2021 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 continued to present challenges for the SMP projects that limited their in-person activities. As a result, the performance data for 2021 do not reflect a normal year of activities for the projects. In 2021, the 54 SMP projects had a total of 5,346 active team members who conducted a total of 12,660 group outreach and education events, reaching an estimated 556,980 people. In addition, the projects had 239,625 individual interactions with, or on behalf of, a Medicare beneficiary.

For 2021, the SMP projects reported $2.5 million in expected Medicare recoveries. Over half of these recoveries came from one project that uncovered a genetic testing fraud scheme in which residents of senior housing complexes were persuaded to submit genetic test specimens to a laboratory without sufficient involvement of a health care professional. The company involved was ordered to pay over $1.4 million in restitution. In addition, cost avoidance totaled $41,498, while savings to beneficiaries totaled $40,798 for all SMP projects.

In comparison to 2020, the projects reported a slight decrease in the number of individual interactions. However, the number of group outreach and education events increased, as did people reached through these events. In addition, in 2021 the projects reported lower amounts for Medicare recoveries than in 2020 ($2.5 million, down from $16.8 million), while cost avoidance also decreased ($41,498, down from $53,768).

In addition, the SMP program released a consumer fraud alert on hospice and continued its consumer fraud alerts on COVID-19 and genetic testing in 2021. The alerts warn beneficiaries about potential fraud schemes involving unsolicited marketing tactics to enroll beneficiaries in hospice services; COVID-19 vaccines and treatments; and genetic testing. The SMP program also provided OIG with 47 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-related unsolicited testing, vaccines, and trials; unsecured personally identifiable information (PII); unlicensed telehealth providers; 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.