Senior Medicare Patrols (SMP) Protect Older New Yorkers and Help Reduce Medicare/Medicaid Fraud and Abuse
The U. S. Office of Inspector General estimates that Medicare and Medicaid loses $60 billion dollars each year due to errors, fraud, waste, and abuse.
Halting Medicare/Medicaid fraud has become a priority for the federal, State and local governments, as the scams that once stole $1 million to $2 million a decade ago have morphed into sophisticated multimillion-dollar networks involving doctors, clinics, patient recruiters and patients.
The SMP program is a grassroots network of volunteers who work to educate older individuals and other Medicare and Medicaid beneficiaries on how to protect, detect, and report health care fraud. SMP began in 1997 as Operation Restore Trust to combat Medicare and Medicaid fraud and abuse. The program not only protects older persons, it also helps preserve the integrity of the Medicare and Medicaid programs.
SMP volunteers teach beneficiaries how to review their Medicare notices to make sure that the charges listed on the summary match the services they received. They also emphasize the importance of "Guarding Your Card," and not to give out the number on the internet, over the phone or anyone who comes to your home uninvited - giving personal information only to doctors or other Medicare approved providers.
"No one from the Social Security, or any other government agency, will ever call you and ask for your Medicare card number. If that happens, it's likely the caller is fraudulent," says Peggy Moran, SMP Coordinator for Senior Services of Albany. "Older individuals who fall victim to this kind of identity theft feel violated. This is serious elder abuse," adds Moran.
Nationwide SMPs recruit and train nearly 5,700 volunteers. There are currently about 418 SMP volunteers in New York State. The program is administered by the New York State Office for the Aging (NYSOFA) with funds from the US Administration for Community Living (ACL).
The NYSOFA SMP partners with our Health Care Insurance Information, Counseling & Assistance Program (HIICAP). Our HIICAP/SMP counselors provide education on various components of Medicare, including Medicare Part D drug benefit. Volunteers and staff conduct education programs throughout the state. They respond to inquiries in person, by phone, or electronic media, present programs to community groups, and participate at senior fairs and related programs. SMP conducts interactive Fraud Summits throughout the state to raise awareness, provide tips on how to protect themselves against fraud, by protecting their number, and reporting suspicious activity. We have intensified our efforts to fight fraud with the Health Care Fraud Prevention & Enforcement Action Team (HEAT).
These joint efforts are beginning to show results. The Office of the Inspector General report shows that the government's health care fraud prevention and enforcement efforts recovered nearly $4.2 billion in taxpayer dollars in fiscal year 2012, according to a recent press release issued by the US Department of Health & Human Services (HHS).
The Centers for Medicare and Medicaid Services (CMS,) defines fraud as "the intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and the individual makes knowing that the deception could result in some unauthorized benefit to himself or herself or some other person."
What is NOT health care fraud:
- An honest mistake by the provider - clerical errors of the wrong billing code
- Charges on the Medicare Summary Notice (MSN) from anesthesiologists, radiologists, etc. that the beneficiary does not remember seeing. These doctors provide specialized services behind the scene or bill separately from the primary care doctors.
- Hospital and medical bills that are "too high". Set rates apply for specific service and/or equipment and are billed accordingly
Fraud can be committed by any of the following people or groups:
- Physicians or other health care practitioners
- home health care companies
- a billing service
- an employee, sales rep, or beneficiary
Examples of Medicare / Medicaid Fraud:
- Billing for services or supplies not needed or provided, especially durable medical goods
- Ordering unnecessary lab tests or therapies
- Using another person's Medicare card to obtain medical care
- Soliciting, offering, or receiving a kickback, bribe, or rebate (for example paying for referrals of patients)
- Using unethical or unfair marketing strategies on TV, radio, or advertisements offering beneficiaries free health screenings, free diabetic supplies, free wheelchairs, or transportation to switch providers
- Medical Identity Theft- information obtained by asking for Social Security number at an event, over the phone, or stealing information from a wallet or the trash
Thanks to the beneficiaries in Orange County, NY, who took the time to notice discrepancies in their MSN and reported this to our SMP hotline. We learned that 3,000 Medicare ID numbers were stolen. Further investigation revealed that this fraud involved a crime syndicate, which was running a fraudulent physical therapy operation in Brooklyn, where beneficiaries were paid $50 for each illegal visit. The group had billed Medicare for over $100 million. As a result of these investigations, 44 individuals were arrested in 2010. See related article in the NY Times.
Learn more about how you can help reduce Medicare fraud. If you suspect fraud, contact your county Office for the Aging or call the SMP hotline at 1 877 678-4697.
More information on NYSOFA's (SMP) Senior Medicare Patrol program.
The best way to play an active role in preventing Medicare fraud and abuse is to become a SMP volunteer. To find out about SMP volunteer opportunities, contact Anne Matthei, SMP Coordinator, at 518 486-2719.