Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Implementation of the 
Administration on Agings 
Health Care Fraud and Abuse Programs 
JUNE GIBBS BROWN 
Inspector General 
AUGUST 1999 
OEI-02-99-00111  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York regional office prepared this report under the direction of John I. Molnar, 
Regional Inspector General, and Renee C. Dunn, Deputy Regional Inspector General.  Principal 
OEI staff included: 
REGION  HEADQUARTERS 
Jodi Nudelman, Project Leader  Susan Burbach, Program Specialist 
Judy Lin  Linda Hall, Program Specialist 
Lucille Cop 
To obtain copies of this report, please call the New York Regional Office at (212) 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To describe the implementation of the Administration on Agings (AoA) two health care fraud 
and abuse control programs and to identify common problems and effective practices. 
BACKGROUND 
The AoA asked the Office of Inspector General (OIG) to assess the implementation and 
performance of its two health care fraud and abuse control programs:  the Health Care Anti-
Fraud, Waste, and Abuse Community Volunteer Program and the Health Insurance Portability 
and Accountability Act (HIPAA)-funded Program.  The AoA will use this information to develop 
guidance for current and future projects and to inform Congress and others about the programs 
performance. 
Both of these programs aim to educate beneficiaries about health care fraud, waste, and abuse but 
operate somewhat differently.  The community volunteer program received $2 million and 
provided grants to 12 organizations to recruit and train retired professionals to educate Medicare 
beneficiaries about health care fraud, waste, and abuse.  This program has recently been expanded 
to $7 million.  The second program received $1.4 million in funding under the Health Insurance 
Portability and Accountability Act of 1996 and provided grants to 18 State units on aging.  The 
goal of this program is to train aging network staff and volunteers to educate Medicare 
beneficiaries about health care fraud, waste, and abuse as part of their ongoing activities. 
In response to AoAs request, the OIG developed two reports.  The following report describes 
the implementation of the two anti-fraud and abuse programs including problems projects 
encountered and practices they developed to overcome these barriers.  A companion report 
entitled, The Administration on Agings Health Care Fraud and Abuse Programs: 18-Month 
Outcomes OEI-02-99-00110, presents 18-month performance data for the two programs. 
FINDINGS 
Organization 
Projects in the two programs followed somewhat different approaches, although overlap 
was evident.  The community volunteer projects generally implemented a train-the-trainer 
approach.  All but one project recruited retired seniors who were new volunteers to the aging 
network.  These  projects trained seniors who then conducted group presentations to educate 
1
 Medicare beneficiaries and others about health care fraud and abuse.  In addition, all of the 
community volunteer projects also trained staff and volunteers in the existing aging network. 
In contrast, the HIPAA-funded projects primarily trained staff and volunteers in the existing aging 
network.  These individuals typically met with Medicare beneficiaries and their family members 
one-on-one and educated them about fraud and abuse as part of their ongoing responsibilities.  In 
addition, about a quarter of the HIPAA-funded projects also recruited and trained new retired 
seniors who conducted group sessions to educate Medicare beneficiaries. 
Projects in both programs utilized existing aging network resources.  All but one project built 
on existing aging programs.  They most commonly used Area Agencies on Aging (AAAs) and 
insurance counseling programs in their States.  To a lesser extent, they utilized senior centers and 
ombudsman programs.  About a third of the projects built on two or more of these aging network 
resources. 
Partnering 
Projects partnered with a variety of organizations to support project goals.  Programs used 
partnerships to establish and operate their projects.  Projects commonly formed partnerships with 
aging network programs, fraud and abuse agencies, health care organizations, and senior 
advocacy organizations.  Partners helped projects recruit and train beneficiaries and handle and 
track complaints. 
Training Trainers 
Training for trainers appeared comprehensive, although its intensity differed across 
projects.  Training typically included an overview of Medicare and Medicaid and a discussion of 
how to detect and report instances of health care waste, fraud, and abuse.  Projects conducted this 
training differently, however.  In some projects, staff were responsible for conducting the training, 
whereas in others, Medicare carriers and other investigative agencies led the training.  In general, 
the training provided by the community volunteer projects was more intensive than that provided 
by the HIPAA-funded projects. 
Complaint-Handling 
Projects had different strategies to handle complaints.  The majority of the projects were 
affiliated with or operated a State or local hotline that Medicare beneficiaries could call to report a 
suspected instance of health care fraud or abuse.  Some projects took complaints directly from the 
beneficiary and sent them to the appropriate investigative agency.  Other projects instructed 
beneficiaries to call their Medicare carrier or the OIG Hotline directly. 
2
 Tracking 
Most projects did not routinely track complaint outcomes.  The majority of projects did not 
systematically track outcomes of complaints.  Several projects had some type of tracking system 
in place, however.  Most of these projects developed partnerships with key agencies and 
discussed the status of complaints with them.  One project was in the process of developing a 
tracking system on the Internet.  Two other projects trained staff at the carriers customer service 
hotline to better track complaints resulting from their efforts. 
Almost all projects received little or no feedback about complaint outcomes.  Not getting 
feedback about complaints was the most common problem cited among projects.  Many projects 
stressed that they routinely referred complaints to the Medicare carrier or the appropriate 
investigative agency, but received little or no information about their status. 
CONCLUSION 
The HIPAA-funded and community volunteer projects have conducted a wide array of activities 
to help fight health care fraud, waste, and abuse.  Despite these differences, it appears that well-
structured projects address several common programmatic elements.  These elements include 
organizing and start-up, partnering, recruiting trainers, training trainers, educating beneficiaries, 
community outreach, complaint handling, and tracking. 
At this stage, it appears that a number of different approaches can be successful and that there is 
not one way to operate a project.  This report therefore highlights the varied strategies and 
practices implemented by the individual projects.  This information will give projects the 
opportunity to learn from one another.  It will also give AoA the ability to provide guidance to 
new projects that will enable them to get off to a running start and avoid delays. 
Additionally, as part of their ongoing implementation efforts we encourage AoA, through their 
regional offices, to: 
<	 Make sure that all projects address the key programmatic elements and provide 
guidance to projects in the areas that they have not yet developed. 
<	 Pay closer attention to tracking.  Specifically, AoA needs to impress upon the 
individual projects the importance of tracking outcomes.  It also needs to identify and 
disseminate effective ways to track trainers activities and complaint outcomes so that 
projects can better document the outcomes of their efforts. 
<	 Provide guidance about ways to improve retention of trainers and about working with 
minority communities and with providers to expand projects efforts. 
3
 COMMENTS 
We received comments from AoA.  They agreed with the major conclusions and are working 
with their grantees and OIG to replicate effective practices.  The full text of these comments 
can be found in Appendix B. 
4
 T A B L E  O F  C O N T E N T S  
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FINDINGS 
Organization and Start-up  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Partnering  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Recruiting Trainers  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Training Trainers  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Educating Beneficiaries  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Community Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Complaint-Handling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Tracking  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

AoAs Guidance  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  23

APPENDICES 

A.  List of Health Care Fraud and Abuse Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

B. AoAs Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

5
 I N T R O D U C T I O N  
PURPOSE 
To describe the implementation of the Administration on Agings (AoA) two health care fraud 
and abuse control programs and to identify common problems and effective practices. 
BACKGROUND 
The AoA asked the Office of Inspector General (OIG) to assess the implementation and 
performance of its two health care fraud and abuse control programs:  the Health Care Anti-
Fraud, Waste, and Abuse Community Volunteer Program and the Health Insurance Portability 
and Accountability Act (HIPAA)-funded Program.  The AoA will use this information to develop 
guidance for current and future projects and to inform Congress and others about the programs 
performance. 
The AoA asked the OIG to evaluate the implementation and performance of its anti-fraud 
initiatives for several reasons.  First, this information is a continuation of other work conducted by 
the OIG.  At AoAs request, the OIG helped develop performance measures for the community 
volunteer program and agreed to collect these data on an ongoing basis.  Second, the results of 
the report that presented first year performance data entitled, Health Care Anti-Fraud, Waste, 
and Abuse Community Volunteer Program: First Year Outcomes OEI-02-97-00522, generated 
interest in implementation issues.  This report found that first year performance varied widely 
among the 12 projects, suggesting that the projects implemented the program differently or that 
some had slower starts than others.  Third, Congress recently expanded the community volunteer 
program and AoA is currently selecting new grantees.  As a result of these factors, AoA believed 
that it was an important time to look at these issues. 
To meet these objectives, the OIG developed two reports.  The following report describes the 
implementation of the two anti-fraud and abuse programs including problems projects 
encountered and practices they developed to overcome these barriers.  A companion report 
entitled, The Administration on Agings Health Care Fraud and Abuse Programs: 18-Month 
Outcomes OEI-02-99-00110, presents 18-month performance data for the two programs. 
Operation Restore Trust 
In 1995, AoA became a partner in a OIG-led demonstration project to fight fraud, waste, and 
abuse in the Medicare and Medicaid programs called Operation Restore Trust (ORT).  This two-
6
 year demonstration program focused on combating health care fraud, waste, and abuse in five 
States.  This initiative showed that Medicare beneficiaries and others could play an important role 
in curbing losses to the Medicare and Medicaid programs by becoming better educated about how 
to identify and report suspected instances of fraud and abuse. The results of the demonstration 
program encouraged AoA to continue and to expand its efforts. 
Health Care Anti-Fraud, Waste, and Abuse Community Volunteer Program 
Congress authorized the Health Care Anti-Fraud, Waste, and Abuse Community Volunteer 
Demonstration Program in the Omnibus Consolidated Appropriation Act of 1997 (P.L. 104-208) 
to further reduce fraud and abuse in the Medicare and Medicaid programs.  At that time, the 
Senate Committee believed that thousands of retired accountants, health professionals, 
investigators, teachers, and others could serve as community volunteers in this effort.  More 
specifically, these retired professionals, with appropriate training, could serve as Medicare 
educators and as expert resources to assist Medicare beneficiaries and others to detect and report 
fraud, waste, and abuse.  Because the language for this program was introduced by Senator Tom 
Harkin of Iowa, these grants are commonly known as Harkin Projects.  For this inspection, they 
are referred to as the community volunteer projects. 
To fund this program, the Senate Report (104-368) directed that $2 million be transferred to AoA 
from the Health Care Financing Administrations (HCFA) research and demonstration budget.  In 
July of 1997, AoA awarded grants to 12 organizations including two area agencies on aging, six 
State units on aging, and four private aging organizations. This report is based on these 12 
projects. 
As of October 1998, the program was expanded.  Under Title IV of the Older Americans Act in 
the FY1999 Omnibus Appropriations Act, funding for the program was increased to $7 million, 
significantly extending the scope of the program.  The AoA is currently reviewing applications 
and selecting grantees for this new round of funding.  These projects will be called the Senior 
Medicare Patrol Projects. 
HIPAA-Funded Program 
The AoA developed a second set of projects that are funded under the Health Insurance 
Portability and Accountability Act of 1996.  The goal of these projects is to combat health care 
fraud, waste, and abuse by training aging network staff and volunteers to educate Medicare 
beneficiaries.  In August 1997, AoA awarded grants to 15 State units on aging.  In March 1998, 
the program was expanded to include three additional States.  The program received a total of 
$3.8 million for the first three fiscal years.  In FY 99, $1.4 million in funding was provided. 
About $900,000 of these funds was granted to State units on aging.  The remaining funds were 
used by AoA for training and technical assistance for the grantees, for facilitating the exchange of 
resources, for identifying best practices, for convening national and regional partnership 
conferences, and for developing and disseminating informational materials. 
7
 It is important to note that the two programs differ in several ways.  First, the HIPAA-funded 
projects primarily train aging network staff and volunteers who educate Medicare beneficiaries as 
part of their ongoing activities.  In contrast, the community volunteer projects recruit and train 
retired seniors who conduct group sessions to educate Medicare beneficiaries.  Second, the 
HIPAA-funded projects are run solely by State agencies, whereas the community volunteer 
projects  are operated by State, local, or non-profit agencies.  Third, the HIPAA-funded projects 
receive less funding than the community volunteer projects.  Specifically, AoA awarded $50,000 
annually to HIPAA-funded projects and between $100,000 and $188,000 per year to community 
volunteer projects. 
Performance Measures 
With the assistance of AoA and the 12 projects, OIG developed a set of performance measures 
for the community volunteer projects.  (See Health Care Anti-Fraud Volunteer Project 
Performance Measures OEI-02-97-00520.)  To provide ongoing information about the program, 
the OIG asked each of the projects to provide data on these agreed upon performance measures 
on the 12, 18, 24, and 30 month anniversary of the initial grant.  As mentioned earlier, first year 
outcomes are presented in the OIG report entitled, Health Care Anti-Fraud, Waste, and Abuse 
Community Volunteer Program: First Year Outcomes OEI-02-97-00522. 
Westat, Inc. a private research corporation under contract with AoA, developed performance 
measures for the HIPAA-funded projects.  Westat, Inc. collected preliminary outcome data for 
the first year and is currently conducting a longer-term evaluation of both fraud and abuse control 
programs.  This evaluation will provide a more in-depth analysis of the implementation and impact 
of the two programs. 
METHODOLOGY 
This inspection was conducted in several phases.  First, OIG staff collected performance data 
from the 12 community volunteer projects and 17 HIPAA-funded projects for the first 18 months 
of the programs.  See Appendix A for a list of all projects.  Note that the New York State Unit on 
Aging which received funding from both programs is considered a community volunteer project 
for the purposes of this report. 
Second, we asked AoA for the projects most recent semi-annual report that they submitted as 
part of AoAs reporting requirements.  Whenever possible, we compared these reports to their 
performance data to check for consistency. 
Third, we interviewed staff from each project.  We conducted interviews with staff members from 
selected projects on-site and interviewed the others by telephone.  We asked project staff about 
their experiences with implementing the program and about problems that they have had.  We also 
8
 asked them to identify practices that have been effective, particularly in tracking outcomes. 
This report is primarily based on data from the staff interviews and reflects the first 18 months of 
most programs.  (Three projects, LA, NJ, and OR, are included that have been in operation for 
only one year.)  Data from the other sources were also analyzed to validate the interview data and 
to further identify problems and effective practices.  As mentioned, the performance data are 
discussed in detail in our companion report entitled, The Administration on Agings Health Care 
Fraud and Abuse Programs: 18 Month Outcomes OEI-02-99-00110. 
Limitations 
There are several limitations of this inspection.  First, the performance data used in this report are 
self-reported and were not independently verified.  Second, certain projects may be used as 
examples for specific activities but may not necessarily represent an exhaustive list of all projects 
that conduct such activities.  Third, the methodology used to identify effective practices does not 
guarantee that a particular practice can be replicated and that it will work as well in a different 
setting.  Lastly, the methodology cannot sufficiently determine whether a successful practice is the 
result of a particular activity or of the characteristics of the practitioners. 
This inspection was conducted in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
9
 F I N D I N G S  
Organization and Start-up 
Projects in the two programs followed somewhat different approaches, although overlap 
was evident. 
The community volunteer projects generally implemented a train-the-trainer approach.  All but 
one project recruited retired seniors who were new volunteers to the aging network.  These 
projects trained these seniors who then conducted group presentations to educate Medicare 
beneficiaries and others about health care fraud and abuse.  In addition, all of the community 
volunteer projects also trained staff and volunteers in the existing aging network.  These 
individuals included State and local long-term care ombudsmen, health insurance counselors, 
senior center volunteers, and others who worked directly with seniors. 
The HIPAA-funded projects focused their efforts somewhat differently.  These projects primarily 
trained staff and volunteers in the existing aging network.  These individuals typically met with 
Medicare beneficiaries and their family members one-on-one, and educated them about fraud and 
abuse as part of their ongoing responsibilities.  In addition, about a quarter of the HIPAA-funded 
projects also recruited and trained new retired seniors who conducted group sessions to educate 
Medicare beneficiaries. 
Projects in both programs utilized existing aging network resources. 
All but one project built on existing aging programs.  In general, the projects in both programs 
utilized similar aging network resources.  They most commonly used area agencies on aging 
(AAAs) and insurance counseling programs in their States.  To a lesser extent, they utilized senior 
centers and ombudsman programs.  About a third of the projects built on two or more of these 
aging network resources. 
As noted, the community volunteer program funded different types of organizations to test 
various approaches to educating seniors.  The grantees that received funding included six State 
units on aging, four  private agencies for seniors, and two local AAAs.  There was no relationship 
between the type of organization of the project and the type of program that the project chose to 
work with. 
10
 Projects faced several challenges in starting up their programs. 
One of the most common problems for projects in both programs was staffing.  At least seven 
projects had difficulty hiring project staff or had problems with staff turnover which caused slow 
starts or delays in implementation.  Additionally, a few of the HIPAA-funded projects stressed 
that their resources were limited, particularly as they tried to develop their program statewide. 
A few projects struggled with the logistics of coordinating a statewide project.  Projects seemed 
to approach this problem in two ways.  The HIPAA-funded project in Pennsylvania, for example, 
tested the program in a few counties before starting to implement it statewide.  In contrast, the 
New York project chose to operate the program in a larger area from the start. 
A few projects also had difficulty in gaining the support of the provider community.  Providers 
initially believed that the program was out to get them.  This issue also affected projects attempts 
to create partnerships.  In one State, for example, the AAAs were reluctant to cooperate with the 
project because they did not want to alienate providers in their area.  In response to this situation 
and to similar incidences, a few projects took the time to develop a more balanced message that 
addressed providers concerns. 
Some projects commented that planning was extremely important to overcoming several start-up 
problems.  Clearly defining the roles of staff and volunteers helped projects operate more 
smoothly.  It was also helpful for projects to plan how they were going to handle and track 
complaints and to clearly map out the flow of information before they started implementing their 
efforts. 
Partnering 
Projects partnered with a variety of organizations. 
Partnerships were an important tool that projects used to establish and operate their programs. 
As mentioned, projects in both programs partnered or built on existing aging network resources 
including local AAAs and health insurance counseling programs.  Projects also contracted with or 
used the ombudsman programs and senior centers to administer their programs. 
Projects in both programs formed partnerships with other organizations as well to help fight 
health care fraud, waste, and abuse.  These organizations commonly included fraud and abuse 
agencies such as the OIG, the Department of Justice (DOJ), the Federal Bureau of Investigations 
(FBI), the U.S. Attorney General, and health care organizations such as Medicare carriers, 
intermediaries, Durable Medical Equipment Regional Carriers (DMERC), and State Medicaid 
Fraud Units.  Projects also reached out to other types of organizations, namely, the American 
Association of Retired Persons (AARP), senior advocacy groups, and the Retired Senior 
Volunteer Program (RSVP).  A few projects collaborated with State agencies, provider groups, 
11
 or consumer rights organizations such as the Office of Consumer Affairs and the Better Business 
Bureau. 
Partnerships helped expand project resources and support project goals. 
Partners helped projects in various ways.  Several projects created advisory boards, steering 
committees, or joined existing task forces that included many of their partners.  In this capacity, 
partners provided guidance and expertise to projects, helping them plan and implement their 
efforts.  Partners also introduced staff to agencies responsible for fraud and abuse and for health 
care, a key step towards building a State infrastructure to address these issues. 
In addition, partners played an important role in the operation of programs.  They often helped 
projects recruit seniors.  They developed and reviewed training and other project materials, 
including brochures and pamphlets that were disseminated to the public.  In some projects, 
partners were directly responsible for training volunteers. They also helped develop complaint 
handling and tracking systems and iron out problems in these areas.  Some projects used the 
contacts they developed to follow-up on and track complaints that they referred to the different 
agencies.  Lastly, partners kept projects abreast of current issues in Medicare as well as new 
trends and fraud scams in health care. 
Some projects had difficulty establishing partnerships and getting diverse agencies to agree on key 
issues.  One project noted that it was challenging to merely get the different agencies to cooperate 
and make fraud and abuse a priority.  Projects particularly had difficulties with partners in 
developing their complaint handling and tracking systems.  Despite these issues, several projects 
highlighted the importance of forming partnerships.  These projects often made substantial 
investments in establishing and maintaining these relationships, but generally believed their efforts 
were well worth it. 
Recruiting Trainers 
Projects looked to the aging network and to other organizations for trainers. 
As noted, many of the projects, particularly in the HIPAA-funded program, recruited and trained 
existing aging network staff and volunteers to be trainers.  These individuals were typically from 
local AAAs, senior centers, ombudsmen programs, and health insurance counseling programs. 
Projects that recruited new retired seniors commonly looked to senior centers and organizations 
that recruited or had existing volunteers.  Projects also advertised on the radio and in newspapers 
for trainers.  Additionally, some seniors heard about the program from other trainers and from the 
projects other outreach activities. 
Many projects had difficulty recruiting trainers, particularly in the beginning stages of their 
program.  In a few cases, trainers believed projects were recruiting them to be Medicare cops or 
12
 fraud busters.  Volunteers, particularly those in the existing aging network, were sometimes 
reluctant to participate in the program for this reason.  Other projects had difficulty with finding 
trainers who were dedicated and willing to do presentations. 
Projects offered several suggestions about how to overcome these barriers and effectively recruit 
trainers.  Projects had success with working with agencies that had existing sources of senior 
volunteers.  Specifically, the three projects, Iowa, Pennsylvania, and Virginia, partnered with 
RSVP which recruited and placed volunteers in different agencies throughout the community. 
Some projects worked with AARP or used lists from the National Association of Retired Federal 
Employees or the Retired Teachers Union to recruit trainers.  In addition, projects from both 
programs stressed the importance of tapping into the aging network for trainers to capitalize on 
volunteers experience working with seniors and expertise in health care issues.  Several projects 
also noted that it was critical to recruit trainers from diverse backgrounds in order to reach 
different audiences in their communities. 
Most projects had requirements to become a trainer. 
Volunteers and staff who were already part of the aging network had to meet certain criteria in 
order to be selected for those programs.  Generally, they were not allowed to have worked in the 
insurance industry or have any conflict of interest relating to the goals of the program. 
Most projects also screened new retired seniors who wanted to become trainers.  Five projects 
required them to have good communication skills. A few projects preferred seniors who already 
had some knowledge of health care.  Among the community volunteer projects, only four required 
their trainers to be retired professionals i.e. teachers, accountants, investigators and health 
professionals.  The remainder of the projects welcomed all retired seniors, indicating that they did 
not believe it was appropriate to limit their program in this manner.  One project noted that having 
requirements for trainers gave the program a certain prestige and ensured that trainers were 
competent. 
Training Trainers 
Training for trainers appeared comprehensive. 
Training for trainers seemed fairly extensive in most projects.  Training for retired seniors new to 
the aging network typically included an overview of Medicare and Medicaid and a discussion of 
health care fraud and abuse.  The training also explained how to detect and report inconsistencies 
and suspected instances of fraud, waste, or abuse.  In some cases, the training also covered issues 
relating to durable medical equipment and home health services.  A few projects instructed 
trainers and provided helpful hints about how to give presentations.  In some projects, training for 
existing aging network volunteers was more focused and specifically addressed how to identify 
and report health care fraud and abuse. 
13
 Projects conducted training somewhat differently. 
In general, the training provided by the community volunteer projects was more intensive than 
that provided by the HIPAA-funded projects.  Training conducted by the community volunteer 
projects ranged from 4 to 32 hours, with a median of 16 hours.  In contrast, training conducted by 
the HIPAA-funded projects ranged from 1 to 36 hours, with a median of 6 hours. 
Projects also organized their training somewhat differently.  In 12 projects, project staff were 
responsible for conducting the training.  In eight projects, outside agencies led the training 
sessions.  These agencies commonly included representatives from the Medicare carriers, 
intermediaries, DMERCs, the HCFA and OIG Regional Offices, Peer Review Organizations, the 
FBI, the U.S. Attorney Generals Office, and local law enforcement agencies.  In the remaining 
projects, staff led sessions but invited individuals from these agencies to assist them. 
Several projects stated that having partners participate in the training had many advantages.  One 
project commented that having the FBI provide training gave their program more weight and 
made their trainers feel important.  Partners also provided projects with experts in their related 
fields as well as helpful training aids such as overheads and brochures. 
Projects came up with a number of innovative practices for training trainers.  Many projects 
produced extensive manuals that trainers used as references and as presentation aids.  Two 
projects used experienced trainers to help train newer recruits.  Another project administered a 
pre and post test to assess trainers knowledge of the program.  The project used these results to 
focus their training and to make sure trainers were getting the intended message. 
Projects provided somewhat limited support for trainers. 
Many projects provided only minimal support for trainers.  Most commonly, they provided 
materials for them to present.  Less than half of the projects, however, reported having a 
coordinator, supervisor, or a telephone number available for trainers to call for assistance. 
Some of the community volunteer projects provided additional support for trainers. These 
projects offered follow-up training or refresher courses.  They also sent out newsletters or 
mailings or conducted meetings to update volunteers on new statistics and changes in regulations 
and laws.  Four community volunteer projects arranged presentations for their trainers or 
advertised that speakers were available to talk about fraud and abuse.  In addition, the community 
volunteer project in Pennsylvania provided a small stipend to its trainers.  The Illinois project, as 
well as the HIPAA-funded project in Florida, reimbursed trainers for their travel expenses. 
Recognition of trainers efforts differed significantly between the two programs.  Almost all of the 
community volunteer projects provided some incentives or recognition for their trainers. Most 
commonly, they featured trainers in their newsletters, invited them to project-related events, and 
gave them certificates or small gifts of appreciation.  Most of the HIPAA-funded projects did not 
specifically recognize trainers achievements, but some suggested that local aging programs did so 
14
 as part of their other activities. 
Retention of trainers appeared to be a significant problem. 
Not all trainers conducted activities after they were trained.  As discussed in the companion 
report, the performance data indicated that projects in both programs had difficulty keeping 
trainers involved in the project.  Specifically, half of the community volunteer projects reported 
that less than one-quarter of trained volunteers had ever conducted activities to educate others. At 
least six of the HIPAA-funded projects also had difficulty retaining trainers. 
At the same time, few projects had suggestions about how to improve retention.  Moreover, our 
analysis showed that retention of trainers in the community volunteer projects was not associated 
with the intensity of the training provided nor was it related to the level of support projects 
provided to trainers.  Additionally, in both programs, retention was not related to whether 
projects had any incentives or forms of recognition for their trainers. 
Educating Beneficiaries 
Projects reached Medicare beneficiaries through various channels. 
One of the primary goals of both programs was to educate beneficiaries about health care fraud 
and abuse.  As mentioned, projects informed beneficiaries who were participating in or receiving 
other aging services. They also conducted larger informational sessions to educate beneficiaries. 
Projects used different strategies to recruit beneficiaries and family members to attend sessions 
about health care fraud and abuse.  Most commonly, they approached senior centers, senior 
residences, nutrition sites, aging advocacy groups such as AARP, senior clubs, retiree 
organizations such as the Retired Teachers Association, church groups, and care-giver support 
groups.  In some projects, volunteers were responsible for recruiting beneficiaries. 
Projects also used the media to recruit beneficiaries.  (These same methods were used to attract 
volunteers.)  Projects aired public service announcements, conducted mass media events, and 
wrote articles about the program in newsletters and other publications.  Some projects conducted 
mass mailings targeted towards the aging population that invited beneficiaries to informational 
sessions.  Many of the projects also relied on contacts their partners had already established in 
their communities. 
15
 Most projects conducted group and one-on-one sessions to educate Medicare beneficiaries. 
The majority of projects used both types of sessions to educate beneficiaries and their family 
members about health care fraud and abuse.  The community volunteer projects were more likely 
to conduct both types of sessions than the HIPAA-funded projects. 
Group Sessions:  In general, group sessions covered the same topics as the training that was 
provided to the trainers, although they tended to be shorter and more interactive.  A typical 
session consisted of a brief overview of the Medicare and Medicaid programs. Trainers then 
showed beneficiaries how to read their Explanation of Medicare Benefits (EOMB) or Medicare 
Summary Notices (MSN), and how to report any inconsistencies.  Specifically, trainers taught 
beneficiaries to look for instances of double billing, upgrading, or billing for services not provided. 
Trainers either presented this information alone or as part of a larger session that included other 
topics relevant to seniors.  Depending upon these factors, sessions usually ranged from 20 minutes 
to over an hour. 
Trainers often tried to get beneficiaries to participate in these sessions.  To do this, they described 
common scenarios and asked about beneficiaries own experiences.  Several projects showed a 
video to highlight key points and to help get the projects message across.  Additionally, trainers 
often took questions and answers, or offered one-on-one assistance following their presentation. 
One-on-one Assistance:  Trainers who were often health insurance counselors or ombudsmen 
typically met with beneficiaries one-on-one for a variety of reasons.  During these sessions, 
trainers answered questions about Medicare and often showed beneficiaries and family members 
how to identify and report suspected instances of fraud, waste, and abuse.  They also helped 
beneficiaries resolve problems or concerns by either taking their complaints directly or by 
directing the beneficiary to the appropriate authority.  In addition, trainers were on the lookout 
for inconsistencies and problems as they went about their other responsibilities. 
Projects stressed the importance of tailoring the message to the audience. 
Projects offered a number of suggestions for educating beneficiaries.  As mentioned earlier, 
several projects highlighted the importance of recruiting trainers from different backgrounds as a 
way to reach diverse groups in their communities.  The community volunteer project in 
Pennsylvania capitalized on this idea; they recruited a diverse group of trainers and encouraged 
them to develop their own presentations and to draw on their own style and personal experiences. 
Some projects also highlighted the need to make presentations easy to follow and relevant to the 
interests of the audience. 
Additionally, several projects suggested that using specific examples was an effective way to get 
the message across.  They noted that anecdotes tended to hold peoples interest.  Projects also 
incorporated role playing exercises, and discussed common scenarios and cases in the media to 
get peoples attention and to promote audience participation.  Some projects recommended using 
a video, whereas others had success with providing handouts or brochures. 
16
 Individual projects had several other innovative ideas.  The Arizona project brought in counselors 
after group presentations for beneficiaries to speak to one-on-one.  The New York project 
distributed  medical records booklets for seniors to record and track their medical services.  The 
Ohio project distributed a similar tracking envelope to beneficiaries.  A few projects focused 
specifically on improving trainers presentations.  To do this, trainers in the community volunteer 
projects in California and Illinois surveyed beneficiaries after each session and used their 
comments to refine their presentations.  In the Pennsylvania community volunteer project, trainers 
gave each other feedback about their presentations. 
Projects that educated the largest number of beneficiaries differed. 
According to performance data, the community volunteer projects in California, Illinois, New 
York, and Pennsylvania reported educating more beneficiaries than any of the other projects. 
Each educated more than 6,000 beneficiaries in the first 18 months of the program.  These 
projects had few similarities, however.  They were organized differently in that they represented 
various types of organizations, and built on different aging network programs.  These projects 
also had different approaches as to whom they trained to be trainers.  The California project 
primarily trained aging network staff.  The Illinois and Pennsylvania project mainly trained new 
retired seniors and the New York project trained both types of trainers.  Despite these differences, 
all of these projects conducted a large number of group sessions to educate beneficiaries. 
Community Outreach 
Projects conducted a wide range of outreach activities. 
Most projects conducted different types of media events for the general public.  Most commonly, 
projects conducted public service announcements or TV and radio interviews and commercials. 
They also wrote articles, placed ads in local newspapers, and produced brochures and other 
publications to raise public awareness about Medicare fraud, waste, and abuse.  To do this, 
several projects established relationships with reporters and the local media.  Projects also issued 
press releases, conducted kick-off events and rallies, and publicized cases that had recouped large 
sums of money to generate interest in the project.  In several projects, the individual AAAs 
conducted additional activities aimed at local media. 
Most projects also conducted community education activities.  These activities typically included 
operating informational booths at health fairs and community festivals, and distributing pamphlets 
to libraries, senior centers, and providers.  Some projects organized community events with other 
agencies for increased exposure.  A few projects spoke to community groups such as professional 
associations and church and civic groups.  The project in Rhode Island took another approach.  It 
conducted a workshop on health care fraud and abuse for residential coordinators who then 
shared this information with their clients.  This project also set up information booths at local 
supermarkets. 
17
 Some projects worked with minority and provider communities to get the word out. 
A number of projects encountered problems reaching out to minority populations.  At the same 
time, a few projects had some success in this area.  These projects, notably the HIPAA-funded 
project in California, created flyers, pamphlets, and brochures in several languages to spread the 
word about their project.  Additionally, in the Florida project, trainers worked with the media to 
specifically target the Hispanic community.  Commenting on the overall approach, one project 
recommended establishing a relationship with a contact person in each community to help open up 
the channels of communication. 
As mentioned earlier, several projects experienced some resistance from providers in their areas. 
Some of the projects tried to allay providers concerns by sharing information with them.  The 
community volunteer project in Missouri, for example, conducted training seminars especially for 
providers.  In Ohio, home care providers objected to the program.  In response, the project 
created a consumer booklet for them about how to select home care services.  In New York, the 
project worked with their Medicare carrier to distribute 25,000 copies of their training manual to 
providers throughout the State.  Five projects also reported partnering with provider groups as 
part of a larger steering committee or task force. 
Other projects developed presentations that took into account providers concerns.  One project 
specifically trained volunteers to present a balanced message that highlighted that not all providers 
committed fraud.  Another approach, taken by the Virginia project, was to enlist providers to 
make presentations which also gave them an opportunity to show that they were concerned about 
these issues. 
Almost all projects believed that outreach activities were effective in educating Medicare 
beneficiaries and others. 
The majority of projects believed their outreach activities were either very effective or 
somewhat effective in educating beneficiaries and others to identify fraud and abuse.  In general, 
projects believed that outreach activities raised community awareness and were an effective way 
to get the message across.  A common response was that these efforts helped to educate people 
who were not previously aware of health care fraud and abuse.  A few projects also noted that 
outreach helped strengthen a projects presence in the community.  As one project commented, 
the media gives the project legitimacy and credibility.  One project pointed out, however, that 
these activities  would not be effective on their own without the trainers and their sessions. 
18
 Complaint-Handling 
Most projects relied on a hotline, although its purpose differed across projects. 
The majority of the projects were affiliated with or operated a State or local hotline that Medicare 
beneficiaries could call to report a suspected instance of health care fraud or abuse.  The type of 
hotline that projects relied on differed, however.  Most projects, particularly in the HIPAA-funded 
program, used a general hotline that handled a wide variety of issues concerning seniors.  These 
hotlines were operated by the State Department of Aging or health insurance counseling 
programs.  In other projects, the AAAs operated local hotlines for beneficiaries to call if they had 
any type of problem.  Only a few community volunteer projects operated their own hotline that 
was dedicated solely to the project and to the reporting of health care fraud, waste, and abuse. 
Several projects advocated using an existing local hotline.  One project that used a local hotline 
operated by benefit counselors stressed that the operators were well-trained in diffusing the 
emotional part of the problem and in getting to the issue.  They are good complaint handlers. 
Several projects also noted that beneficiaries preferred to talk to someone who was local.  The 
advantage of having a separate hotline operated by project staff, however, was that it made it 
easier to track complaints that resulted from the projects efforts. 
Projects developed different strategies to handle complaints. 
Some projects took complaints directly from the beneficiary.  Most commonly, they took 
complaints after a group session, during a one-on-one session, or over the telephone.  At this 
time, staff and volunteers usually filled out a form that included detailed information about the 
complaint.  In some cases, they also asked the beneficiary to sign a release form.  The project then 
sent the complaint to the appropriate investigative agency for action. 
Other projects instructed beneficiaries to call their Medicare carrier, the OIG Hotline, or another 
agency directly.  Several of these projects saw their role in this part of the process as more 
limited.  One project, for example, explained, We see our job as a referral agent. We let others 
do the investigating and tracking. We do the training and the detecting of fraud and abuse. 
Finally, a few projects used a combination of these two approaches.  The Maryland project often 
conducted three-way calls with the Medicare carrier, the beneficiary, and the project coordinator 
to assist the beneficiary in making a complaint.  Other projects encouraged the beneficiary to 
make the complaint directly but would also assist the individual if he or she needed help. 
Projects referred complaints to the appropriate investigative agency, although some 
referred only to the Medicare carrier. 
Many projects referred complaints to a number of different agencies including Medicare carriers, 
intermediaries, the Regional Inspector Generals office, the Regional HCFA office, and the OIG 
Hotline.  They typically referred Medicaid complaints to the Attorney Generals Office or to the 
19
 State Medicaid Fraud Units.  In some cases, they directed other types of complaints to insurance 
counseling programs or ombudsman programs.  One project believed that shopping the case, or 
giving the complaint to the agency that was most likely to act on it, was effective.  A few projects, 
however, had agreements with or referred all complaints to the Medicare carrier.  The carrier then 
triaged the complaints and sent them to other agencies if necessary. 
Most projects instructed beneficiaries to use some form of the 1-2-3 approach. 
Projects almost universally instructed beneficiaries to follow some version of the 1-2-3 approach, 
that is to call their provider, followed by the appropriate Medicare contractor, and then the OIG 
or local hotline.  The national campaign to fight fraud and abuse also advocated this approach and 
encouraged beneficiaries to call the OIG Hotline.  Several projects agreed that this approach was 
effective in getting beneficiaries to check and report any discrepancies on their Medicare 
statements.  One project was somewhat concerned that beneficiaries may get confused about 
whether to call the OIG Hotline or a local hotline. 
Tracking 
Most projects did not routinely track complaint outcomes. 
The majority of projects did not systematically track outcomes of complaints.  The HIPAA-
funded projects were less likely to track outcomes than community volunteer projects.  A typical 
response was that their purpose was to educate and train beneficiaries and not to track them.  In 
some of these projects, tracking was inconsistent.  For example, one project relied on beneficiaries 
to call the project about the outcome of their complaint. 
Several projects developed informal tracking systems.  These projects typically developed 
relationships or informal partnerships with key agencies or they had advisory committees that 
included agencies such as Medicare carriers, the HCFA, and the Attorney General.  These groups 
met regularly to discuss the project or fraud and abuse issues more generally.  During these 
meetings, projects also discussed outcomes of individual complaints. 
Tracking was difficult because there were many ways to report fraud and abuse.  Although some 
projects recognized that it was important to track outcomes, they also stressed that it was almost 
impossible to follow all complaints that resulted from projects efforts.  Most projects, for 
example, had no way of tracking how many beneficiaries and others called the Medicare carrier or 
the OIG Hotline directly as a result of their efforts.  A few projects noted that for these reasons, 
their outcomes were under-reported and the impact of the program was therefore underestimated. 
Several projects had some type of system in place to track complaints. 
Some projects developed more formal mechanisms to track, often in addition to forming 
20
 partnerships.  Some of these projects kept a list of the complaints that they had referred and 
periodically called the carrier or other agencies to inquire about their outcomes.  Two projects 
maintained a tickler file to follow up on complaints.  The Pennsylvania HIPAA-funded project 
experimented with tracking complaints in some areas by asking  beneficiaries to ask the carrier to 
send the letter about the status of their complaint to the AAA, rather than to them.  This process 
also helped maintain confidentiality which was particularly important when the person was 
residing in a nursing home. 
Two projects were experimenting with other methods of tracking. The Ohio project was in the 
process of developing a tracking system on the Internet that allowed different agencies to report 
electronically about what happened to a complaint.  The California HIPAA-funded project 
integrated measures into the National Ombudsman Reporting System (NORS) to track the type of 
fraud and abuse complaints that they received. 
Other innovative approaches included efforts by the Pennsylvania HIPAA-funded project and the 
New York project to train staff at the carriers customer service hotline.  These projects asked 
staff  to collect information about the source of the complaint so that they could more accurately 
track the number of complaints that could be attributed to their efforts. 
Most projects received little or no feedback about complaint outcomes. 
Not getting feedback about complaints was the most common problem cited among projects. 
Many projects stressed that they routinely referred complaints to the Medicare carrier or the 
appropriate investigative agency, but received little or no information about their status. 
There were a few exceptions, however.  The New York project which had several years to 
develop the project under ORT, forged a strong relationship with the carrier.  As a result, the 
carrier agreed to inform the project about the status of complaints and any money that was 
recouped, including overpayments, that resulted from complaints referred by the project.  The 
Minnesota project developed a specific contact person or division in each carrier that reported 
back to the project on a quarterly basis.  A few other projects reported receiving some feedback 
from carriers and others about complaints they referred. 
Some projects noted that the lack of feedback was partly due to issues of confidentiality.  In some 
cases, carriers, as well as other agencies, maintained that information provided by beneficiaries 
was confidential and that projects were not privy to it.  In response, a few projects asked 
beneficiaries to fill out a release form which allowed the project to follow up on the complaint. 
Two projects found that working with HCFA helped them gain access to complaint information 
from the carriers.  Lack of feedback may have also been due to the lengthy investigative process. 
As a few projects noted, establishing that actual fraud or abuse was committed could take months 
or years. 
Projects also tracked trainers and outreach activities. 
21
 Most projects collected key information about trainers activities.  Community volunteer projects, 
however, were somewhat more likely to track this information than HIPAA-funded projects. 
Projects typically collected the number of presentations or contacts that volunteers made, and the 
number of people who attended these sessions.  To do this, volunteers were usually asked to fill 
out a report form that they then sent to project staff.  In some projects, AAA staff or health 
insurance counselors added this information to monthly reports that they were already required to 
submit.  In addition, a few projects developed an evaluation form for beneficiaries to complete 
about the session which was also used to track trainers activities. 
Fewer projects routinely tracked outreach activities.  Many of these projects tracked the number 
of activities and the number of people who attended these activities.  Some projects also asked 
people who called the hotline about how they heard about the project.  None of the projects was 
able to determine the impact of these activities; they could only provide anecdotal evidence. 
AoAs Guidance 
Guidance from AoA was helpful, particularly in promoting communication. 
The majority of projects in both programs reported that AoAs guidance had been helpful to the 
program.  Most notably, AoA was instrumental in promoting communication between the 
grantees.  The agency created a newsletter and a website and also arranged regional meetings and 
two national conferences for grantees to meet each other and exchange ideas.  As a result of these 
efforts, many projects reported they communicated with other grantees by telephone or e-mail. 
Some projects also expressed satisfaction with the national conference and were interested in 
having this forum continue. 
At the same time, projects offered several suggestions to strengthen AoAs efforts.  A few 
projects stressed the need for more feedback from AoA, particularly during the start-up phase. 
Projects specifically asked for more assistance with training volunteers and with tracking 
outcomes.  One project advocated that AoA support a few grantees to develop a system to report 
and track complaints that other projects could use as a model.  In addition, a few projects 
commented that knowing the performance measures earlier in the process would have given them 
a better idea about what to record and track.  Lastly, a few projects requested that AoA 
coordinate additional regional meetings, noting that AoA was in the best position to bring the 
grantees together. 
22
 C O N C L U S I O N  
The HIPAA-funded and community volunteer projects have conducted a wide array of activities 
to help fight health care fraud, waste, and abuse.  Despite these differences, it appears that well-
structured projects address several common programmatic elements.  These elements include 
organizing and start-up, partnering, recruiting trainers, training trainers, educating beneficiaries, 
community outreach, complaint handling, and tracking. 
Our analysis of specific practices in these areas, however, shows that none was strongly 
associated with key outcome measures.  This result may be due to the fact that many projects had 
difficulty tracking outcomes and that the projects are relatively new.  These factors also suggest 
that it may be too early to do a systematic analysis to distinguish which practices are most 
effective. 
Rather, at this stage, it appears that a number of different approaches can be successful and that 
there is not one way to operate a project.  This report therefore highlights the varied strategies 
and practices implemented by the individual projects.  This information will give projects the 
opportunity to learn from one another.  It will also give AoA the ability to provide guidance to 
new projects that will enable them to get off to a running start and avoid delays. 
Additionally, as part of their ongoing implementation efforts we encourage AoA, through their 
regional offices, to: 
<	 Make sure that all projects address the key programmatic elements and provide 
guidance to projects in the areas that they have not yet developed. 
<	 Pay closer attention to tracking.  Specifically, AoA needs to impress upon the 
individual projects the importance of tracking outcomes.  It also needs to identify 
and disseminate effective ways to track trainers activities and complaint outcomes 
so that projects can better document the outcomes of their efforts. 
<	 Provide guidance about ways to improve retention of trainers and about working 
with minority communities and with providers to expand projects efforts. 
COMMENTS 
We received comments from AoA.  They agreed with the major conclusions and are working with 
their grantees and OIG to replicate effective practices.  The full text of these comments can be 
found in Appendix B. 
23
 APPENDIX A 
The Health Care Fraud and Abuse Programs 
Community Volunteer Projects  HIPAA-Funded Projects 
State Units on Aging  State Units on Aging 
Hawaii
 Arizona 
Iowa
 California 
Maryland
 Colorado 
Minnesota
 Florida 
New Hampshire
 Georgia 
New York*
 Illinois 
Louisiana+ 
Area Agencies on Aging  Massachusetts 
District III AAA, Missouri  Missouri 
Suburban AAA, Illinois  New Jersey+ 
New York* 
Private Aging Organizations  Ohio 
Aging 2000, Rhode Island  Oregon+ 
California Health Insurance  Pennsylvania 
Counseling Advocacy Programs  Tennessee 
Coalition of Advocates for the Rights  Texas 
of the Infirm Elderly, Pennsylvania  Virginia 
Coalition of Wisconsin Aging Groups  Washington 
* Note: The New York State Unit on Aging receives both types of grants. For the purposes 
of this report, it is considered a community volunteer project. 
+ Note: Louisiana, New Jersey, and Oregon were incorporated at a later date and have only 
received funding for one year. 
24
 APPENDIX B 
Comments 
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