2016 Performance Data for the Senior Medicare Patrol Projects

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.

HOW WE DID THIS STUDY

We based our review on data reported by 53 SMP projects for 5 performance measures pertaining to recoveries, savings, and cost avoidance and 5 performance measures relating to volunteer and outreach 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 attending events).

The five measures relating to volunteer and outreach activities are new, and we provide data on them for the first time. (In 2015, ACL reduced the number of SMP performance measures from 21 to 10 by keeping the 5 measures pertaining to recoveries, savings, and cost avoidance and condensing from 16 to 5 the measures pertaining to volunteer and outreach activities.)

WHAT WE FOUND

In 2016, the 53 SMP projects had a total of 6,126 total active team members who conducted a total of 26,220 group outreach and education events, reaching an estimated 1.5 million people. In addition, the projects had 195,386 individual interactions with, or on behalf of, a Medicare beneficiary.

For 2016, the projects reported $163,904 in cost avoidance on behalf of Medicare, Medicaid, beneficiaries, and others. Savings to beneficiaries and others totaled $53,449. Expected Medicare recoveries totaled $2,672. Further, two projects provided information to Federal prosecutors that resulted in settlements totaling an additional $9.2 million in expected Medicare recoveries. There were no expected Medicaid recoveries.

Compared to 2015, the projects reported much higher amounts for cost avoidance ($163,904, up from $21,533) and somewhat higher amounts of savings to beneficiaries and others ($53,449, up from $35,059). However, the projects reported significantly lower expected Medicare recoveries ($2,672, down from $2.5 million). The projects reported no Medicaid recoveries in either year.

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.