorder or its symptoms, may at times function normally and at other times function quite poorly.
Allegations of severe mental problems first surface during an appeal or subsequent application process.
CAUTION: Consider that claimants are sometimes reluctant to bring up mental illness or that individuals dealing with chronic illness/pain may begin to exhibit symptoms of depression.
2. Back Impairments
A back impairment is alleged with unremitting or frequent, severe pain with no clearly documented pathology and with no treatment source, a medical history that is not consistent with the alleged impairment, or an unexplained lack of response to treatment. Medical findings or other circumstances suggest that exaggerated symptoms are being reported.
3. Seizure Disorders
Seizure disorder is alleged, and any of the following:
Reports show no indication of observed seizures.
No seizure descriptions:
No monitoring of blood drug levels of prescribed medication.
Minimal or nonexistent history of medical consultation and/or treatment.
4. Pain
Unremitting or frequent severe pain is alleged, with no clearly documented pathology and with either no treatment source contact or with lack of response to treatment. Although there may be instances where pain does not respond to treatment, consider whether there are any inconsistencies in the evidence, or conflicts between the claimant’s statement and the rest of the evidence. (SSR 96-7p explains the criteria for evaluating pain.)
5. Other
Generalized allegations such as visual problems, headaches, fatigue, or nervousness, without supporting documentation, may suggest the need for special handling.