2022 Performance Data for the Senior Medicare Patrol Projects

06-16-2023 | OEI-02-23-00150 | Complete Report

WHY WE DID THIS STUDY

This memorandum report presents performance data for the Senior Medicare Patrol (SMP) projects, which receive grants from ACL to recruit and train retired professionals and other older adults and community members to recognize and report instances or patterns of health care fraud. OIG has collected these performance data since 1997.

HOW WE DID THIS STUDY

We based on our review on data reported by 54 SMP projects for 7 performance measures pertaining to recoveries, savings, and cost avoidance and 5 performance measures relating to SMP activities. For the first group of measures, we reviewed supporting documentation for the data. For the second group, we reviewed the data for any discrepancies (e.g., if a project reported holding no events but reported a number of people who attended events).

WHAT WE FOUND

The COVID-19 pandemic continued to present challenges for the SMP projects that limited their ability to perform in-person activities. As a result, the performance data for 2022 do not reflect a normal year of activities for the projects. End of
Translation In 2022, the 53 reporting SMP projects had a total of 5,365 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 246,722 individual interactions with, or on behalf of, a Medicare beneficiary. The Guam SMP project did not submit performance data for 2022.

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 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 and others totaled $74,459 for all SMP projects.

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).

In addition, the SMP program continued its consumer fraud alerts on COVID-19, hospice, and genetic testing in 2022. The alerts warn beneficiaries about potential fraud schemes involving COVID-19 vaccines, testing, and treatments; unsolicited marketing tactics to enroll beneficiaries in hospice services; and genetic testing. The SMP program also provided OIG with 22 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-related testing sites and kits, as well as genetic counseling, hospice fraud, licensing board impersonation, and other topics.

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 to beneficiaries and to others to the extent possible. Furthermore, ACL needs to ensure that all SMP projects submit performance data.