Senior Medicare Patrol Fraud Recoveries Plummeted in 2016

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By James Swann

The federal government recovered a mere $2,672 in improper Medicare payments in 2016 thanks to volunteer Medicare beneficiary efforts, a sharp drop-off from the $2.5 million recovered in 2015.

The Health and Human Services Office of Inspector General’s report didn’t explain the drop in Senior Medicare Patrol recoveries, but the bulk of 2015’s recoveries came from an Oklahoma SMP’s uncovering of a hospice fraud scheme.

While fraud recoveries were one 1/1000th of 2015’s recoveries, amounts have varied since the program began in 1997 due to the voluntary nature of the program. SMPs received $18 million in federal funding in 2016.

Patrol results depend on the retired seniors who are recruited and trained each year, and recovery amounts can vary from year to year, Elizabeth Carder-Thompson, a health-care attorney at Reed Smith LLP in Washington, told Bloomberg BNA June 13.

“As the report itself notes, some of the SMP projects may not be receiving full credit for recoveries, savings, and cost avoidances attributable to their work,” Carder-Thompson said, expanding on the drop in recoveries in 2016.

Effective Weapon

Despite the drop in fraud recoveries, involving Medicare beneficiaries in fraud fighting still seems to be an effective weapon in the federal government’s arsenal, Carder-Thompson said.

The lowered recoveries are likely a temporary blip caused by a change in methodology that went into place in 2016, Linda Baumann, a health-care attorney with Arent Fox in Washington, told Bloomberg BNA June 13.

“If the numbers stay this low next year, there may some further evaluation or modification of the SMP program, but there were no recommendations in the report so it’s unlikely any further action will be taken at this time,” Baumann said.

The methodology change involved reducing the number of performance measures from 21 to 10. The five measures associated with recoveries, savings, and cost avoidance were kept, while the remaining measures associated with volunteering and outreach efforts were reduced to five new measures.

SMP programs are active in all 50 states as well as the District of Columbia, Puerto Rico, and Guam. They involve Medicare beneficiaries who help identify and deter fraud and educate other beneficiaries about identifying fraud.

While recoveries were down in 2016, the 53 SMPs did boost cost avoidance for Medicare beneficiaries from $21,533 to $163,904, and increased savings to beneficiaries to $53,449, up from $35,059.

Cost avoidance refers to health-care expenditures the government doesn’t have to make as a result of SMP activity, while beneficiary savings refers to money recovered directly by beneficiaries, such as co-payments, deductibles, or other out-of-pocket costs.

SMP efforts have resulted in $117 million in improper Medicare payment recoveries since 1997, and the program has saved Medicare beneficiaries $7.1 million over the same period.

The Centers for Medicare & Medicaid Service’s Administration for Community Living runs the SMP program, while the OIG is responsible for conducting an annual performance review.

To contact the reporter on this story: James Swann in Washington at jswann1@bna.com

To contact the editor responsible for this story: Kendra Casey Plank at kcasey@bna.com

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