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Fact Sheets

U.S. Department of Health and Human Services
August 2, 2000
Contact: Moya Benoit Thompson or Chris Rhatigan 202-401-4541

Anti-Fraud and Abuse Initiatives

Overview
The General Accounting Office estimates that billions of Medicare dollars are lost each year to waste, fraud and abuse. These losses are due, to a large extent, to the many ways in which the funds are dispersed as well as to the sheer magnitude of health care expenditures. Since 1993 the Clinton Administration has focused much attention on fighting waste, fraud and abuse which has led to a series of investigations, indictments and convictions, as well as new management tools to identify wasteful mispayments to health care providers.

In 1995, the Administration on Aging (AoA) became a partner in a government-led effort to fight fraud, waste and abuse in the Medicare and Medicaid programs through the implementation of a ground-breaking demonstration project called Operation Restore Trust (ORT). ORT’s purpose is to coordinate and target federal, state, local and private resources on those areas most plagued by abuse. President Clinton announced Operation Restore Trust at the 1995 White House Conference on Aging.

During its demonstration phase, ORT has returned $23 for every $1 spent looking at the fastest growing areas of Medicare, including home health care, skilled nursing facilities, and providers of durable medical equipment. This comprehensive anti-fraud initiative began in five states--California, Florida, Illinois, New York and Texas. It has created a partnership in the Department of Health and Human Services between the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), the Office of Inspector General, and the Administration on Aging which are working as a team to carry out ORT. Other critical partners in this effort include the U.S. Department of Justice, state Medicaid agencies, state survey and certification agencies, Medicare contractors, State and Area Agencies on Aging, and other members of AoA's national aging network, including long-term care ombudsman.

AoA and Operation Restore Trust

The AoA and its national aging network, which includes 57 State Units on Aging (SUAs), 655 Area Agencies on Aging (AAA’s), 221 Tribal Organizations, representing over 300 tribes, and thousands of service providers, play a key role in providing important home and community-based services to older Americans on a daily basis.

The AoA focused its initial anti-fraud and abuse efforts on training state and local ombudsmen and ombudsmen volunteers to recognize and report suspected cases of fraud and abuse in nursing homes. It later expanded its efforts by providing training to other aging network personnel, including staff and volunteers of State and Area Agencies on Aging, health insurance counselors, and other service providers.

Throughout the demonstration stage of ORT, AoA staff trained an estimated 2,500 people in the five ORT states, which contributed to the overall collection of $187 million in fines, recoveries, settlements, audit disallowances and civil monetary penalties owed to the federal government.

The Health Care Waste, Fraud and Abuse Community Volunteer Demonstration Program

The AoA has been able to continue to play a key role in this Administration's ongoing anti-fraud efforts through the enactment of P.L. 104-209, the Omnibus Consolidated Appropriations Act of 1997. Language in this legislation, offered by Senator Tom Harkin (D-IA), was adopted, directing the AoA to establish demonstration projects that utilize the skills and expertise of retired professionals in identifying and reporting waste, fraud and abuse.

These projects are designed to recruit and train, retired professionals, such as doctors, nurses, teachers, lawyers, accountants, and others, to work with their peers in senior centers and other places where older persons gather. In May of 1997, the AoA first awarded funds to 12 agencies and organizations for this purpose.

Based on the success of these activities, in June, 1999, the AoA awarded 41 grants, totaling $7 million, to expand funding to 29 new and 12 renewed community-based programs. Known as the "Senior Medicare Patrol Projects," these grants operate in 36 states, plus Washington, D.C. and Puerto Rico to train retired volunteers to work as community resources in the identification of waste, fraud, and abuse.

In June 2000 the AoA awarded 7 more grants, bringing the total to 48 projects, operating in 43 states plus Washington, D.C. and Puerto Rico. Volunteers work in their communities and in local senior centers to help identify deceptive health care practices, such as overbilling, overcharging, or providing unnecessary or inappropriate services. Senior volunteers undergo several days of training reviewing health care benefit statements and outlining steps individuals can take to protect themselves.
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