Billions of federal dollars are lost annually due to healthcare fraud, errors, and abuse. The Administration for Community Living (ACL) Office of Healthcare Information & Counseling manages the Senior Medicare Patrol (SMP) grants. The SMP mission is to empower and assist Medicare beneficiaries, their families, and caregivers, to prevent, detect, and report suspected healthcare fraud, errors, and abuse through outreach, counseling, and education. SMPs work to resolve beneficiary complaints of potential healthcare fraud in collaboration with state and federal partners, including the U. S. Department of Health & Human Services Office of the Inspector General, Centers for Medicare & Medicaid Services, state Medicaid fraud control units, and state attorneys general.
SMPs recruit and train retired professionals and other volunteers to recognize and report instances or patterns of healthcare fraud. These activities support ACL’s goals of promoting increased choice and greater independence among older adults and individuals with disabilities. SMP activities also serve to enhance the financial, emotional, physical, and mental well-being of older adults, thereby increasing their capacity to maintain security in retirement and make better financial and healthcare choices.
History and Structure
SMPs were authorized in 1997 under Titles II and IV of the Older Americans Act, the Omnibus Consolidated Appropriation Act of 1997 and the Health Insurance Portability and Accountability Act of 1996. SMPs began as demonstration projects in 12 states. Currently, SMP grants are provided to all 50 states, District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. Nationally, the SMP network includes nearly 9,700 Team Members (staff and volunteers) at more than 500 local sites.
SMP Team members are trained to:
- Promote community awareness of healthcare fraud, errors, and abuse;
- Disseminate consumer education materials about Medicare fraud through presentations, health fairs, and other community events;
- Provide counseling, and when needed, serve as consumer advocates to resolve billing disputes/issues; and
- Make appropriate referrals to state and federal partners for suspected cases of Medicare fraud, errors, and abuse for further investigation.
In addition to SMP program services, many grantees also offer State Health Insurance Assistance Program (SHIP) services which provide health insurance counseling, outreach, and training to Medicare beneficiaries, their families, and caregivers.
SMPs are funded by the Health Care Fraud and Abuse Control (HCFAC) program for its antifraud activities. In 2018 funding for the SMP program totaled approximately $18 million. Approximately $15.6 million of the total funding available was distributed to the state SMP projects to help beneficiaries prevent, detect, and report Medicare fraud, errors, and abuse.
SMP Performance Outcomes
Each year, the Office of the Inspector General (OIG) completes an annual performance report on the SMP projects. The 2019 OIG SMP Performance Report documents the following outcomes for 2018 activities:
- Community Outreach Events: In 2018, SMP projects reached 1.7 million people through 26,932 group outreach and education events.
- One-on-One Counseling: SMP projects held more than 278,761 individual counseling sessions with, or on behalf of, Medicare beneficiaries regarding potential fraud, errors, or abuse.
Past OIG SMP Reports:
- May 2018 OIG SMP Performance Report
- June 2017 OIG SMP Performance Report
- June 2016 OIG SMP Performance Report
Resources and Useful Links
The Senior Medicare Patrol Resource Center (SMP Resource Center) provides training and technical assistance to SMP grantees. The SMP Resource Center also provides key consumer services such as fraud alerts and maintains the SMP locator, which helps consumers find their local SMP program.
Volunteer Risk and Program Management (VRPM) Policies: ACL has developed a set of policies to assist the SMP and SHIP grantees with managing their programs. The policies describe the governing principles and values that shape and guide Team Member involvement, set expectations regarding the management of volunteer programs, delineate core expectations of SMP/SHIP Team Members, and broadly describe what Team Members may expect from the SMP/SHIP. The purpose of these policies is to enhance the quality, effectiveness, and safety of SMP/SHIP services through the provision of guidance and direction to SMP/SHIP staff and volunteers.
Managing Conflicts of Interest: ACL has developed 'Conflict of Interest: Identification, Remedy, and Removal' to provide technical assistance to SHIP/SMP/MIPPA programs and their partner Community-Based Organizations (CBOs) on how to avoid actual and perceived Conflicts of Interest (COI) and mitigate risk.