Medicare Compliance & Reimbursement

The government recruits different types of people to check for Medicare fraud, but not all of those recruits are attorneys or federal employees. In fact, some of them might be your very own Medicare patients, who are eligible to join the Senior Medicare Patrol (SMP), a group of over 4,400 volunteers who are trained to detect fraud, waste, and abuse in the Medicare system.

Last year, the government brought in $76,176 that it attributed to the SMP, which was a more than three-fold increase over the 2008 recoveries of $21,068. The SMP achieved the higher recovery last year despite having 200 fewer volunteers in 2009 than it had in 2008. The increase in recoveries may have been thanks to an increase in the number of group education and one-on-one counseling sessions that the SMP offered in 2009.

The SMP has been in business since 1997, and during that 13-year period, its members have recovered nearly $4.6 million for Medicare. In addition, the SMP has been responsible for over $100 million total in savings to the government via Medicare, Medicaid, Social Security, and other programs.

"The SMP's mission is to ensure that Medicare and Medicaid beneficiaries (and, in some cases, their caregivers) are educated healthcare consumers so they can help prevent fraud, waste, and abuse," says Ginny Paulson, director of the National Consumer Protection Technical Resource Center, the Center of Service and Information for SMPs, which supports and promotes the SMPs nationwide, and offers information about the program on its Web site, www.smpresource.org.

For instance, the SMP program offers sessions to train beneficiaries on the importance of reading their explanations of benefits (EOBs), says Paulson. If they see a problem, they are encouraged to contact their provider and work it out. "In addition, beneficiaries who review their EOBs can better notice whether someone has fraudulently gotten hold of their Medicare I.D. number and misused it," Paulson says. "The SMP program can help patients recognize identity theft that way."

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, experts say.

"Reports are only made regarding specific providers if the beneficiary or the caregiver was unable to sort things out directly with the provider or the CMS carrier about the issue," Paulson says. "The SMPs don't have their volunteers act as 'secret shoppers' or anything covert like that -- we would consider that potentially dangerous for the volunteer. We stick to educating the patients and their caregivers instead."

The government is interested in growing the SMP program, noting in the DOJ's "Health Care Fraud and Abuse Control Program's Annual Report for Fiscal Year 2009" report to Congress that SMP volunteers contributed close to 113,000 hours to share the program's message of fraud awareness and prevention throughout the senior community, because "outreach is a key element of the SMP program."

"Our departments have a long history of working together in the fight against health care fraud," said Attorney General Eric Holder upon releasing the May 13 report to Congress that included details on the SMP program's progress, along with other features of the government's efforts to combat fraud. "Today's report shows the success of our collaborative efforts to prevent, identify, and prosecute the most egregious instances of health care fraud."

To read the complete OIG report on the SMP's performance for 2009, visit www.oig.hhs.gov/oei/reports/oei-02-10-00100.pdf.