Medicare Compliance & Reimbursement

SMART FACTS replaced with SIRS.

The Centers for Medicare & Medicaid Services (CMS) has an able partner in its fight against fraud and abuse — the Senior Medicare Patrol (SMP). These volunteers are vigilant about uncovering Medicare and Medicaid abuse and errors, and their efforts include training others to recognize these issues when they go for treatment.

Achievements and reports: In its June 2016 report, the HHS Office of Inspector General (OIG) published a memorandum on changes, challenges, and accomplishments related to the SMP 2015 data. Despite a lack of Medicaid recoveries this past year, the SMP outdid itself with a 282 percent increase from its 2014 returns in expected Medicare funds recapture equaling upwards of $2.5 million. The majority of this project’s recoveries concerned the “conviction of a hospice company owner for Medicare fraud,” says the OIG document.

Savings and Refunds Abound

The report notes that the SMP did suffer a 56 percent decline in beneficiary savings from 2014 to 2015 with a total savings of $35,059 this year compared to $80,228 in 2014. Refunds from providers to beneficiaries across the spectrum of CMS programs are also part of the SMP checkbox and totaled $21,533 in 2015, “a substantial decrease of 89 percent from $200,598 in 2014.”

Explanation for the decreases: “Expected Medicare and Medicaid recoveries may vary widely from year to year,” the OIG report maintains, “depending on the number and nature of the cases that are resolved each year.”

System Changes Go into Effect

The Administration for Community Living (ACL), which funds and manages the SMP, put into effect some major overhauls of the performance and reporting systems in 2015.

Performance: The ACL dropped the number of performance measures from 21 to 10 to better regulate and coordinate the findings with the SMP’s results. Of the 10 performance factors, five have remained intact that relate to “recovery, savings and cost avoidance” from the original 21 — however, five new criteria were added or altered to calculate volunteer and outreach endeavors.

Tracking: This past October, the ACL replaced the old SMP tracking system — Seniors Medicare Assistance and Reporting Tool for Fraud and Complaint Tracking System (SMART FACTS) — with a new and improved program called SMP Information and Reporting System (SIRS). The jury is out on whether the switch has been successful at helping the SMP with its efforts.

Resource: For an in-depth review of the OIG collected data on the SMP’s 2015 results, visit http://oig.hhs.gov/oei/reports/oei-02-16-00190.pdf.