The SMP projects receive grants from the Administration for Community Living (ACL) to recruit and train retired professionals and other older adults and community members to prevent, recognize, and report health care fraud, errors, and abuse. These SMP team members then participate in outreach events to help educate Medicare and Medicaid beneficiaries on the same prevention, recognition, and reporting techniques.
The SMP program model is one of prevention. SMPs educated Medicare beneficiaries to scrutinize their medical statements and bills and subsequently reduce fraud and errors. Though beneficiaries have several avenues they can take to report fraud, such as the Office of Inspector General (OIG) hotline or 1-800-Medicare, some beneficiaries choose to report fraud to the SMP. In these cases, SMPs refer the complaint to the appropriate entity.
The COVID-19 pandemic continued to present challenges for the SMP projects that limited their in-person activities. In 2023, the 54 SMP projects had a total of 5,532 active team members who conducted a total of 22,356 group outreach and education events, reaching an estimated 1,244,697 people. In addition, the projects had 270,348 individual interactions with, or on behalf of, a Medicare beneficiary.
For 2023, the SMP projects reported $111,277,683 in expected Medicare recoveries. Nearly all of these recoveries came from one project that identified a nurse practitioner who billed for genetic tests and durable medical equipment that patients did not need and telemedicine visits that never occurred. This provider was ordered to pay nearly $111.3 million in restitution. In addition, cost avoidance in 2023 totaled $34,306, while savings to beneficiaries and others totaled $45,081 for all SMP projects.
In comparison to 2022, the projects reported a 10-percent increase in the number of individual interactions in 2023 (270,348, up from 246,722). The number of group outreach and education events increased by 22 percent (22,356, up from 18,274), and the number of people reached through these channels increased by 24 percent (to 1,244,697, up from 1,000,240). The projects also reported higher amounts for expected Medicare recoveries ($111,277,683, up from $153,812) as well as cost avoidance ($34,306, up from $31,122). The SMP program also provided OIG with 26 reports—referred to as Special Notifications—of new fraud trends based on ground-level insights from the SMP projects. These notifications focused on fraud schemes involving COVID-19, remote patient monitoring, urinary catheters, continuous glucose monitors, internal employee complaints, unsolicited annual wellness visits, fraudulent disenrollment, and other concerning trends.
We note 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.
Nonetheless, ACL needs to work with SMP projects to further focus on and document expected Medicare and Medicaid recoveries; additional Medicare and Medicaid recoveries; cost avoidance; and savings both to beneficiaries and to others to the extent possible.
SOURCE: 2023 Performance Data for the Senior Medicare Patrol Projects
For More Information
See the OIG Report page.