2020 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 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 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 presented many challenges for the SMP projects that limited their activities. As a result, the performance data for 2020 do not reflect a normal year of activities for the projects. In 2020, the 54 SMP projects had a total of 5,720 active team members who conducted a total of 9,870 group outreach and education events, reaching an estimated 425,103 people. In addition, the projects had 249,134 individual interactions with, or on behalf of, a Medicare beneficiary.

For 2020, the SMP projects reported $16.8 million in expected Medicare recoveries. Over half of these recoveries came from one project that uncovered a fraud scheme in which a provider paid beneficiaries to receive home health services that were never rendered. The provider then submitted fraudulent claims to Medicare for millions of dollars while also receiving illegal kickback payments from the home health agencies. The provider was sentenced and ordered to pay a total of $9.5 million in restitution and forfeitures. In addition, cost avoidance totaled $53,768, while savings to beneficiaries and others totaled $33,554 for all SMP projects in 2020.

Due to the COVID-19 pandemic, the SMP projects were not able to conduct in-person outreach events and face-to-face individual interactions as they have done in the past. As such, in 2020, the projects reported a decrease in the number of group outreach and education events, the number of people reached through these events, and the number of individual interactions, compared to 2019. However, the projects reported significantly higher amounts of Medicare recoveries in 2020, an increase from $2.4 million to $16.8 million. The majority of these recoveries were the result of investigations that were resolved in 2020 but had begun several years prior.

In addition, the SMP program released two consumer fraud alerts on COVID-19 and genetic testing in 2020. The alerts warn beneficiaries about potential fraud schemes involving COVID-19 vaccines and treatments and genetic testing. The SMP program also provided OIG with 42 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 testing and vaccines, opioids, hospice services, drug prescribing, durable medical equipment, genetic testing, 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.