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Home > Grantee Info > Promising Practices From the Field |
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Promising Practices From the Field A number of pioneering strategies and best practice recommendations have been compiled to help serve as a checklist and guidance for projects and organizations involved in health care anti-fraud, error and abuse activities. The following is a summary of the recommendations made during workshop sessions at AoA's National Health Care Fraud and Abuse Control Program Conferences, designed to share issues, strategies, best practices, and the collective thinking of hundreds of individuals and professionals who are working to improve the quality of health care.
• A local kick-off of the initiative should be held off until the network and volunteers are trained and can handle inquiries that might be generated. • Don’t reinvent the wheel. Utilize, as much as possible, the best practices of states and projects which have developed materials and strategies. AoA should play the lead role in helping to exchange information and materials between grantees and partners. • Start small with regional demonstrations. A key challenge is obtaining support from state Medicaid fraud control units. One strategy is to try to gain other state-level support early on in the process, which should then help open up a number of doors with the fraud control units and with other agencies throughout the state. • Initial coordination with state and local groups and agencies is imperative because many are involved in similar efforts. • When forming partnerships, work carefully to develop approaches which can overcome the suspicions frequently held by contractors, fiscal intermediaries, providers, and beneficiaries. • Form coalitions and steering committees to break down turf issues. It is useful to have frequent meetings, involving federal as well as state participants. • Build on existing insurance counseling programs. • AoA should provide a central resource bank. • There is a need for better and more frequent information from CMS regarding rapidly-changing health care systems. Projects should work to collectively convey their information needs to CMS. • Be realistic about what can be accomplished with these small grants and the fact that these anti-fraud and abuse responsibilities are being added on to a series of other staff duties.
• Established Insurance Counseling Assistance (ICA) programs can recruit retired professionals via a "tell a friend" method. Insurance counselors provide a good source of expertise and knowledge, particularly in providing one-on-one counseling as opposed to group presentations. • Recruit through professional organizations (such as retired teachers groups, accountants, nurses, doctors, real estate brokers, etc.), the Retired Senior Volunteer Program (RSVP) and existing senior volunteer programs - take the training to where the people are. • Establish local guidelines for various skill levels of volunteers. Screening at the front end of the recruitment process is important. Be aware that not all volunteers possess the skills that are needed. • Establish a set of principles which outline the ingredients of a successful program and the roles and expectations of volunteers. • Extra effort should be made to recruit non-English speaking volunteers. • Be sensitive to inflammatory or emotionally charged words when recruiting, training, and presenting in communities. Prospective volunteers may be hesitant about participating if confronted with "overzealous" volunteers.
• Retired professionals need background information on the aging and health care networks. There’s also a particular need to educate volunteers about the Medicaid program and related issues. It’s important to have a system for periodically obtaining the most recent information and updating training sessions. • Two-person teams work well. • Give volunteers guidance on how to direct questions back to the project - during the presentation give out phone numbers and easy-to-understand forms. • It is best in geographically large states to begin training in a specific part of the state. This provides projects with feedback before expanding training efforts to other parts of the state. • It is a good idea for volunteers to attend periodic training and follow-up sessions. • Providing shorter, ongoing training seems to be more effective than initiating extensive up-front training. • Make use of existing resources by making an effort to determine what’s available from various agencies. • Utilize different levels of volunteers, based on experience and needs. (Ex.: fraud counselors vs. public information volunteers). • Use the electronic network to do training in many sites, but understand that it does not substitute for personal contact, support, and follow-up. • Establish a support structure for setting appointments - some volunteers set their own appointments, others use a coordinator. • It helps to have a volunteer who is accompanied by a "professional" such as a Medicare carrier, the FBI, the Justice Department, the Office of Inspector General, etc., to make presentations. • Partnering with insurance counseling programs is an ideal way to provide training for volunteers and counselors. • Don’t avoid using providers in training - especially in helping to train staff. • Give pre- and post-tests at each training session to measure whether goals of sessions have been reached. Provide incentives to keep people for the entire training session. One idea is to announce that lottery tickets will be handed out at the end of the training session. • A key word is trust - volunteers need to come across as someone whom beneficiaries can trust. Training should reflect this principle.
• Volunteers are excited at start-up, but follow-through is harder; • Volunteers are sometimes overwhelmed by initial training; • Volunteers and beneficiaries are often frustrated by length of time it takes to resolve a complaint - "I told you what was wrong and you didn’t do anything... " • Successful programs have frequent contact with and support for volunteers - some projects have "call-in" resources who serve as on-site counselors. Others have a "buddy system." • It’s important to have techniques which keep volunteer morale and interest high, such as weekly meetings to discuss cases. Issuing a monthly newsletter helps with volunteer morale. • Utilizing host sites with paid coordinators, if possible, helps volunteers with day-to-day issues and assists them when presentations are done. • Keeping volunteers busy keeps them interested. Find a variety of areas and tasks which challenge volunteer skills. • Provide a regular mechanism for volunteer input and recommendations. Take the time to provide feedback and guidance to volunteers. • "Loyalty" is an essential component of a successful program - periodic training is a way to instill this. One option is to establish an "administration council" of volunteers, which meets monthly. • Distance and time commitments can be a problem. If possible, provide a small stipend or mileage for volunteers as an incentive (though this is difficult given limited budgets). • Highlight local cases of fraud. It helps to create interest. • Recognize and reward volunteer efforts and achievements. Try to get press coverage.
• The curriculum should include a segment not only on Medicare, but on Medicaid. Discuss how Medicaid fraud differs from Medicare fraud, providing trends and examples. • The ICA program is an excellent source of training on Medicare and Medicaid. Medicare carriers and Medicare/Medicaid fraud units are also good resources. • The curriculum should include a section which educates beneficiaries to distinguish and understand what is not fraud. • The curriculum should be reviewed by the advisory committee. • Don’t train volunteers to be experts. Volunteers need not have all the answers, but as resource persons, they should have a basic understanding about where to get information. Training should take this into account. • Standard definitions should be used in the sessions. • Take advantage of internet web sites. Manuals and other materials can be posted and downloaded on the AoA web page. • Training sessions should include videos that are short and to the point (use trained volunteers in the segments) and utilize good anecdotes and examples of fraud and abuse stories tied to the state or locality, if possible.
• Set up outreach partnerships with other states, beneficiaries, providers, AARP, FBI, CMS, OIG, state fraud units, area agencies on aging, and Insurance Counseling Assistance (ICA) programs. Local AARP chapters, for instance, can help arrange sites for presentations. • Get a spokesperson, such as a local politician, to do public service announcements. • Given that Medicaid has no built-in system of outreach, and that beneficiaries are less likely to initiate contacts, particular attention should be focused on strategies for reaching the Medicaid population. • There is a need for appropriate materials targeted to beneficiaries who have some familiarity with the issues, as well as basic introductory information for others.
• Although the media are most responsive to stories about fraud victims, programs should also direct the media to the newsworthy efforts of volunteers. • A national focus is good, but projects need to cultivate local media interest, as well. • Prepare and distribute a series of letters to the editors. • Have media representation on the advisory committee. • AoA should sponsor a national media effort to get Senior Medicare Patrols volunteers. • Establish and maintain a file of people the media can contact for feature stories. • Small newspapers often look for filler and are good resources for getting the word out, but be prepared for articles that may not be totally accurate. People also may misinterpret what they read. Try to keep the message and information simple and to the point.
• Work with contractors to add data fields which can assist grantees in tracking complaints. • Emphasize the "1-2-3 process" for handling inquiries. First, beneficiaries should contact their provider with questions. Second, they should call their Medicare carrier, and third, if the issue is still not resolved, they should use the appropriate fraud hotline. • Spend at least as much effort on complaint-handling and follow-up as is done on promotional items. • It’s important to focus on getting information back to the people who make the complaints. Projects need to set up a consumer feedback system when designing the program, which includes a complaint form, a system for tracking the case, and a system for getting back to beneficiaries to let them know it’s still being investigated. • A key to complaint-handling is having a reliable system which can be readily accessed. Having the backdoor approach to the Inspector General’s hotline for reporting cases is very important. • Setting up a dedicated, all-purpose toll-free number that is answered by a live person is the best way to serve beneficiaries, but this type of system is harder to promote and operate because problems are complex. Projects should therefore provide an informational and screening function which can steer beneficiaries to the proper source of assistance. • Since many people feel guilty or have fears when they report their own doctor, one-on-one support should be readily available. • CMS needs to provide direction to get more state Medicaid agencies involved. • The system must be changed to address the fact that dual-eligible beneficiaries don’t get Explanation of Medicare Benefit Statements (EOMBs). Contractors who wish to get around the law know that this makes it hard to trace errors. Also, suppression of EOMBs and Medicare Summary Notices by CMS should be halted immediately. • Projects need to try to overcome the following issues: • There are few incentives to report Medicaid and Medicare fraud. Even if beneficiaries are aware of possible fraud or errors, many are afraid to report them out of fear of possible repercussions to their health care. • Many advocates are sometimes uncomfortable reporting things that may not follow Medicare guidelines when people who need service are getting a little extra help. • State Medicaid Fraud Control Units look for high profile/high $ cases and many not always be interested in smaller cases of fraud and abuse.
• It’s hard to keep track of who is making referrals where. The system needs to track outcomes across many different phone numbers. • Post-report resolutions are difficult to document, particularly in terms of recovery of dollars to the system. However, the outcomes of this project are not always best measured in actual dollars restored to the Medicare trust fund, but in education provided and improvement of health care in total. The data collection instrument should include these outcomes. • Projects need to get credit for the screening process and valuable information and referral they provide. • In addition to training retired professionals, some Harkin projects also train professionals working in the aging and health care fields. There needs to be a category in the data collection instrument which captures this activity. • The data instrument should have a mechanism to measure in-kind federal and state total resources dedicated to this effort. • Ombudsman training doesn’t get captured or reported, but perhaps it should. • Training should be provided on how to fill out the reporting forms so that it’s consistent across projects. Better and clearer definitions on line items should be contained in the forms. The OIG needs to provide consistent advice on complaint handling. • AoA should ask the OIG for a report on the number of calls over time from a given location.
• There is a need for someone at the federal level to speak with a single voice. • The ICA programs have many names. It might be a good idea to have a nationally recognized or standard name for these programs. • Build fraud and abuse into Medicare Plus Choice training for volunteers. Develop communication and dialogue with CMS on fraud and abuse. CMS and AoA must provide training on fraud as it relates to Medicare Plus Choice and managed care. For example, one grantee found that disabled persons seem to be routinely penalized in managed care through denial of payment. This practice may be a warning for frail elders and it may be especially true for durable medical equipment issues. • Grantees need information on current trends and prosecutions related to fraud and abuse. AoA should provide a monthly or periodic mailing of pertinent information to grantees. • The greatest benefit of this effort is that it provides a support network to investigate complaints. Federal agencies need to partner better together to get regional offices to take this effort seriously. AoA should advocate that entities within the health care system partner with grantees. |
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