Kusserow on Compliance: OIG reports on the Senior Medicare Patrol (SMP) program

The OIG issued a report on the 2016 performance data for the Senior Medicare Patrol (SMP) program. It is a little known program for many people designed to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education. SMPs are grant-funded projects of HHS, U.S. Administration for Community Living (ACL). They play a unique role in the fight against Medicare errors, fraud, and abuse. SMP volunteers and staff are viewed as “eyes and ears” in their communities, educating beneficiaries to be the first line of defense; a sort of ‘neighborhood watch” team. Their work involves conducting presentations to groups, exhibit at events, and work one-on-one with Medicare beneficiaries; engaging volunteers to protect elderly person’s health, finances, and medical identity while saving precious Medicare dollars is a cause that attracts civic-minded Americans; and receiving beneficiary complaints and determining whether it may involve fraud, errors, or abuse. When fraud or abuse is suspected, they make referrals to the appropriate state and federal agencies for further investigation.

The OIG used five performance measures pertaining to recoveries, savings, and cost avoidance; and another five performance measures relating to volunteer and outreach activities.  In 2016, there were 53 SMP projects that had a total of 6,126 total active team members who conducted a total of 26,220 group outreach and education events that reached an estimated 1.5 million people.   The projects also had 195,386 individual interactions with, or on behalf of, a Medicare beneficiary.  The projects reported $163,904 in cost avoidance on behalf of Medicare, Medicaid, beneficiaries, and others. Savings to beneficiaries and others totaled $53,449. Expected Medicare recoveries totaled $2,672. Further, two projects provided information to federal prosecutors that resulted in settlements totaling an additional $9.2 million in expected Medicare recoveries. There were no expected Medicaid recoveries.

Compared to 2015, the projects reported much higher amounts for cost avoidance ($163,904, up from $21,533) and somewhat higher amounts of savings to beneficiaries and others ($53,449, up from $35,059). However, the projects reported significantly lower expected Medicare recoveries ($2,672, down from $2.5 million). The projects reported no Medicaid recoveries in either year. Some common examples of suspected Medicare fraud or abuse identified by the SMP include:

  • Billing for services or supplies that were not provided
  • Providing unsolicited supplies to beneficiaries
  • Misrepresenting a diagnosis, beneficiary’s identity, service provided, or other facts
  • Prescribing or providing excessive or unnecessary tests and services
  • Violating the participating provider agreement with Medicare by refusing to bill Medicare for covered services or items and billing the beneficiary instead
  • Offering or receiving a kickback (bribe) in exchange for a beneficiary’s Medicare number
  • Requesting Medicare numbers at an educational presentation or in an unsolicited phone call
  • Routinely waiving co-insurance or deductibles

The OIG noted that the projects may not be receiving full credit for recoveries, savings, and cost avoidance attributable to their work. It is not always possible to track referrals to Medicare contractors or law enforcement from beneficiaries who have learned to detect fraud, waste, and abuse from the projects. In addition, the projects are unable to track the potentially substantial savings derived from a sentinel effect, whereby Medicare beneficiaries’ scrutiny of their bills reduces fraud and errors.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.