Getting the Word Out: Hotlines and Campaigns as Tools Against Medicare Fraud

October 2011

IN THIS ISSUE

— Senior Medicare Patrols: Eyes on the Ground Against Fraud
— Hotlines as a Tool in the Private Sector Versus Government Programs

GREETINGS!

Welcome to the October edition of our newsletter! In this issue, we’ll look at increased efforts to raise awareness among senior citizens about Medicare fraud, and gauge their efficacy in actually deterring fraudulent activity.

SENIOR MEDICARE PATROLS: EYES ON THE GROUND AGAINST FRAUD

“Fraud, waste and abuse” are often part of the discussion when talking of reducing the federal budget, where payments toward obligations concerning Social Security and Medicare are cited as serious long-term drivers of the federal deficit. In 1997, the Department of Health and Human Services launched “Senior Medicare Patrols” to, in the program’s words, empower seniors “through increased awareness and understanding of healthcare programs. This knowledge helps seniors to protect themselves from the economic and health-related consequences of Medicare and Medicaid fraud, error and abuse.” The agency said as much as $60 billion per year is lost to the Medicare program due to fraud, and as of December 2010 nearly 3 million seniors had been educated about fraud in the program, with the agency stating that $106 million was recovered by Medicare and Medicaid as a result of complaints made through the program.

In addition to education programs, the Inspector General for the Department of Health and Human Services maintains a hotline to report suspected fraud or abuse of the system. While employee hotlines are well-documented within the private sector as a wellspring of leads toward fraudulent activity, does the same hold true for the recipients of government benefits?

HOTLINES AS A TOOL IN THE PRIVATE SECTOR VERSUS GOVERNMENT PROGRAMS

In March 2001, the Department of Health and Human services Inspector General analyzed the effectiveness of that agency’s handling of complaints to their hotline and found, in analyzing data from a six-month period in 2008, that after one year’s time, 12 percent of complaints were not yet resolved. “Overall, 32 percent of complaints were confirmed as services billed in error,” the inspector general wrote. “Eleven percent of complaints involved allegations of fraud. Contractors closed 11 percent of complaints administratively. For another 32 percent, contractors researched complaints and found no problems. Two percent of complaints were referred to another agency. CMS had not resolved 12 percent of the complaints it received during our period of review.” The inspector general noted that while many investigations began within 30 days of receiving a complaint, 29 percent took “more than four months” to begin an inquiry after a complaint was made. The inspector general suggested establishing and distributing written guidelines “defining the roles and responsibilities of CMS and contractor staff and timeframes for assigning, researching, and resolving complaints,” and also to invest in upgrading information technology infrastructure for hotline functions.

While building awareness among Medicare recipients concerning the hallmarks of typical fraud schemes is a critical step to reducing fraud, responsibility lies both with the federal government and the private vendors which provide services under the program. For large health-care providers, the first step toward combating fraud should be working directly with a patient to resolve the issue, but if those efforts are unsuccessful, the establishment of a separate, practice-wide anonymous hotline — and, as the inspector general’s report stresses, equipping staff members with the means to use it effectively — will help private practitioners mitigate any fraudulent practices long before the federal government has a need to become involved.