Senior Medicare Patrol Had Significant Drop in Fraud Recoveries Last Year

The Senior Medicare Patrol (SMP) has been an initiative of the Centers for Medicare & Medicaid Services (CMS) since the late 1990s, initially as a pilot project, and now operates initiatives in every state and territory, staffed by more than 5,000 volunteers.

Despite the fairly dramatic notion behind the SMP—enlisting Medicare enrollees to be on the lookout for and report what they believe might be fraud—it has had modest results in recent years, according to a new report from the Office of the Inspector General for the U.S. Department of Health and Human Services.

In calendar 2014, recoveries from Medicare and Medicaid fraud inquiries led to expected recoveries of ill-gotten payments totaling $661,333—a 93 percent decrease from 2013. But in 2013, much of the $9.1 million of expected recoveries were tied to what the agency called “a single event.”

The OIG also noted that “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 substantial savings derived from a sentinel effect whereby fraud and errors are reduced by Medicare beneficiaries’ scrutiny of their bills.”

Since the program was launched in 1997, SMP has led to $115.1 million worth of recoveries, with $20.3 million pegged to the Medicare program and the large bulk of it connected to Medicaid.

The OIG has not provided any specifics about recoveries, and little has been published over the past 20 years about how the SMP has been connected to specific Medicare or Medicaid fraud allegations and investigations.

However, laboratories are suspected to contribute to excessive billing in the Medicare program. According to an OIG report issued last year, Medicare Part B enrollment increased 10 percent from 2005 to 2010, but spending on lab services increased by 29 percent during that same period.

A survey determined that more than 1,000 labs had exceeded five or more thresholds for what is considered to be questionable billing. They included claims that are ordered by a physician located more than 150 miles away from the beneficiary (the average distance for each claim was actually 851 miles); duplicate tests (nearly 1 million in total); and claims submitted with compromised lab provider or ordering physician numbers.

Altogether, the OIG concluded that Medicare allowed $1.5 billion in questionable laboratory claims in 2010. It recommended that CMS review those labs it had concluded had engaged in submitting a significant number of questionable claims.

Takeaway: The Senior Medicare Patrol has had significant but uneven success over the years in leading to recoveries from Medicare and Medicaid fraud.


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