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When Dick Hilton retired, he left 40 years of medical billing behind. He explored volunteer activities , signing up with a local chapter of Meals on Wheels. There, he heard about another volunteer option--in a familiar field. He couldn't stay away.
"I just fell into what I was naturally good at, which is billing and coding and helping people," Hilton said.
For the past 5 years, the retiree has been logging hours with the Maine Senior Medicare Patrol (SMP). Part of a nationwide Administration on Aging initiative, the program enlists senior citizens to combat Medicare fraud by educating and counseling beneficiaries about risks and red flags. It's one of several strategies to quell the rising incidence of fraud and abuse--and a fitting role for HIM retirees.
Rampant Risk
Medicare fraud is a widespread and costly trend; false claims and improper billing bilk taxpayers out of $60 billion per year, according to estimates. Offenses range from double billing for devices to charging for services never rendered, with suspects pooling millions to purchase cars and luxury items on the government buck.
In recent years, national and local officials has been ramping up efforts to capture fraudsters and protect vulnerable beneficiaries. The Department of Health and Human Services (HHS) teamed up with the Department of Justice last May to launch the Health Care Fraud Prevention and Enforcement Action Team, which builds upon existing fraud fighting efforts. In the meantime, SMP volunteers have been waging a war on fraud from the home front.
Targeting Peers
SMP volunteer roles vary by location and skill; some focus on delivering presentations to senior communities, while others specialize in one-on-one consultations. "Education is a huge component of the program," said Rebecca Nurick, SMP project coordinator for Pennsylvania, who enlists volunteers to speak at senior centers, Rotary clubs, churches and other beneficiary gatherings. 
Terri Ivers, a volunteer from Langhorne, PA, got involved because she had public speaking skills and a history in government. "I have a very strong feeling about justice and law," she said.
Ivers now conducts presentations and volunteers at health fairs several times a year to inform Medicare beneficiaries about the risks and signs of fraud, plus how to investigate potential billing errors. Numerous audience members have thanked her after the presentation, noting that they had no idea of their personal responsibility to read and check Medicare summary notices. "It's gratifying," Ivers said. "It's an ego boost, as well as a feeling that you are doing something constructive for society."
The talks have also opened eyes to medical device scams. Ivers pointed out that many device companies overbill Medicare to make up the 20 percent that's not reimbursed by the government payer; many seniors just think they're getting it free.
That being said, "Not every problem is fraud; errors do occur," Nurick noted. "We want to make people aware, first of all, most providers, doctors, hospitals are honest; they want the best for their patients. But errors do occur, so we want to try and determine: is this an error, and is this something we can correct?"
"A Natural" for HIM
To ensure volunteers are giving accurate, up-to-date information, SMP conducts preliminary and ongoing training on Medicare rules and regulations. By the time they head out, all volunteers are well-equipped to field questions, but those with coding and billing backgrounds bring something extra. "It's a natural for them," Hilton said. "They have a leg up on most volunteers because most volunteers just help people with complaints, whereas [coders] can actually see the problem."
Hilton worked for Medicare before starting his own billing and consulting company, so he already knew the ins and outs of benefits and where to find payer updates. As a volunteer for the SMP, he speaks publicly and meets one-on-one with beneficiaries to talk about everything from potential fraud to prescription costs. Seniors notice an air of confidence about Hilton, which makes them more comfortable about sharing personal and financial information. "The more knowledgeable a person is, such as coders, the easier it is for the patient to open up," he said.
Maine isn't rife with Medicare fraud--abuse, or unintentional error, is more often the problem, according to Hilton--but the program is making a difference nationwide. Now in its 13th year, SMP has saved beneficiaries more than $105.7 million, due largely in part to the efforts of volunteers. Last August, Ivers and Hilton were among 10 SMP volunteers honored by HHS for their dedication to fraud prevention.
Still, more volunteers are needed, Hilton said, and HIM professionals have an ideal background to fit the bill. "It's so important that when [coders] come out and retire, that's one thing they really should go after--for patients," he said.
Cheryl McEvoy is an assistant editor with ADVANCE.
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