The mission of the SMP program is to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling and education.
The SMP program model is one of prevention. SMPs educated Medicare beneficiaries to scrutinize their medical statements and bills and subsequently reduce fraud and errors. Though beneficiaries have several avenues they can take to report fraud, such as the Office of Inspector General (OIG) hotline or 1-800-Medicare, some beneficiaries choose to report fraud to the SMP. In these cases, SMPs refer the complaint to the appropriate entity.
In 2016, the 53 SMP projects had a total of 6,126 total active team members who conducted 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.
They reported $163,904 in cost avoidance on behalf of Medicare, Medicaid, beneficiaries, and others; $53,449 in total savings to beneficiaries and others; and $2,672 in expected Medicare recoveries. Further, two projects provided information to federal prosecutors that resulted in settlements totaling an additional $9.2 million in expected Medicare recoveries.
The OIG reports that since 1997 the SMP projects have saved more than $124.7 million. This includes cost avoidance on behalf of Medicare, Medicaid, beneficiaries, or others of more than $9.2 million; expected Medicare recoveries of more than $22.8 million; and expected Medicaid recoveries of more than $94.8 million. Total savings to beneficiaries and others is approximately $7.1 million.
The OIG emphasizes that it is not always possible to track SMP referrals to Medicare contractors or law enforcement from beneficiaries who have learned to detect fraud, waste, and abuse from the projects. Therefore, SMPs may not be receiving full credit for savings, recoveries, and cost avoidance attributable to their work. In addition, SMPs are unable to track the potentially substantial savings derived from a sentinel effect whereby fraud and errors are reduced by Medicare beneficiaries’ scrutiny of their bills.
SOURCE: Office of Inspector 2016 Performance Data for the Senior Medicare Patrol Projects