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 coronavirus disease 2019 (COVID-19) pandemic continued to present challenges for the SMP projects that limited their in-person activities. During this period, the projects conducted virtual outreach. Where local restrictions and beneficiary and team member comfort and safety allowed, in-person outreach and education events were also held. By the end of 2022, most SMP projects reintegrated in-person activities, although the rate at which these activities had not yet reached pre-COVID levels.
In 2022, the 54 SMP projects had a total of 5,346 active team members who conducted a total of 18,274 group outreach and education events, reaching an estimated 1,000,240 people. In addition, the projects had 246,725 individual interactions with, or on behalf of, a Medicare beneficiary.
For 2022, the SMP projects reported $153,812 in expected Medicare recoveries. Over half of these recoveries came from one project that identified a provider who billed for Evaluation & Management (E&M) claims when the only service rendered was the administration of the COVID-19 vaccine. The E&M claims were not supported by the medical record. The provider Memorandum Report: 2022 Performance Data for the Senior Medicare Patrol Projects (OEI-02-23-00150) was ordered to pay over $86,000 to resolve their civil liability In addition, cost avoidance in 2022 totaled $31,122, while savings to beneficiaries totaled $74,459 for all SMP projects.
In addition, the SMP program continued its educational outreach on fraud schemes involving hospice. The alert warns beneficiaries about potential fraud schemes that involve unsolicited marketing tactics to enroll beneficiaries in hospice services. It advises beneficiaries to be sure that their doctor has assessed their condition and certified that they are terminally ill and expected to live 6 months or less. The alert also advises beneficiaries never to accept gifts in return for hospice services and to be wary of “too-good-to-be-true” offers. In 2022, the SMP projects conducted 322 group education events covering hospice fraud issues, reaching a total of 25,535 people. In addition, they conducted 121 instances of media outreach on this topic, reaching 12.9 million people.
The SMP program also continued its educational outreach on fraud schemes involving COVID19. Its fraud alert on COVID-19 advises beneficiaries to be suspicious of strangers offering free COVID-19 testing, supplies, treatments, or vaccines. The alert also advises beneficiaries to be cautious about sharing their personal information, including their Medicare identification number, because this information can be used in fraud schemes. The SMP projects conducted 645 group education events covering COVID-19 fraud issues in 2021, reaching a total of 26,704 people. In addition, they conducted 454 instances of media outreach on this topic, reaching 21.4 million people.
In comparison to 2021, the projects reported a 3-percent increase in the number of individual interactions in 2022 (to 246,722, up from 239,625). The number of group outreach and education events increased by 44 percent (to 18,274, up from 12,660), and the number of people reached through these channels increased by 80 percent (to 1,000,240, up from 556,980). However, the projects reported lower amounts for expected Medicare recoveries ($153,812, down from $2.5 million), while cost avoidance also decreased (to $31,122, down from $41,498).
The OIG notes 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.
For More Information
See the OIG Report page.