Medicare Compliance & Reimbursement

$9.1 million record recovery by SMP gives you more reason to be wary.

Not every person checking for fraud is a government entity. Watch out: Your very own Medicare patients, who are eligible to join the Senior Medicare Patrol (SMP), could be looking for patterns that might constitute fraudulent billing or coding trends.

SMP is a group of over 5,400 volunteers who are trained to detect fraud, waste, and abuse in the Medicare system. The members of the Patrol also teach other seniors how to recognize fraud and abuse, and how to protect their identities and avoid falling for scams.

The Senior Medicare Patrol has been in existence since 1997, and during that 17-year period, its members have recovered over $114.5 million for Medicare and Medicaid, according to the HHS Office of the Inspector General’s (OIG’s) June 13 document “Performance Data for the Senior Medicare Patrol Projects: June 2014 Performance Report.”

The SMP Program’s Web page states that the organization teaches its volunteers to watch for fraud and abuse, such as unnecessary or inappropriate services, charges for services that doctors never provided, or illegal marketing practices.

The SMP also advises seniors of Medicare and Medicaid scams that they might encounter and offers information on how to identify and report any such scams. In 2013, the program prompted recoveries worth $9.1 million, saving beneficiaries $41,718 and avoiding costs of $143,282 to the Medicare and Medicaid programs, the OIG’s recent report states.

Stay Stress-Free

Upon learning of the SMP’s intentions, some medical practices have expressed concern that they are being audited even when they are not aware of it. But the program isn’t designed to turn Medicare patients into undercover detectives. Instead, the Senior Medicare Patrol is an education-based program showing Medicare beneficiaries and their families how to watch for Medicare fraud.

Because the SMP is more of an awareness group, they know to question a physician if they are billed for a service they didn’t receive. However, they aren’t necessarily gathering evidence to make legal cases against providers. If, however, the SMP administrators see a pattern among the volunteers’ reports and find complaints about a particular provider, the agency determines whether they’ve found a trend which might result in them looking at a provider more closely.

For example: If SMP volunteers report that a certain provider was billing a 99215 E/M code for every patient he sees, whether or not an E/M was actually performed, the SMP administrators might refer the case for further investigation.

To read the OIG’s report on the Senior Medicare Patrol program, visit oig.hhs.gov/oei/reports/oei-02-14-00140.pdf.