A program that recruits and trains retired professionals and other older Americans to recognize and report instances or patterns of health care fraud helped bring in more than $9 million in Medicare and Medicaid recoveries, but total savings to beneficiaries and others decreased.
The Health and Human Services Department’s Office of Inspector General reports that data for the Senior Medicare Patrol show that its 5,406 volunteers worked on 54 projects, recouping $9.1 million in Medicare and Medicaid recoveries, but total savings to beneficiaries and others decreased from $133,971 in 2012 to $41,718 in 2013. Cost avoidance on behalf of Medicare, Medicaid, beneficiaries and others increased by 26%, from about $114,000 in 2012 to over $143,000 in 2013.
Cost avoidance is the health care expenditures for which Medicare, Medicaid, a beneficiary or another entity such as a pharmacy was relieved of responsibility for payment as a result of an SMP project. For example, if a beneficiary discovers charges for services that he or she did not receive and an SMP project on behalf of the beneficiary contacts the provider and receives a corrected billing statement, the project may report this as cost avoidance.
In 2013, funding for each SMP project in each of the 50 states and the District of Columbia, Puerto Rico, Guam and the Virgin Islands totaled $19.6 million - $8.9 million from the Administration for Community Living and $10.7 million in Health Care Fraud and Abuse Control Program funding.
The inspector general’s office said it’s 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 so the projects “may not be receiving full credit for savings attributable to their work.” The office plans to continue to monitor the projects and provide ACL with an annual report.
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