The New York Senior Medicare Patrol (SMP) project is part of a nationwide campaign to educate Medicare beneficiaries about the consequences and direct impact of healthcare fraud. Medicare serves over 52 million older adults which constitutes approximately $550 billion dollars in Medicare expenditures; Fraud consititues 3-10% of these expenditures which is approximately $55 billion dollars lost each year.
The SMP purpose is to help Medicare and dually eligible Medicare-Medicaid beneficiaries avoid, detect, and prevent health care fraud. In doing so, they promote integrity in the Medicare program, protect older adults against this fraud and safeguard them from medical identity theft, and large personal financial losses.
SMP Volunteer Complex Interactions Specialist
Purpose: Volunteers who handle complex issues assist Medicare beneficiaries in reporting specific instances of suspected health care fraud, error and abuse. They help beneficiaries distinguish error from potential fraud or abuse and, as a result of their research, may act on a beneficiary's behalf to correct an error or refer suspected fraud and abuse to appropriate authorities. Because SMPs work closely together in a unique relationship with Medicare and Medicare fraud and abuse investigators, they have the ability to provide individual assistance and expedited referrals when beneficiaries report suspected fraud, error, and abuse. Through this relationship, volunteers who handle complex issues respond to beneficiary concerns about health care fraud.
Suggested Activities: Volunteers who handle complex issues respond to beneficiary and caregiver inquiries that involve complaints of fraud, error, and abuse by:
- Interviewing the beneficiary and/or caregiver in person or by telephone
- Obtaining signed release of information form from the beneficiary or beneficiary's designee
- Obtaining detailed information related to the report of fraud, error, or abuse
- Gathering information and documentation about the case, such as Medicare Summary Notices (MSN), Explanation of Benefit (EOB) records, billing statements, other financial records that contain confidential personal identifying information, or legal documentation related to the complaint
- Reviewing and evaluating information and documentation about the case with a SMP volunteer coordinator
- Researching issues using SMP manuals and other Medicare program integrity resources
- Providing completed complex issues form and associated documentation of suspected fraud, error, or abuse to SMP headquarters to be reported in the SMART FACTS reporting and referrals system and for reporting to the appropriate government entity for investigation
- Assessing the case for further investigation and/or referral
- Supporting and following up with beneficiaries as their reported issue moves through the investigation and resolution process
- Research and case management skills
- Ability and willingness to learn and share information related to preventing, detecting, and reporting health care billing mistakes, fraud, and abuse
- Ability to follow case referral protocols
- Ability to work independently
- Computer literacy, including ability to use the Internet and on line reporting programs
Time Commitment: Volunteer schedules are flexible. The local SMP coordinator of volunteers works with each volunteer to determine the number of hours the volunteer works each month, and to schedule assignments accordingly. Because of the training SMP volunteers receive, they are asked to commit to a minimum of one year.
Training/Support: All New York SMP volunteers receive training on the SMP program, Medicare Basics, and Medicare Fraud and Abuse. Volunteers will also be invited to attend update trainings made available by the New York SMP program or other program partner agencies. Volunteers report their activities to a local SMP program coordinator and, when appropriate, to the New York SMP statewide program coordinator. SMP volunteers are welcome to contact their local coordinator or the statewide SMP coordinator at any time with questions or for other support.
Benefits: SMP volunteers receive training on the basics of Medicare and health care fraud, error, and abuse. SMP Complex Issues Volunteers receive additional training on case development and management skills, and procedures for referring complaints for further investigation. All SMP volunteers have the satisfaction of participating in a national effort to educate and empower Medicare beneficiaries, their caregivers, and the general public about health care fraud, errors, and abuse. They receive recognition for their contributions to the program.
- Case Work / Management
- Administrative Support
Good Match For
People 55+ Group
Requirements & Commitment
- Orientation or Training