Willie Ousley v. Comm'r of Soc. Sec.
This text of 909 F.3d 786 (Willie Ousley v. Comm'r of Soc. Sec.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
Opinions
KAREN NELSON MOORE, Circuit Judge.
When individuals in this country are unable to work because of physical or mental disabilities, they may file for Social Security Disability Insurance ("SSDI") and Supplemental Security Income ("SSI") benefits. The eleven plaintiffs here all filed for these benefits, and they all eventually received them. The trouble, however, is that they were represented in their efforts by Eric Conn, a Kentucky attorney who secured benefits for his clients by submitting fraudulent reports to the Social Security Administration ("SSA"). An Administrative Law Judge ("ALJ"), David Daugherty, also participated in the scheme by taking *792bribes from Conn to assign Conn's cases to himself and issue favorable rulings.
Nearly ten years after the SSA first learned of Conn's and Daugherty's possible wrongdoings, it initiated efforts to "redetermine" plaintiffs' eligibility for benefits. The SSA held new hearings before new ALJs to determine plaintiffs' entitlement to benefits as of the date of their original applications-i.e., seven to ten years earlier. During the redetermination process, the SSA disregarded all medical evidence submitted by the four doctors participating in Conn's scheme on the ground that such evidence was tainted by fraud. Plaintiffs had no opportunity to rebut the agency's assertion of fraud as to this medical evidence. Ultimately, all plaintiffs were deemed ineligible for SSDI and SSI benefits as of the date of their original applications, and their benefits were terminated. After exhausting all administrative remedies, plaintiffs brought suit in federal district court.
The eleven cases presented in this consolidated appeal appeared before three different district judges. Though the precise nature of their claims somewhat varied, all plaintiffs alleged that the SSA's procedures and actions violated the Due Process Clause of the Fifth Amendment, the Administrative Procedure Act ("APA"), and the Social Security Act. We now hold that the plaintiffs are entitled to summary judgment on their due-process claim, the SSA is entitled to summary judgment on plaintiffs' claims under the Social Security Act, and the SSA is not entitled to summary judgment on plaintiffs' claims under the APA. We therefore AFFIRM the district court's judgment in cases numbered 17-5206, 17-5211, 17-5212, 17-5213, 17-5214, 17-5215, 17-5216, and AFFIRM in part, REVERSE in part, and REMAND for further proceedings consistent with this opinion in cases numbered 17-5598 and 17-5614.
I. BACKGROUND
The SSDI and SSI programs provide disability benefits to individuals with physical or mental impairments that preclude them from working.
Having considered all of the evidence, I am satisfied that the information provided by Dr. [Adkins, Ammisetty, Huffnagle, or Herr] most accurately reflects the claimant's impairments and limitations. Therefore, the claimant is limited to less than sedentary work at best.
After considering the evidence of record, the undersigned finds that the claimant's medically determinable impairment could reasonably be expected to produce the alleged symptoms, and that the *793claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are generally credible.
E.g. , 16-cv-53 (Blackburn), R. 26-1 (Ex. 6A, Daugherty Decision at 3) (Page ID #281).
According to the SSA, plaintiffs' change of fortune was not coincidental. Instead, SSA alleges that Conn, Daugherty, and the four doctors identified above were engaged in a widespread scheme to secure SSI and SSDI benefits for Conn's clients based on fraudulent disability applications. SSA Br. at 12-15. The scheme, according to the SSA, worked like this: Conn created a limited number of template Residual Functional Capacity ("RFC") forms, which he or attorneys in his office filled out ahead of time.
The SSA first learned about possible wrongdoing involving Daugherty and Conn as far back as 2006, when a senior case technician and a master docket clerk in the SSA's Office of Disability Adjudication and Review (which houses the ALJs) raised concerns that Daugherty was reassigning Conn's cases to himself and rapidly deciding them in the claimants' favor. U.S. ex rel. Griffith v. Conn , No. CIV. 11-157-ART,
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KAREN NELSON MOORE, Circuit Judge.
When individuals in this country are unable to work because of physical or mental disabilities, they may file for Social Security Disability Insurance ("SSDI") and Supplemental Security Income ("SSI") benefits. The eleven plaintiffs here all filed for these benefits, and they all eventually received them. The trouble, however, is that they were represented in their efforts by Eric Conn, a Kentucky attorney who secured benefits for his clients by submitting fraudulent reports to the Social Security Administration ("SSA"). An Administrative Law Judge ("ALJ"), David Daugherty, also participated in the scheme by taking *792bribes from Conn to assign Conn's cases to himself and issue favorable rulings.
Nearly ten years after the SSA first learned of Conn's and Daugherty's possible wrongdoings, it initiated efforts to "redetermine" plaintiffs' eligibility for benefits. The SSA held new hearings before new ALJs to determine plaintiffs' entitlement to benefits as of the date of their original applications-i.e., seven to ten years earlier. During the redetermination process, the SSA disregarded all medical evidence submitted by the four doctors participating in Conn's scheme on the ground that such evidence was tainted by fraud. Plaintiffs had no opportunity to rebut the agency's assertion of fraud as to this medical evidence. Ultimately, all plaintiffs were deemed ineligible for SSDI and SSI benefits as of the date of their original applications, and their benefits were terminated. After exhausting all administrative remedies, plaintiffs brought suit in federal district court.
The eleven cases presented in this consolidated appeal appeared before three different district judges. Though the precise nature of their claims somewhat varied, all plaintiffs alleged that the SSA's procedures and actions violated the Due Process Clause of the Fifth Amendment, the Administrative Procedure Act ("APA"), and the Social Security Act. We now hold that the plaintiffs are entitled to summary judgment on their due-process claim, the SSA is entitled to summary judgment on plaintiffs' claims under the Social Security Act, and the SSA is not entitled to summary judgment on plaintiffs' claims under the APA. We therefore AFFIRM the district court's judgment in cases numbered 17-5206, 17-5211, 17-5212, 17-5213, 17-5214, 17-5215, 17-5216, and AFFIRM in part, REVERSE in part, and REMAND for further proceedings consistent with this opinion in cases numbered 17-5598 and 17-5614.
I. BACKGROUND
The SSDI and SSI programs provide disability benefits to individuals with physical or mental impairments that preclude them from working.
Having considered all of the evidence, I am satisfied that the information provided by Dr. [Adkins, Ammisetty, Huffnagle, or Herr] most accurately reflects the claimant's impairments and limitations. Therefore, the claimant is limited to less than sedentary work at best.
After considering the evidence of record, the undersigned finds that the claimant's medically determinable impairment could reasonably be expected to produce the alleged symptoms, and that the *793claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are generally credible.
E.g. , 16-cv-53 (Blackburn), R. 26-1 (Ex. 6A, Daugherty Decision at 3) (Page ID #281).
According to the SSA, plaintiffs' change of fortune was not coincidental. Instead, SSA alleges that Conn, Daugherty, and the four doctors identified above were engaged in a widespread scheme to secure SSI and SSDI benefits for Conn's clients based on fraudulent disability applications. SSA Br. at 12-15. The scheme, according to the SSA, worked like this: Conn created a limited number of template Residual Functional Capacity ("RFC") forms, which he or attorneys in his office filled out ahead of time.
The SSA first learned about possible wrongdoing involving Daugherty and Conn as far back as 2006, when a senior case technician and a master docket clerk in the SSA's Office of Disability Adjudication and Review (which houses the ALJs) raised concerns that Daugherty was reassigning Conn's cases to himself and rapidly deciding them in the claimants' favor. U.S. ex rel. Griffith v. Conn , No. CIV. 11-157-ART,
After the Wall Street Journal article was published, but before the SSA took any steps to initiate redetermination proceedings in these cases, Conn purportedly made significant efforts to destroy records, "including medical records for active disability claims." Id. at 121. According to the Senate Report, a shredding company sent Conn an invoice on June 23, 2011 for the destruction of more than 26.5 thousand pounds of documents for the Conn Law Firm, which is, according to the Report, the equivalent of 2.65 million sheets of paper. Id. at 122. Before the article, the shredding company had previously shred documents for Conn in smaller batches *794(e.g., 5.6 thousand pounds of paper in June 2010; 5.9 thousand pounds of paper in September 2010; and 7.3 thousand pounds of paper in November 2010). Id. An affidavit submitted by a former Conn Law Firm employee in one of the cases below confirms that medical records "were destroyed by fire or by shredding, although not all medical records were destroyed." 16-cv-154 (Hicks), R. 22-1 (Slone Aff. ¶ 3) (Page ID #1082). This former employee also averred that "[i]t was routine practice in Mr. Conn's office not to submit any medical records to Social Security or the Office of Disability Adjudication and Review on a claimant's claim once they were assigned to Judge David B. Daugherty." Id.
By July 2014, the Social Security Administration's Office of the Inspector General ("OIG") had identified 1,787 individuals-all of whom had been represented by Conn-whose applications, the OIG "had reason to believe," were tainted by fraud. 16-cv-154 (Hicks), R. 10-1 (OIG Letter) (Page ID #146). This tag has statutory significance. Under the Social Security Act, the SSA is required to "immediately redetermine" a beneficiary's entitlement to disability benefits if, at any point after granting benefits, the SSA has "reason to believe that fraud or similar fault was involved in the application" for benefits.
On May 12, 2015, the OIG sent the SSA another letter stating that the OIG "still has[ ] reason to believe" that fraud was involved in the 1,787 applications identified in July 2014.
With that, the SSA sent letters on May 18, 2015 to each of the eleven plaintiffs in this case (along with approximately 1,500 other individuals, see 16-cv-154 (Hicks), R. 25-1 (Salzmann Aff. ¶ 5) (Page ID #1125) ). Citing sections 205(u) and 1631(e)(7) of the Social Security Act (
According to the May 18, 2015 letters, the SSA had already reviewed plaintiffs' cases (less than a week after receiving notice from the OIG that it could proceed with the redetermination process) and had concluded that the remaining evidence in plaintiffs' files did not support their favorable benefits determinations.
The SSA held new hearings in plaintiffs' cases between December 2015 and March 2016. In each hearing, the new ALJ disregarded the medical reports initially submitted by Adkins, Ammisetty, Huffnagle, or Herr, considered all other medical evidence in plaintiffs' files, including newly submitted evidence that satisfied the two criteria above, and concluded that plaintiffs should not have been awarded benefits in the first place. E.g. , 16-cv-53 (Blackburn), R. 26-1 (Redetermination Decision at 13-25) (Page ID #212-24). The ALJs therefore "terminated" plaintiffs' benefits and informed plaintiffs that the "SSA may treat any benefits previously received as an overpayment."
Notably, in redetermining plaintiffs' eligibility for benefits, the SSA excluded all evidence submitted by Adkins, Ammisetty, Huffnagle, and Herr-not just the RFC forms that the OIG had identified as possibly fraudulent in its referral to the SSA.1 See 16-cv-154 (Hicks), R. 10-1 (OIG Letter) (Page ID #146). Beyond the RFC forms, the four doctors had submitted evidence detailing their examinations of plaintiffs, including any testing that they had performed and behavioral observations they had made. For Hicks, for instance, Dr. Adkins submitted a report stating that he had examined Hicks for three-and-a-half hours and had administered a third-edition Wechsler Adult Intelligence Scale test ("WAIS-III"). 16-cv-154 (Hicks), R. 42-2 (Adkins Report at 1) (Page ID #1429). Adkins determined that Hicks had an IQ of 69 and a Global Assessment of Functioning ("GAF") score of 47.
After exhausting their administrative remedies, plaintiffs sought relief in federal district court. Plaintiffs challenged the SSA's procedures, actions, and decisions as violations of the Social Security Act, the Due Process Clause of the Fifth Amendment, and the Administrative Procedure Act. See, e.g. , 16-cv-154 (Hicks), R. 1 (Compl. ¶¶ 11-20) (Page ID #3-4). Seven of the cases proceeded before Judge Thapar (Hicks, Adams, Blackburn, Hale, Jenkins, Justice, and Ousley), which are referred to collectively here as Hicks v. Colvin ; three cases proceeded before Judge Reeves (Griffith, Howard, and Martin) and were decided together under the name Carter v. Colvin ; and one case proceeded before Judge Hood (Perkins v. Colvin ).
Judge Thapar focused first on Hicks, where he decided the constitutional due-process claim in Hicks's favor and granted partial summary judgment to Hicks on that ground on October 12, 2016. 16-cv-154 (Hicks), R. 36 (Mem. Op. & Order) (Page ID #1328-60). He then issued an order in each of the other six cases applying the Hicks opinion to them. E.g. , 16-cv-53 (Blackburn), R. 39 (Order) (Page ID #854-55). The SSA moved for reconsideration of the Hicks opinion, which Judge Thapar denied on December 21, 2016. 16-cv-154 (Hicks), R. 48 (Mem. Op. & Order) (Page ID #1608-21). In the meantime, Judge Reeves rejected plaintiffs' statutory and constitutional claims regarding the SSA's redetermination procedures in Carter and granted partial summary judgment to the SSA on November 15, 2016.2 E.g. , 16-cv-101 (Griffith), R. 43 (Mem. Op. & Order) (Page ID #950-89). Judge Hood largely adopted Judge Reeves's opinion and granted partial summary judgment to the SSA in Perkins on December 16, 2016. 16-cv-35 (Perkins), R. 55 (Mem. Op. & Order) (Page ID #1489-98). The SSA filed a notice of appeal in the seven cases proceeding before Judge Thapar on February 21, 2017. E.g. , 16-cv-154 (Hicks), R. 57 (Notice of Appeal) (Page ID #1658-59). The remaining four plaintiffs obtained leave to appeal Judge Reeves's and Judge Hood's interlocutory orders granting partial summary judgment to the SSA on May 24, 2017. E.g., 16-cv-35 (Perkins), R. 70 (Order) (Page ID #1653-56). This appeal followed.
II. DISCUSSION
A. Due Process
Plaintiffs' due-process challenge focuses on the SSA's refusal to accord them an opportunity to rebut the OIG's assertion of fraud as to the Conn-related medical reports. Pls. Br. at 17. A preliminary question in this case is whether the three-factor balancing test laid out in Mathews v. Eldridge ,
Mathews dictates that the process due in any given instance is determined by weighing "the private interest that will be affected by the official action" against the Government's asserted interest, "including the function involved" and the burdens the Government would face in providing greater process. The Mathews calculus then contemplates a judicious balancing of these concerns, through an analysis of "the risk of an erroneous deprivation" of the private interest if the process were reduced and the "probable value, if any, of additional or substitute procedural safeguards."
Plaintiffs argue that this is "a case about the minimum protections of due process," and Mathews -which plaintiffs understand as a test "used to determine whether additional process (i.e., beyond the minimum) is required"-does not apply. Pls. Br. at 32. In particular, plaintiffs insist that "procedural due process" requires, at a minimum, "a fair opportunity to rebut the Government's factual assertions before a neutral decisionmaker," and this baseline procedural protection may not be "balanced away." Id. at 19 (quoting Hamdi ,
1. Minimum Due-Process Analysis
Long before Mathews , the Supreme Court recognized the "immutable" principle that "where governmental action seriously injures an individual, and the reasonableness of the action depends on fact findings, the evidence used to prove the Government's case must be disclosed to the individual so that he has an opportunity to show that it is untrue." Greene v. McElroy ,
The SSA argues, in effect, that the deprivation of plaintiffs' benefits in this case did not "depend on" the government's finding that the reports by Conn's doctors involved fraud, see
Moreover, in this consolidated appeal, the exclusion of the Conn-related medical reports is inextricably bound up with the denial of plaintiffs' benefits because, according to plaintiffs, they are now unable to provide sufficient substitute evidence of their initial eligibility for benefits. See Pls. Br. at 28-29. Perhaps plaintiffs would not have received a favorable outcome if their initial medical records were considered in the redetermination process,
According to the SSA, "the potential value of the excluded report" is irrelevant because "the 'right to present relevant evidence is not unlimited, but rather is subject to reasonable restrictions.' " SSA Br. at 45 (quoting United States v. Scheffer ,
Even if Scheffer were a relevant precedent, it offers no support for the SSA's contention that "the potential value of the excluded report" is irrelevant. Rather, Scheffer recognized that even generally applicable evidentiary rules may "raise a constitutional concern" if they "implicate a sufficiently weighty interest of the [plaintiff]."
2. Due-Process Analysis under Mathews
Applying the Mathews test leads to the same result. Mathews directs courts to weigh the private interest in a property right against the government's interest in avoiding additional or substitute process, in light of "the risk of an erroneous deprivation" of a property holder's interest "and the probable value, if any, of additional or substitute procedural safeguards." Mathews ,
[d]epending upon the tilt of the Mathews balance in a particular case, ... the timing and content of the [required] hearing may vary. Nevertheless, however weighty the governmental interest may be in a given case, the amount of process required can never be reduced to zero-that is, the government is never relieved of its duty to provide some notice and some opportunity to be heard prior to final deprivation of a property interest.
Propert v. District of Columbia ,
*800First, courts must consider when, in Mathews 's parlance, the "risk of an erroneous deprivation" is too high. At some foundational level, this factor is dispositive. After all, "some form of hearing is required before an individual is finally deprived of a property interest," Mathews ,
This is essentially how a plurality of the Supreme Court approached the Mathews test in Hamdi . The plurality first noted the strong interests at stake both for Hamdi and the government, Hamdi ,
Applying Mathews here, we conclude that the risk of an erroneous deprivation under the SSA's current framework is too high. The SSA argues that the current process leaves little room for error, as plaintiffs may rely on a host of other evidence beyond the Conn-related medical reports, including evidence that was not submitted in the initial determination, and the Conn-related reports would, in any event, be a low-weighted factor in the ALJ's analysis. SSA Br. at 35-43. But Supreme Court precedent, including precedent applying Mathews , indicates that any time a citizen is deprived of "notice of the factual basis" for a governmental determination and "a fair opportunity to rebut the Government's factual assertions before a neutral decisionmaker," the risk of error is too high. Hamdi ,
Moreover, even if the risk of an erroneous deprivation were not intolerably high whenever claimants are precluded from rebutting material factual assertions about their case, the risk of an erroneous deprivation is nevertheless too high in these cases. Even assuming fraud could be reliably detected through a blanket rule-a point the Supreme Court has previously called into doubt, see Califano v. Yamasaki ,
The divergence between the material identified by the OIG and the material excluded by the SSA highlights the danger of the SSA's approach. Not only are the OIG's assertions of fraud unreviewable, but the SSA's application of those assertions is unreviewable. Currently, the SSA asserts that it has "reason to believe" that all reports signed by Adkins, Ammisetty, Huffnagle, and Herr and submitted by Conn between January 2007 and May 2011 contained fraud. But what if the SSA instead declared that all reports signed by the four doctors-regardless of whether they were submitted by Conn-were tainted by fraud? What would preclude the SSA from interpreting the OIG's referral this broadly? In effect, the SSA insists that it may unilaterally select the criteria for fraud (based on vague statutory guidance) and then unilaterally select which evidence satisfies those criteria. With no adversarial input and no judicial oversight, the risk that nonfraudulent material will be erroneously excluded is impermissibly high.3
The dissent essentially argues that the "reason to believe" standard is "nearly irrebuttable," and therefore due process affords plaintiffs no entitlement to attempt to rebut it. See Dissent at 821-22. We see things differently. The considerable liberties that the SSA has taken in interpreting and administering the "reason to believe" standard advocate in favor of a procedural check, not against it. In extolling the virtues of the non-adversarial "reason to believe" determination, the dissent draws an analogy to the Supreme Court's approval of a non-adversarial probable cause determination in criminal cases. See Dissent at 820-21 (discussing Kaley v. United States ,
The SSA nevertheless argues that it does not matter much whether nonfraudulent material is wrongly disregarded because the likelihood of a wrongful benefit determination remains low. SSA Br. 38-41. In support, the SSA notes that plaintiffs may submit new evidence showing the same facts as the excluded reports. Id. at 38-39. But plaintiffs persuasively argue that this procedural protection may be of little practical value for most claimants affected by Conn's scheme. Conn failed to turn in claimants' medical files once their cases were assigned to Daugherty and then seemingly destroyed a great deal of the files when news of his misconduct began to break, Senate Report at 122; 16-cv-154 (Hicks), R. 22-1 (Slone Aff. ¶ 3) (Page ID #1082), and it is understandably difficult to obtain new evidence of past disability. The SSA notes that plaintiffs did, for the most part, supplement their files with new evidence during the redetermination process. SSA Br. at 39. But simply because they fought on with whatever means remained available does not imply that they were not disadvantaged by their inability to contest the SSA's denial of their use of the reports. For similar reasons, the SSA's claim, which the dissent wholeheartedly embraces, see Dissent at 819-20, 821-22, that the excluded medical reports are relatively insignificant because they were never supposed to receive controlling weight in the benefits determination also fails, see SSA Br. at 39-41. Even if the excluded reports would generally not override contrary evidence from treating physicians, see
The remaining two Mathews factors also favor plaintiffs. The Supreme Court has long recognized that social security disability beneficiaries have a substantial interest in receiving their benefits, as "the hardship imposed upon the erroneously terminated disability recipient may be significant." Mathews ,
As to the government's interest in avoiding additional procedures, the SSA's position boils down to arguments about cost and administrative burden. The SSA believes plaintiffs' requested procedure would require an ALJ to hold a hearing in which an OIG agent would "testif[y] about how he came to believe that here was fraud in part of [the plaintiffs'] file[s]," and the plaintiffs would "cross-examine[ ] the agent and present[ ] evidence to show why [their medical reports] were all true." SSA Br. at 33 (quoting 16-cv-154 (Hicks), R. 36 (Mem. Op. & Order at 29) (Page ID #1356) ). The SSA contends that such a process would be "extraordinarily burdensome" and would "infringe on law enforcement efforts concerning the fraud scheme" because it would require ALJs to review the sufficiency and merits of the OIG's investigatory efforts. SSA Br. at 33-34. The SSA further argues that additional procedures would frustrate Congress's efforts to ensure that redeterminations occur quickly, as evidenced by the requirement that SSA "immediately redetermine" benefits upon developing a "reason to believe" that fraud was involved in the initial application. Id. at 35 (citing
These arguments are not compelling. We are particularly unpersuaded by the SSA's timing claims, given that the SSA waited nearly ten years after first learning about possible misconduct involving Conn and Daugherty to initiate redetermination proceedings. It seems disingenuous now to claim that plaintiffs should receive fewer procedural protections because the SSA is statutorily obligated to move quickly. Nor do we believe that "forcing OIG investigators to testify in over 1,500 redetermination hearings" would be particularly onerous given that SSA investigators would have to do the same thing if they developed a "reason to believe" fraud existed in 1,500 applications for benefits. See SSA Reply Br. at 18;
*804is concerned about interfering with ongoing law enforcement efforts, the SSA may secure a certification, in writing, from a state or federal prosecutor with jurisdiction over the investigations saying that the redeterminations would "jeopardize the criminal prosecution of a person involved in a suspected fraud," and the redetermination proceedings would halt.
At bottom, the district court in Hicks was right to conclude that refusing to allow plaintiffs to rebut the OIG's assertion of fraud as to their individual applications violates the Due Process Clause of the Fifth Amendment. We therefore AFFIRM the grant of partial summary judgment to plaintiffs in Hicks and REVERSE the partial grant of summary judgment to the SSA in Carter and Perkins .
B. Administrative Procedure Act ("APA")
Plaintiffs argue that the SSA violated the APA by (1) failing to comply with the APA's requirements concerning formal adjudications and (2) acting in an arbitrary and capricious manner by allowing claimants whose benefit determinations are suspected of fraud by the SSA to rebut assertions of fraud, but denying the same procedural protection to claimants whose benefit-determinations are suspected of fraud by the OIG. The district courts in Perkins and Carter rejected these arguments and entered partial summary judgment in the SSA's favor on plaintiffs' APA claims. We now REVERSE .
1. Failure to Comply with the Administrative Procedure Act's Formal-Adjudication Requirements
The APA distinguishes between formal adjudications, which must follow a set of "trial-type procedures," including "notice of 'the matters of fact and law asserted,' an opportunity for 'the submission and consideration of facts [and] arguments,' and an opportunity to submit 'proposed findings and conclusions' or 'exceptions,' " and informal adjudications, which "do not include such elements." Pension Ben. Guar. Corp. v. LTV Corp. ,
*805Pls. Reply Br. at 3; SSA Reply Br. at 36-37. The parties then part ways on two points. First, plaintiffs contend that the redetermination hearings, which were required to comply with the APA's requirements for formal adjudications, did not in fact do so. The SSA, in turn, argues that the redetermination hearings necessarily complied with the APA's formal-adjudication requirements because they conformed to
The SSA's first argument is somewhat hard to follow. If, as the SSA argues, "the protections provided by § 405(b)(1) are co-extensive with the APA's provisions on formal adjudication," SSA Reply Br. at 37, then the SSA's failure to comply with one act amounts to a violation of the other.6 And here, plaintiffs have identified at least one way in which the SSA's procedures failed to comply with the APA's formal-adjudication requirements. In particular, the APA provides that "[w]hen an agency decision rests on official notice of a material fact not appearing in the evidence in the record, a party is entitled, on timely request, to an opportunity to show the contrary."
*806Baker ,
The SSA's second argument-that plaintiffs are actually contesting the OIG's fraud-determination process rather than the benefits-redetermination hearing, SSA Reply Br. at 37-38-fares no better. Plainly, plaintiffs' suit concerns the level of process they were accorded by the SSA in their redetermination hearings, not at the OIG-referral stage. The SSA cannot reframe plaintiffs' complaint to evade responsibility for failing to abide by the APA's requirements. The district courts in Perkins and Carter therefore erred in granting summary judgment to the SSA on plaintiffs' claims that the SSA's redetermination process violated the APA's formal-adjudication requirements
2. Disparate Treatment of Fraud Allegations Based on Originating Source
According to plaintiffs, the SSA also violated the APA's prohibition on "arbitrary" or "capricious" decisionmaking, see
In response, the SSA argues that it makes sense to treat OIG-based determinations of fraud differently than SSA-based determinations of fraud because adopting plaintiffs' proposed procedure would (1) be unduly burdensome on "both the law enforcement agency and SSA's ALJ corps," as the OIG is more likely than the SSA to conduct large-scale investigations, and therefore more beneficiaries are affected by OIG-based determinations of fraud than SSA-based determinations; (2) "risk interference with the investigation and resulting criminal prosecution"; and (3) "place the ALJs in the untenable position of reviewing the sufficiency of law enforcement efforts." SSA Reply Br. at 40.10
*808Plainly, the SSA did not include any of the reasons it now offers for treating OIG-based determinations of fraud differently than SSA-based determinations of fraud in HALLEX. "[A]n agency's actions must be upheld, if at all, on the basis articulated by the agency itself," Motor Vehicle Mfrs. Ass'n of U.S., Inc. v. State Farm Mut. Auto. Ins. Co. ,
In any event, even if we were to credit the SSA's post-hoc explanations for distinguishing between OIG- and SSA-based determinations of fraud, its purported justifications are insufficient. All of the SSA's rationales for distinguishing between claimants whose files were deemed fraudulent by the OIG and claimants whose files were deemed fraudulent by SSA turn on differences between the OIG and the SSA-not between the claimants. The SSA has not provided any citations to suggest agencies can distinguish between similarly situated claimants based on circumstances entirely outside their control, and there is good reason to believe such action violates the APA. In Miller v. Bond ,
We therefore REVERSE the district courts' grant of summary judgment in the Perkins and Carter cases to the SSA on plaintiffs' claims under the APA and REMAND for further proceedings consistent with this opinion.
C. Social Security Act
Plaintiffs allege two violations of the Social Security Act ("the Act"). First, they allege that the SSA violated the Act by redetermining plaintiffs' benefits without first proving that their initial determinations involved fraud, in violation of the SSA's procedures governing reopenings and common-law and statutory principles of res judicata. Second, plaintiffs argue that the SSA violated the Act by failing "immediately" to redetermine plaintiffs' entitlement to benefits, as required under
1. Reopenings and Res Judicata
Turning first to plaintiffs' "reopening" argument: SSA regulations authorize the SSA to "reopen" a determination of benefits if "[i]t was obtained by fraud or similar fault."
This claim is a nonstarter, as plaintiffs cannot establish that the procedures governing reopenings also govern redeterminations. Title
Plaintiffs' broader res-judicata argument fails for similar reasons. As plaintiffs note, common-law principles of res judicata generally preclude agencies from readjudicating prior determinations. Drummond v. Comm'r of Soc. Sec. ,
The SSA concedes that res judicata principles apply in the agency setting, but it argues that courts may not "impose rules of preclusion, as a matter of policy, when the interpretation of a statute is at hand. In this context, the question is not whether administrative estoppel is wise but whether it is intended by the legislature." SSA Reply Br. at 44 (quoting Astoria Fed. Sav. & Loan Ass'n v. Solimino ,
2. Failure to Act Immediately
In their final claim, plaintiffs argue that the SSA violated the Act by failing to "immediately redetermine" plaintiffs' entitlements to benefits, as required under
In response, the SSA contends that it complied with § 405(u), as it issued notices to plaintiffs regarding their redetermination hearings within a week of receiving a letter from the OIG stating there were no "objections to SSA moving forward with its administrative processing of the redeterminations" of the applications implicated in Conn's scheme. 16-cv-154 (Hicks), R. 10-1 (OIG Letter) (Page ID #146); SSA Reply Br. at 45-46. As plaintiffs rightly note, however, nothing in § 405(u) permits the SSA to delay redetermination proceedings until it receives a green light from the OIG. Pls. Reply Br. at 23-24. Section 405(u) directs the SSA to "immediately redetermine" benefits when "there is reason to believe that fraud or similar fault was involved in the application."
Nevertheless, the SSA prevails on this claim. In United States v. Montalvo-Murillo ,
[a] prompt hearing is necessary, and the time limitations of the Act must be followed with care and precision. But the Act is silent on the issue of a remedy for violations of its time limits. Neither the timing requirements nor any other part of the Act can be read to require, or even suggest, that a timing error must result in release of a person who should otherwise be detained.
Plaintiffs identify two exceptions to this general principle. First, they note that courts will enforce statutory timing requirements where the requirement is a "condition precedent" to authorizing agency action. Pls. Reply Br. at 26. The Supreme Court, however, has recently construed a statute with similar mandatory language as § 405(u) as not containing a condition precedent. See State Farm Fire & Cas. Co. v. United States ex rel. Rigsby , --- U.S. ----,
Plaintiffs argue that § 405(u) is "functionally identical to statutes in which the Supreme Court has held a condition precedent to be mandatory," Pls. Reply Br. at 26, but the sole case plaintiffs cite in support of this proposition- Hallstrom v. Tillamook Cty. ,
Second, plaintiffs argue that an agency's failure to comply with a statutory timing requirement may preclude later action "if individuals are 'injuriously affected' by the procedural violation." Pls. Br. at 66 (quoting French v. Edwards ,
However, the Supreme Court has also cautioned courts to consider "the general purpose" of statutes before imposing sanctions that "would undermine the very governmental interests that [the statute] is *813meant to protect." Rigsby ,
III. CONCLUSION
The Due Process Clause of the Constitution and the Administrative Procedure Act required the SSA to allow plaintiffs an opportunity to show why the medical reports uniformly and entirely disregarded in their redetermination proceedings were not, in fact, tainted by fraud. Because the district courts in the Perkins and Carter cases reached the opposite conclusion, we REVERSE and REMAND those cases, in part, for further proceedings consistent with this opinion. Because we agree with the district court's resolution of the Due Process claims in the Hicks line of cases, and because we agree with the district courts' resolutions of the Social Security Act claims in the Perkins and Carter cases, we AFFIRM the district courts' judgments as to those issues.
DISSENT
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Cite This Page — Counsel Stack
909 F.3d 786, Counsel Stack Legal Research, https://law.counselstack.com/opinion/willie-ousley-v-commr-of-soc-sec-ca6-2018.