SMP Foundations Training Manual CHAPTER 1 ... - SMPresource.org

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SMP FOUNDATIONS TRAINING MANUAL Background The Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) estimates that the Medicare program loses billions of dollars each year due to errors, fraud, and abuse. This problem affects all Americans. It affects beneficiaries by wasting Medicare money that could be used to increase and improve health care services. And, it affects everyone who pays taxes by wasting billions of tax dollars. While the vast majority of health care providers are honest, those operating unscrupulously—intent on obtaining precious health care dollars illegally—have done so based on the notion that the risks of being detected have lessened over the years. In 1997, through the Omnibus Consolidated Appropriation Act of 1997 (Public Law 104-208), the U.S. Administration on Aging (AoA) established 12 grant-funded demonstration projects. These projects were designed to recruit and train retired professionals, such as doctors, nurses, teachers, lawyers, accountants, and others to identify and report error, fraud, and abuse. The Senate report (Senate Report 104-368) on the appropriations bill noted that “senior citizens are also our best front line defense against these losses. Yet often they don't have the information and expertise needed…” to recognize and accurately report cases of error, fraud, and abuse. Medicare is more than a health care program. It’s a promise from one generation of Americans to another. Keeping the promise is everyone’s responsibility. KEY TERMS Office of Inspector General (OIG): The HHS (Department of Health and Human Services) agency that is responsible for the investigation of suspected fraud and abuse and performing audits and inspections of HHS programs. The OIG has authority to levy certain sanctions and Civil Monetary Penalties. U.S. Administration on Aging (AoA): The HHS agency that is a focal point and advocacy agency for older persons and their concerns at the Federal level. AoA works closely with its nationwide network of State and Area Agencies on Aging (AAA) to plan, coordinate, and develop community-level systems of services that meet the unique needs of individual older persons and their caregivers. SMP Foundations Training Manual May 2011 Chapter 1 – Page 2
SMP FOUNDATIONS TRAINING MANUAL National SMP Program Overview Since its inception in 1997, the SMP program has evolved from a handful of diverse demonstration projects to a nationwide program. The SMP program includes projects in all 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. Every three years AoA develops a new request for proposals for the SMP program and then competitively awards grants to projects that are selected. Funding for the program is provided by a grant from AoA. In addition, each project is required to provide “matching” contributions of a certain amount. Even though the program has been around for more than a decade, it is still not considered a permanent program. The goal of the SMP program is to empower seniors to prevent health care fraud through outreach and education. SMPs have made great progress in recruiting and training retired professionals and other senior citizens about Medicare and Medicaid error, fraud, and abuse. These volunteers work in their communities, senior centers, and elsewhere to educate Medicare and Medicaid beneficiaries, family members, and caregivers to actively protect themselves against health care fraud, waste, and abuse by reviewing their Medicare Summary Notices (MSNs) to detect and report suspected errors. KEY TERMS Medicaid: A joint Federal and State program that helps with medical costs of people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. Medicare: The Federal insurance program for people 65 years of age and older and certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, abbreviated ESRD) or Amyotrophic Lateral Sclerosis (ALS). Medicare Summary Notices (MSNs): The notices you get after the doctor or provider files a claim for Part A or Part B services in original Medicare. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you may be billed. SMP Foundations Training Manual May 2011 Chapter 1 – Page 3
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