For Professionals: Medicare fraud and abuse

California’s Senior Medicare Patrol Project Saves Medicare Over $7 Million in Fraud Claims

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Published: June 16, 2008

California Health Advocates’ (CHA) Senior Medicare Patrol (SMP) project helped Medicare avoid paying over $7 million in fraudulent claims last year. According to the Office of Inspector General’s 2007 SMP performance data report, this amount accounts for 99% of Medicare’s avoided costs for all 57 SMP projects nationwide. Most of these avoided payments came from a single case where California’s SMP helped expose the fraudulent billing of medical services that were never provided, resulting in 13 providers having their Medicare provider identification numbers revoked. (See our previous newsletter article for more information on this case).

The SMP projects, which are funded by the Administration on Aging (AoA) to recruit retired professionals to volunteer in educating and helping beneficiaries detect and report Medicare fraud, waste, and abuse, were required for the first time last year to claim and calculate cost avoidance to the Medicare program. This calculation helps better capture more of the monetary value and savings SMP brings to Medicare. Cost avoidance specifically means health care expenditures for which the Medicare program, the Medicaid program, a beneficiary, or other entity (e.g., secondary health insurer, pharmacy) did not have the responsibility to pay as a result of the projects.

In addition to this substantial accomplishment, last year California’s SMP project and its volunteers also held:

  • 26 media events;
  • 54 health fairs and other community outreach events, reaching close to 15,000 individuals;
  • 368 community education events reaching over 10,000 individuals; and
  • Investigated 99 complex cases that were turned over to California’s Program Safeguard Contractors (PSCs) for Part A, B, and D claims.

These case investigations returned $97,583 to the Medicare program, almost 1/3 of the total monies recovered nationwide.

CHA’s SMP extends our heartfelt thanks and recognition to our volunteers and to the Health Insurance Counseling & Advocacy Programs (HICAPs) for their continued strong partnership in Medicare fraud education and counseling efforts. We look forward to another eventful and successful year in the fight against Medicare fraud and abuse.

To learn more about Medicare fraud and abuse, how to detect and prevent it, and how to report a case, visit our website section on Medicare fraud. Beneficiaries and advocates can also contact a SMP counselor in their local HICAP office by calling 1-800-434-0222. To reach CHA’s SMP office directly, call Julie Schoen or Anne Gray, SMP Project Director and SMP Project Coordinator respectively, at 714-560-0309.

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