Performance Data for the Senior Medicare Patrol Projects: June 2016 Performance 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 senior citizens to recognize and report instances or patterns of health care fraud. OIG has collected these performance data since 1997. In July 2010, the Administration on Aging (AoA)-now part of ACL-requested that OIG continue to collect and report these data to support its efforts to evaluate and improve the SMP projects' performance. (ACL was established in 2012, bringing together AoA and two other offices.)

HOW WE DID THIS STUDY

In 2015, ACL implemented a number of major changes to the SMP projects. It substantially changed the performance measures and implemented a new data system. As a result, ACL requested that for 2015, OIG focus its report on the performance measures related to recoveries, savings, and cost avoidance. We based our review on data reported by 54 SMP projects. We requested and reviewed the projects' documentation for expected recoveries of funds for the Medicare and Medicaid programs. We also requested and reviewed documentation for savings to beneficiaries and others that were attributable to the projects, as well as documentation for cost avoidance.

WHAT WE FOUND

In 2015, the SMP projects reported $2.5 million in expected Medicare recoveries that were attributable to their projects. The vast majority of these recoveries resulted from one project's efforts, which led to the conviction of a hospice company owner for Medicare fraud. Expected Medicare recoveries in 2015 increased by 282 percent from $660,829 in 2014. In 2015, the projects did not report any expected Medicaid recoveries; in 2014, they reported $504.

In 2015, the projects reported a total of $35,059 savings to beneficiaries and others. This was a 56 percent decrease from $80,228 in 2014. The majority of the savings reported in 2015 was the result of one project's efforts involving four separate beneficiary complaints pertaining to one provider. The provider had charged the beneficiaries for monthly treatments when Medicare covered these treatments. The SMP project helped the beneficiaries obtain refunds from the provider. In addition, the projects reported a total of $21,533 in cost avoidance on behalf of Medicare, Medicaid, beneficiaries, and others. This was a substantial decrease of 89 percent from $200,598 in 2014.

We continue to emphasize that the projects may not be receiving full credit for savings 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 reduce fraud and errors.