Senior Medicare Patrol Projects Show Low ROI in Fighting Fraud and Abuse

An Office of Inspector General report detailing results of 2015 enforcement efforts by the Senior Medicare Patrol (SMP) show success but not overwhelming recoveries. However, the report cautions that SMP projects “may not be receiving full credit for recoveries, savings, and cost avoidance attributable to their work.” That’s because it isn’t always easy to track enforcement referrals from beneficiaries to the projects. The SMP program operates in every state and recruits and trains volunteer retired professionals and senior citizens to “prevent, recognize, and report health care fraud, errors, and abuse.” The trained volunteers also educate other Medicare and Medicaid beneficiaries to similarly ferret out fraud and abuse.

For 2015, the OIG reported the following data on SMP enforcement efforts:

• “$2.5 million in expected Medicare recoveries” attributable to SMP Projects, which is 282 percent increase from 2014 recoveries. Most of that was attributable to one project involving a hospice company whose owner was convicted of Medicare fraud.
• $35,059 savings to beneficiaries and others, which is a 56 percent decline from 2014 savings (Kentucky had $28,500 in savings to beneficiaries).
• $21,533 in cost avoidance for Medicare, Medicaid, beneficiaries, and others, which is 89 percent better than 2014 totals for cost avoidance.

These findings continue a downward trend. Last year, the OIG indicated 2014 recoveries had declined from those achieved in 2013 for the program. See “Senior Medicare Patrol Had Significant Drop in Fraud Recoveries Last Year,” National Intelligence Report, 8/20/15, p. 4. Funding for SMP in 2015 on the other hand was $17.6 million with $8.7 million of that coming from the Health Care Fraud and Abuse Control Program. That’s an increase from 2014 funding of $15.5 million. The SMP program has yielded $117.6 million in expected recoveries thanks to 72 SMP projects that reported performance data over an 18 year period. Total savings was $7 million and cost avoidance on behalf of beneficiaries was $9 million.

Takeaway: Government efforts to use trained beneficiaries to detect and report fraud and abuse achieve modest results in comparison to investment made; though OIG questions whether results truly reflect program’s achievements.