Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

August 1999 

OEI-02-99-00110 

Administration 

Fraud and Abuse Programs 

18-Month Outcomes 

on Aging’s Health Care 
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 

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 
EXECUTIVE SUMMARY 

PURPOSE 

To report on 18-month performance of the Administration on Aging’s (AoA) two health care 

fraud and abuse control programs. 

BACKGROUND 

The AoA asked the Office of Inspector General (OIG) to assess the performance and 

implementation of its two health care fraud and abuse control programs: the Health Care AntiFraud, Waste, and Abuse Community Volunteer Program and the Health Insurance Portability 

and Accountability Act (HIPAA)-funded Program. AoA will use this information to inform 

Congress and others about the programs’ performance and to develop guidance for current and 

future projects. 

Both of these programs aim to educate beneficiaries about health care fraud, waste, and abuse, 

but operate somewhat differently. The community volunteer program receives $2 million and 

provides grants to 12 organizations to recruit and train retired professionals to conduct group 

sessions to educate beneficiaries. This program has recently been expanded to $7 million. The 

second program receives $1.4 million in funding under the Health Insurance Portability and 

Accountability Act (HIPAA) of 1996. 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 AoA’s request, the OIG developed two reports. This report presents 18-month 

performance data for the two programs and a companion report entitled, AoA’s Health Care 

Fraud and Abuse Programs: Implementation Issues OEI-02-99-00111, describes implementation 

issues and effective practices of the two programs. The findings in these reports are based on 

self-reported data that were not independently verified. 

FINDINGS 

The AoA’s two anti-fraud programs educated thousands of beneficiaries who identified 

some instances of health care fraud, waste, and abuse. 

In their first 18 months of operation, AoA’s two anti-fraud programs trained a total of 13,700 

aging network staff, volunteers, and retired seniors to be Medicare educators and resources. 

These trainers educated at least 71,460 Medicare beneficiaries about how to identify and report 

1
suspected instances of health care fraud and abuse. Additionally, the two programs reported 

conducting 570 media events and 2,880 community education activities. 

In total, the programs referred 871 allegations to Medicare contractors or other agencies for 

follow-up. These referrals generated 133 complaints that resulted in some action. The projects 

also reported that an estimated $1.24 million in Medicare funds and $102,000 in Medicaid and 

other funds may be recouped as a result of their efforts. 

The two programs produced different results. 

The community volunteer projects recruited and trained 3,700 individuals to educate beneficiaries. 

More than half were retired professionals. These trainers educated about 58,700 beneficiaries and 

family members in group sessions, teaching them how to identify and report health care fraud and 

abuse. They reached another 2,000 beneficiaries in one-on-one sessions. In total, five community 

volunteer projects reported a potential $1.24 million in Medicare savings. 

The HIPAA-funded projects trained over 10,000 individuals who were primarily ombudsman staff 

and volunteers or health insurance counselors. These trainers were able to reach at least 10,000 

beneficiaries. The HIPAA-funded projects did not specifically report data on the number of 

beneficiaries reached in one-on-one sessions. None of these projects could document any 

potential Medicare savings as of 18 months, partly because many of these projects did not track 

complaint outcomes. 

CONCLUSION 

Two outcome measures are particularly important for measuring the performance of these two 

programs: the number of beneficiaries educated and the amount of money saved by the programs. 

Educating Beneficiaries: Both programs educated an impressive number of beneficiaries. The 

community volunteer program, however, appeared to reach a greater number of beneficiaries than 

the HIPAA-funded program. This difference was partly due to the different approaches that the 

two programs implemented. Specifically, the community volunteer program generally followed a 

train-the-trainer approach in which the trainers conducted group sessions, whereas the HIPAAfunded program trained existing network staff and volunteers who met with beneficiaries one-onone, as part of their ongoing responsibilities. 

Tracking Savings: Direct evidence about savings was difficult to obtain. While the programs 

were successful in educating beneficiaries, there was no direct evidence that they produced more 

savings than the amount of money that was invested in them. There are a number of reasons for 

this lack of evidence. First, beneficiaries are often encouraged to call their provider or Medicare 

contractor with problems and projects may not be aware of these activities. Second, the projects 

2
are relatively new and not all of them have developed tracking systems for the complaints that 

come to their attention. Third, the investigative and prosecutorial processes are lengthy and 

therefore 18 months may not be enough time to achieve significant savings. Lastly, there is likely 

to be a sentinel effect from this initiative that is reducing inappropriate billing. 

Additionally, we found that performance among the projects was very uneven. While many 

projects were successful in educating beneficiaries and in identifying some savings, almost an 

equal number produced minimal results during the first 18 months of the program. 

Based on these findings, we encourage AoA to continue its work with the projects to identify and 

institutionalize effective practices. Further, as AoA expands the community volunteer program, it 

needs to assist new grantees so that they do not “reinvent the wheel” as they start-up their 

efforts. We hope that this report and our companion report will help AoA achieve these 

objectives and help new grantees, as well as current projects, implement effective practices and 

improve future performance. 

COMMENTS 

We received comments from AoA. They pointed out the difficulty in tracking specific dollar 

savings early in the program. However, they are optimistic that the thousands of trained 

beneficiaries will have a significant impact on fraud, waste, and abuse in the Medicare program. 

The full text of AoA’s comments can be found in Appendix D. 

3
TABLE OF CONTENTS 

PAGE

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

INTRODUCTION .......................................................... 5

FINDINGS

AoA’s Anti-Fraud Programs ............................................. 9

Community Volunteer Projects .......................................... 10

HIPAA-Funded Projects ............................................... 13

Performance Measures ................................................. 16

CONCLUSION ...................................................... 18

APPENDICES

A. List of Health Care Fraud and Abuse Projects ............................. 19

B. Performance Data Reported by Community Volunteer Projects ................ 20

C. Performance Data Reported by HIPAA-Funded Projects ..................... 25

D. AoA’s Comments .................................................. 34

4
INTRODUCTION 

PURPOSE 

To report on 18-month performance of the Administration on Aging’s (AoA) two health care 

fraud and abuse control programs. 

BACKGROUND 

The AoA asked the Office of Inspector General (OIG) to assess the performance and 

implementation of its two health care fraud and abuse control programs: the Health Care AntiFraud, Waste, and Abuse Community Volunteer Program and the Health Insurance Portability 

and Accountability Act (HIPAA)-funded Program. AoA will use this information to inform 

Congress and others about the programs’ performance and to develop guidance for current and 

future projects. 

AoA asked OIG to evaluate the performance and the implementation of its anti-fraud initiatives 

for several reasons. First, this information is a continuation of other work conducted by the OIG. 

At AoA’s 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 presents 18-

month performance data for the two programs. A companion report entitled, AoA’s Health Care 

Fraud and Abuse Programs: Implementation Issues OEI-02-99-00111, describes the 

implementation of these two programs including problems projects encountered and practices 

they developed to overcome these barriers. 

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 twoyear 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 

5
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 Administration’s 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. 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 (HIPAA) 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. 

6
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. Appendix A provides a list of all projects. Note that the New York State Unit 

on Aging which receives funding from both programs is considered a community volunteer 

project for the purposes of this report.1 Also, this report includes first year performance data for 

the three HIPAA-funded projects that received funding in the second year. 

Community volunteer projects reported data for the measures developed by the OIG for the time 

period covering July 1, 1997 through December 31, 1998. The HIPAA-funded projects reported 

data for the measures developed by Westat, Inc. for August 1,1997 through January 31, 1999. 

1

Project staff explained that they use the community volunteer grant to fund several area 

agencies on aging to conduct anti-fraud activities and the HIPAA grant for administrative 

purposes. 

7 
The OIG staff reviewed these data for consistency and compared them to 12-month data when 

appropriate. Appendices B and C present the data reported by each project. In addition, we 

asked grantees to provide documentation about any money that was identified due to their 

project’s efforts. 

Second, we asked AoA for the projects’ most recent semi-annual report that they submitted as 

part of AoA’s 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 

asked them to identify practices that have been effective, particularly in tracking outcomes. The 

results of these data are reported in detail in our companion report entitled, AoA’s Health Care 

Fraud and Abuse Programs: Implementation Issues OEI-02-99-00111. 

As described, the two programs took different approaches to fighting health care fraud, waste, 

and abuse. The measures that the programs were asked to report also differ in several ways. For 

these reasons, we believe that a side-by-side comparison of the two programs is not appropriate. 

A separate analysis of each program is therefore presented. 

Limitations 

It is important to note that the findings in this report are based on self-reported data that were not 

independently verified. Furthermore, outcome findings gauge the extent to which the program is 

achieving its intended goals; they do not provide information about the quality of these outcomes 

nor the implementation of the program. 

The following analysis does not solely focus on complaint outcomes for several reasons. As 

described below, projects tracked these outcomes to different degrees. The number of complaints 

that resulted in some action therefore may be an indication of a project’s capacity to track, rather 

than its performance. Additionally, complaints may take a long time to investigate and therefore it 

may be too early to evaluate a project based on these measures. 

This inspection was conducted in accordance with the Quality Standards for Inspections issued 

by the President’s Council on Integrity and Efficiency. 

8
FINDINGS 

The AoA’s two anti-fraud programs educated thousands of beneficiaries 

who identified some instances of fraud and abuse. 

In their first 18 months of operation, AoA’s two anti-fraud programs trained a total of 13,700 

aging network staff, volunteers, and retired seniors to be Medicare educators and resources. 

About 3,200 of these individuals, or 38 percent, went on to educate others or to conduct outreach 

activities about health care fraud, waste, and abuse. 

Trainers in the two program educated at least 71,460 Medicare beneficiaries and family members. 

Typically, they conducted group sessions or met with beneficiaries one-on-one, instructing them 

how to review their health care bills, statements, and other documents, and how to identify and 

report any suspected instances of fraud and abuse. The two programs also reported conducting a 

total of 570 media events and 2,880 community education activities. These activities were 

generally aimed at informing the larger public about these issues. 

In total, the programs referred 871 allegations to Medicare contractors or other agencies for 

follow-up. These referrals generated 133 complaints that resulted in some action. The projects 

also reported that an estimated $1.24 million in Medicare funds and $102,000 in Medicaid and 

other funds may be recouped as a result of their efforts. Not all projects were able to identify 

potential Medicare savings. 

Several projects qualified the data they reported about complaints. A few stressed that their 

numbers underestimated the impact of the program. They explained that they sometimes 

encouraged beneficiaries to make complaints to their Medicare carrier or to the OIG Hotline 

directly. They did not, however, have the capacity to track complaints made through these 

channels. In addition, several projects noted that complaints often took a long time to investigate 

and therefore their outcomes may not be known at this time. 

9
COMMUNITY VOLUNTEER PROJECTS 

The community volunteer projects generally implemented a train-the-trainer approach. Projects 

typically recruited seniors at senior centers and in the community at large. They then trained them 

to conduct presentations or group sessions to educate Medicare beneficiaries. Additionally, most 

projects also trained aging network staff and volunteers who educated beneficiaries about fraud 

and abuse as part of their ongoing responsibilities. These individuals typically included State and 

local long-term care ombudsmen, health insurance counselors, and others who worked directly 

with seniors. 

Training Trainers 

The 12 projects recruited and trained many retired seniors to be Medicare educators and 

trainers. 

Overall, the 12 community volunteer projects reported recruiting and training a total of 3,691 

individuals, at least half of whom were retired professionals.2 Projects employed different 

strategies to recruit individuals such as advertising in local newspapers and approaching members 

of existing senior organizations. As shown in Figure 1, the number of trainers varied greatly by 

project. 

Figure 1 

Number of Trainers Trained in 18 Months 

Total: 3,691 

Note: Each grantee does not necessarily serve the entire State. Source: OEI Survey, 1999 

2 Note that projects defined who they considered to be professional differently. 

Additionally, three projects did not track this type of information. 

10 
Not all seniors who were trained, however, continued to stay involved in the projects. Most 

projects maintained a smaller corps of active volunteers. Taking into account the projects that 

tracked this information, about half of all individuals trained by the community volunteer projects 

ever conducted activities to educate beneficiaries. This rate varied by project, indicating that 

some projects were less successful than others at getting trainers involved once they had 

completed training. Six projects, for example, retained less than one-quarter of trainers, whereas 

the remaining five projects were able to involve at least two-thirds of all those trained. 

Educating Seniors 

Projects educated a large number of beneficiaries and others to identify and report health 

care fraud, waste, and abuse. 

Collectively, the 12 community volunteer projects reported educating about 60,734 beneficiaries, 

family members, and others in the first 18 months of the program. As shown in Figure 2, the 

number of beneficiaries educated varied by project. 

The community volunteer projects typically conducted two types of training: group and one-onone. In total, trainers led 1,422 group sessions that reached nearly 58,691 beneficiaries and 

others. All but two projects also conducted one-on-one sessions that reached another 2,043 

individuals. Projects provided one-on-one assistance to varying degrees. 

Figure 2 

Number of Beneficiaries and Others Educated in 18 Months 

Total: 60,734 

Note: Each grantee does not necessarily serve the entire State. Source: OEI Survey, 1999 

11
There did not appear to be a strong relationship between the number of beneficiaries educated and 

the number of trainers in a project. Some projects that trained relatively few trainers were able to 

reach many beneficiaries. The project in Pennsylvania, for example, trained 60 individuals, 40 of 

whom ever conducted activities, and educated more than 6,000 beneficiaries. Similarly, some 

projects that trained large numbers of trainers reached relatively few beneficiaries. The project in 

New Hampshire, for example, trained 238 individuals, all of whom conducted some activities, but 

educated only 1,300 beneficiaries. 

Community Awareness 

Projects conducted various outreach activities, raising awareness about health care fraud 

and abuse. 

The 12 projects reported conducting a total of 420 media events that reached an estimated 68.5 

million people in the first 18 months of the program. The projects also performed about 1,200 

community education activities that informed an estimated 168,850 individuals. Overall, projects 

conducted a median of 20 media events and 51 community education activities. Some projects 

placed more emphasis on these types of activities than others. The project in Minnesota, for 

example, conducted 223 media events. The projects in New York and Iowa each conducted 

about 300 community activities. In contrast, a few projects held less than 15 of these types of 

activities. 

Identifying Referrals 

The projects identified suspected instances of fraud, waste and abuse, some of which may 

result in recouped Medicare funds. 

Overall, the projects referred about 400 allegations to appropriate authorities. The majority of 

these referrals came from two projects, Iowa and New York, which referred 171 and 52 

allegations, respectively. Five other projects reported referring at least 20 complaints. One 

project did not make any referrals. 

Projects reported that these referrals generated a total of 93 complaints that resulted in some 

action. Five projects also reported that an estimated $1.24 million in Medicare funds may be 

recouped as a result of their efforts. The other seven projects did not know or reported that none 

of the complaints they referred had resulted in Medicare funds being recouped. In addition, six 

projects estimated that $102,000 in Medicaid and other funds may be recouped due to their 

projects’ efforts. 

12
HIPAA-FUNDED PROJECTS 

The HIPAA-funded projects implemented the program differently than the community volunteer 

projects. The HIPAA-funded projects primarily trained aging network staff and volunteers about 

fraud and abuse. These individuals typically met with Medicare beneficiaries and others one-onone and integrated what they learned about fraud, waste, and abuse in their usual activities. In 

general, these projects placed less emphasis on conducting group sessions to educate Medicare 

beneficiaries compared to the community volunteer projects. 

Training Trainers 

The HIPAA-funded projects trained large numbers of staff and volunteers, primarily in the 

aging network 

The 17 HIPAA-funded projects reported training a total of about 10,000 staff and volunteers to 

be Medicare resources and educators in the first 18 months of the program. As shown Figure 3, 

the number of individuals trained varied greatly by project. Unlike the community volunteer 

projects, it was not uncommon for these trainers to also educate additional staff and volunteers. 

Collectively, the projects reported conducting sessions to educate another 3,000 staff and 

volunteers about fraud and abuse. 

The variation in the number of trainers reflects the different approaches taken by the projects. 

The project in Colorado, for example, trained a small number of staff and volunteers who trained 

additional staff and volunteers. In contrast, the project in Massachusetts, trained a large number 

of staff and volunteers who did not conduct any additional sessions to train others. 

In all but one project, the majority of people trained were staff and volunteers in the aging 

network. These individuals typically included State and local long-term care ombudsmen, health 

insurance counselors, aging network service staff, and others who worked directly with older 

people. Only five projects reported training staff and volunteers who were not in the aging 

network. These individuals typically included senior advocates, retired seniors, and others. 

Although projects trained a large number of staff and volunteers, not all remained active. Taking 

into account only the projects that tracked this information, an estimated 2,141 individuals, or 34 

percent of all those trained, were promoting awareness and the reporting of health care fraud and 

abuse at the end of the 18-month reporting period. This rate greatly varied among the projects, 

indicating that some projects had greater difficulty retaining volunteers than others. 

13
Figure 3 

Number of Trainers Trained in 18 Months 

Total: 10,001 

Note: Data for LA, NJ, and OR include only the first year of the program. Source: OEI Survey, 1999 

Educating Seniors 

Several projects educated many Medicare beneficiaries and others. 

The HIPAA-funded projects reported educating a total of about 10,700 Medicare beneficiaries, 

family members, caregivers, and others. As discussed, not all projects implemented the program 

in this way. Also, the HIPAA-funded projects were not asked to specifically report the number of 

one-on-one sessions that they conducted. Most likely, this information would have substantially 

increased the number of beneficiaries that were informed about fraud and abuse as a result of 

these projects. 

Most projects reported conducting some sessions to educate beneficiaries and others about health 

care fraud and abuse. Six projects conducted at least 30 sessions each or informed more than 850 

beneficiaries each in this manner. These projects appeared to be similar to the community 

volunteer projects. For example, the project in Florida which followed the train-the-trainer 

model, reached the largest number of beneficiaries, over 4,100, or about 38 percent of the total 

number educated by all projects. 

14
Figure 4 

Number of Beneficiaries and Others Educated in 18 Months 

Total: 10,727 

DK DK 

Note: Data may not include beneficiaries educated in one-on-one sessions. Source: OEI Survey, 1999 Data for LA, NJ, and OR include only the first year of the program. 

DK indicates grantee was unable to provide specific information. 

Community Awareness 

The HIPAA-funded projects also conducted public awareness campaigns and other 

community outreach activities to reach a broader audience. 

HIPAA-funded projects reported conducting about 1,672 community education activities that 

informed more than 26,873 individuals about how to identify and report health care fraud and 

abuse. The number of outreach activities conducted varied by project. Specifically, seven 

projects conducted less than six presentations or other outreach activities each. Two projects 

organized more than 320 of these types of activities each. 

The projects also developed a total of 152 public service announcements, press releases, or other 

media events. In addition, all of the projects developed several types of other outreach materials 

that most distributed widely. Collectively, the projects produced 155 brochures, posters, videos, 

public information documents, and training and other outreach materials. Projects distributed 

about 192,200 copies of these materials to members in their respective communities. 

15
Identifying Referrals 

Projects identified some instances of suspected fraud and abuse, although their outcomes 

are generally unknown. 

The HIPAA-funded projects reported receiving a total of 2,586 calls concerning health care fraud 

and abuse, during the 18-month reporting period. They also reported referring 469 allegations to 

other agencies, forwarding almost half of them to Medicare contractors including carriers, 

intermediaries, or regional durable medical equipment carriers. They referred another 20 percent 

of the allegations to the OIG Hotline. The remaining complaints were sent to other health care 

programs such as insurance counseling agencies, State Medicaid Fraud Control Units, State 

Attorney General’s Offices, or other fraud and abuse agencies. 

Few HIPAA-funded projects tracked the outcomes of these complaints. Seven projects reported 

that a total of 22 complaints were accepted for investigation by complaint-handling agencies. 

None of the projects documented that any complaints resulted in money being recouped or in a 

conviction or other punitive action, although it may be too early to know this information. Two 

projects reported that 40 complaints resulted in some other type of action. 

It is important to note that the HIPAA-funded projects were not required to track complaint 

outcomes. A few projects stressed that their role was to educate beneficiaries about how to 

detect and report fraud and abuse. They believed the tracking and investigation was best left to 

investigative agencies such as the Medicare contractors, the OIG, and State Attorney General’s 

Offices. In addition, a few projects noted that they had not received any feedback about 

complaints that they forwarded to the OIG Hotline. 

PERFORMANCE MEASURES 

Performance measures are viewed as too complex. 

Performance measures for the two grant programs were developed separately and take somewhat 

different approaches. Project staff had mixed reactions to the performance measures. They most 

commonly stressed the need for simplified, well-defined measures that were not too burdensome 

to complete. 

The community volunteer projects were generally positive about the measures. A few commented 

that it is somewhat difficult to gather the information, particularly the amount of money recouped 

as a result of their project. They also noted that volunteers and AAA staff are often overworked 

and should not be overburdened with excessive paperwork. A few grantees specifically noted that 

it is very difficult, and perhaps unnecessary, to divide outcomes by retired professionals and 

others. Several projects also suggested that if it is mandatory to collect these measures then they 

should be part of AoA’s reporting requirements. 

16
The HIPAA-funded projects had additional comments about their performance measures. Several 

expressed that they were too detailed or cumbersome. One project suggested eliminating some of 

the questions, noting that “the easier the form, the more complete it will be.” A few reacted more 

strongly, stating that the measures did not fit what their project was doing. As one grantee 

argued, “there is a large gap between the reality of what we are doing and what is being 

reported.” Others stressed that they do not track outcomes nor do they have the capacity to 

divide their data into the required categories. Several projects had some difficulty distinguishing 

between the categories and suggested clarifying key definitions. 

17
CONCLUSION 

Two outcome measures are particularly important for measuring the performance of these two 

programs: the number of beneficiaries educated and the amount of money saved by the programs. 

Educating Beneficiaries: Both programs educated an impressive number of beneficiaries. The 

community volunteer program, however, appeared to reach a greater number of beneficiaries than 

the HIPAA-funded program. This difference was partly due to the different approaches that the 

two programs implemented. Specifically, the community volunteer program generally followed a 

train-the-trainer approach in which the trainers conducted group sessions, whereas the HIPAAfunded program trained existing network staff and volunteers who met with beneficiaries one-onone, as part of their ongoing responsibilities. 

Tracking Savings: Direct evidence about savings was difficult to obtain. While the programs 

were successful in educating beneficiaries, there was no direct evidence that they produced more 

savings than the amount of money that was invested in them. There are a number of reasons for 

this lack of evidence. First, beneficiaries are often encouraged to call their provider or Medicare 

contractor with problems and projects may not be aware of these activities. Second, the projects 

are relatively new and not all of them have developed tracking systems for the complaints that 

come to their attention. Third, the investigative and prosecutorial processes are lengthy and 

therefore 18 months may not be enough time to achieve significant savings. Lastly, there is likely 

to be a sentinel effect from this initiative that is reducing inappropriate billing. 

Additionally, we found that performance among the projects was very uneven. While many 

projects were successful in educating beneficiaries and in identifying some savings, almost an 

equal number produced minimal results during the first 18 months of the program. 

Based on these findings, we encourage AoA to continue its work with the projects to identify and 

institutionalize effective practices. Further, as AoA expands the community volunteer program, it 

needs to assist new grantees so that they do not “reinvent the wheel” as they start-up their 

efforts. We hope that this report and our companion report will help AoA achieve these 

objectives and help new grantees, as well as current projects, implement effective practices and 

improve future performance. 

COMMENTS 

We received comments from AoA. They pointed out the difficulty in tracking specific dollar 

savings early in the program. However, they are optimistic that the thousands of trained 

beneficiaries will have a significant impact on fraud, waste, and abuse in the Medicare program. 

The full text of AoA’s comments can be found in Appendix D. 

18
APPENDIX A 

The Health Care Fraud and Abuse Programs 

Community Volunteer Projects 

State Units on Aging 

Hawaii

Iowa

Maryland

Minnesota

New Hampshire

New York*

Area Agencies on Aging 

District III AAA, Missouri 

Suburban AAA, Illinois 

Private Aging Organizations 

Aging 2000, Rhode Island 

California Health Insurance 

Counseling Advocacy Programs 

Coalition of Advocates for the Rights 

of the Infirm Elderly, Pennsylvania 

Coalition of Wisconsin Aging Groups 

HIPAA-Funded Projects 

State Units on Aging 

Arizona 

California 

Colorado 

Florida 

Georgia 

Illinois 

Louisiana+ 

Massachusetts 

Missouri 

New Jersey+ 

New York* 

Ohio 

Oregon+ 

Pennsylvania 

Tennessee 

Texas 

Virginia 

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: Incorporated at a later date and have only received funding for 

the second year. 

19
APPENDIX B 

18-Month Outcomes Reported by the Community Volunteer Projects

State RI IL PA MD CA MO MN IA HI WI NY NH TOTAL 

Projects Aging 2000 Sub.AAA CARIE MD SUA CHA Dist 3 AAA MN SUA IA SUA HI SUA CWAG NY SUA NH SUA 

$ recruiting retired prof 20,000 35,445 20,200 0 7,447 19,692 30,818 0 12,693 0 12,870 12,663 171,828 

$ recruiting others 0 12,510 2,050 9,000 25,000 7,816 2,694 37,779 0 16,000 19,454 2,533 134,836 

$ training retired prof 40,000 45,870 30,000 0 57,344 22,225 8,245 0 38,078 0 10,329 37,990 290,081 

$ training others 34,362 14,595 10,000 2,380 15,000 6,821 11,369 5,941 0 19,100 23,968 6,332 149,868 

$ support retired prof 26,030 39,615 10,000 0 12,460 20,688 11,276 0 4,847 0 6,505 18,990 150,411 

$ support others 2,000 16,680 5,000 2,500 30,810 5,713 8,531 38,912 0 29,400 3,360 6,332 149,238 

$ community education 62,392 22,935 10,000 9,000 17,130 18,896 52,775 0 9,680 DK 54,581 37,990 295,379 

$ tracking system 19,000 20,850 15,000 3,750 22,140 3,833 2,828 675 0 1,650 1,307 3,799 94,832 

total $ spent 203,784 208,500 102,250 26,630 187,331 105,684 128,536 83,307 65,298 66,150 132,374 126,629 1,436,473 

# training sessions 4 7 15 1 24 9 15 15 6 14 DK 3 113 

# retired prof trained 23 85 50 0 483 31 28 0 42 0 941 215 1,898 

# of others trained 71 20 10 60 74 4 79 382 19 400 651 23 1,793 

total # of people trained 94 105 60 60 557 35 107 382 61 400 1,592 238 3,691 

# media events 7 28 20 27 39 24 223 DK 20 3 17 12 420 

# community ed. activities 14 46 100 187 0 48 53 334 11 79 297 40 1,209 

Note: DK indicates grantees were unable to provide specific data. 

20
APPENDIX B 

18-Month Outcomes for the Community Volunteer Projects

State RI IL PA MD CA MO MN IA HI WI NY NH TOTAL 

Projects Aging 2000 Sub.AAA CARIE MD SUA CHA Dist 3 AAA MN SUA IA SUA HI SUA CWAG NY SUA NH SUA 

# trainers who did activities 23 105 40 10 505 35 23 30 5 40 DK 238 1,054 

# group sessions by prof 67 329 125 0 100 13 39 0 15 0 104 1 793 

# group sessions by others 20 21 25 23 104 40 43 156 25 67 70 35 629 

total # sessions 87 350 150 23 204 53 82 156 40 67 174 36 1,422 

# of benes at ses. by prof 1,372 14,857 5,000 0 7,417 346 804 0 292 0 4,006 1,200 35,294 

# of benes at ses. by others 209 340 1,000 368 7,715 1,439 1,460 4,259 1,071 2,027 3,409 100 23,397 

total # of benes at ses. 1,581 15,197 6,000 368 15,132 1,785 2,264 4,259 1,363 2,027 7,415 1,300 58,691 

# of 1-on-1 by retired prof 0 114 100 0 185 319 3 0 0 0 350 15 1,086 

# of 1-on-1 by others 0 0 30 272 61 227 15 75 0 35 237 5 957 

total of 1-on-1 0 114 130 272 246 546 18 75 0 35 587 20 2,043 

total of benes educated 1,581 15,311 6,130 640 15,378 2,331 2,282 4,334 1,363 2,062 8,002 1,320 60,734 

est. # of people by media hits 1,648,400 2,256,796 2,000,000 100,000 1,750,000 50,000 119,950 59,350,299 54,300 100,500 360,200 750,000 68,540,445 

est # of people by com ed. 3,440 4,583 3,000 8,000 0 50,000 7,353 12,726 446 11,179 66,118 2,000 168,845 

# complaints received 14 114 50 116 185 9 13 298 1 25 52 162 1,039 

# complaints referred 14 26 35 29 24 7 2 171 0 16 52 26 402 

# complaints resulted in action DK DK 10 29 4 0 0 12 0 10 23 5 93 

Medicare $ recouped DK DK 74,124 DK 22,000 0 0 1,138,534 0 1,972 2,999 0 1,239,628 

Other $ recouped DK DK DK DK 210 87,094 12,110 658 0 1,865 DK 100 102,036 

Total $ recouped DK DK 74,124 DK 22,210 87,094 12,110 1,139,192 0 3,836 2,999 100 1,341,665 

Note: DK indicates grantees were unable to provide specific data. 

21
APPENDIX B 

Community Volunteer Projects:

Definitions

RETIRED PROFESSIONAL These are retired individuals who were professionals (e.g., teachers, lawyers, 

doctors, or accountants), who are new volunteers to the aging network, and who 

are trained to help beneficiaries identify Medicare fraud. 

OTHERS These are any other individuals who are trained to help beneficiaries identify 

Medicare fraud. 

RECRUITING Any effort to get individuals to take the training to become a trainer. 

TRAINING The process of training the trainer. 

SUPPORT Any activity to help the trainers, such as transportation, renting space, printing 

material, and telecommunications. 

COMMUNITY EDUCATION Any training, outreach, or education activity not directed at the trainers nor 

specifically in support of the trainers. It is geared to a broad audience. 

TRACKING SYSTEM The process of receiving, referring, and monitoring complaints. 

TRAINED Completed training to conduct beneficiary education. 

22
APPENDIX B 

Definitions (continued)

MEDIA EVENTS Any individual airing or publishing of media (e.g., print, radio, television, or 

electronic) to educate beneficiaries and their families about Medicare fraud. (If it 

is geared to trainers it is recruiting.) 

COMMUNITY EDUCATION 

ACTIVITIES Any beneficiary education activity not given by trainers or counted as media 

events. 

BENEFICIARIES Includes beneficiaries, family members, caregivers, and others who attended 

sessions. 

GROUP SESSIONS Medicare fraud education sessions for beneficiaries, family members, caregivers, 

and others led by trainers. 

ONE-ON-ONE ENCOUNTER Sessions led by trainers for an individual beneficiary and/or his or her family. 

COMPLAINTS Allegations of health care fraud and abuse reported by any individual as a result of 

the project’s efforts. 

Definitions (continued) 

23
APPENDIX B 

COMPLAINTS REFERRED 

FOR ACTION Complaints deemed worthy of referring to a Medicare contractor or an 

investigative agency. 

COMPLAINTS THAT 

RESULTED IN SOME ACTION Referrals successfully closed by a Medicare contractor or an investigative agency 

(e.g., conviction, judgement, plea, or overpayment). 

MEDICARE $ RECOUPED Funds returned to the Medicare Trust Fund. 

24
APPENDIX C 

18-Month Outcomes Reported by the HIPAA-Funded Projects 

Activity AZ CA CO FL GA IL LA MA MO NJ NY OH OR PA TN TX VA WA TOTAL 

I. Training, Education, and 

A. Materials development 

1. # of brochures, posters, media 

products, or 

other public information documents 

3 4 4 1 2 2 2 2 1 0 33 9 2 3 1 6 5 3 50 

2. # of videos 2 0 0 1 0 0 0 0 0 0 5 1 1 0 0 DK 3 2 10 

3. # of training curricula, manuals, 

handouts, 

or related instructional material 

2 3 2 4 2 3 1 5 2 25 35 DK 2 3 0 2 2 1 59 

4. # of other training, education, and 

outreach 

materials 

2 12 4 2 1 DK 3 0 0 0 5 5 2 DK 2 DK 2 1 36 

Total 9 19 10 8 5 5 6 7 3 25 78 15 7 6 3 8 12 7 155 

B. Training and public information 

1. # of training sessions for network on 

aging 

agency staff, volunteers, and others 

56 8 2 9 11 10 3 20 15 0 275 3 7 5 3 15 1 35 203 

2. # of network on aging staff and 

volunteers 

trained 

875 350 2 130 600 345 46 2,200 736 0 1,397 188 660 217 95 654 80 1,130 8,308 

3. # of other staff and volunteers trained 88 1,114 0 31 0 0 0 0 0 0 100 0 DK DK 0 460 0 DK 1,693 

4. # of forums and other public 

information 

presentations conducted (not in 1-3) 

81 701 25 70 2 2 2 5 0 12 137 37 3 5 32 24 37 86 1,124 

Note: The total does not include New York.

25
APPENDIX C 

5. 2,081 2,000 DK 5,257 65 12 100 300 0 1,500 10,12 4,200 160 228 1,42 1,00 5,168 3,373 26,873 

and 5 2 7 

other public information 

presentations 

6. 9 0 2 76 7 2 1 0 0 0 69 0 3 6 3 10 0 33 152 

7. 45,15 14,00 1,75 15,58 800 1 1 500 2,00 0 DK 19,11 10,00 15,00 5,42 DK 12,88 50,00 192,21 

distributed 6 0 0 2 0 3 0 0 8 8 0 9 

(# of copies) 

8. 86 0 300 79 26 1 2 0 2 0 224 0 0 DK 0 26 50 1 548 

outreach activities 

# of persons attending these forums 

# of media events conducted 

# of public information items 

# of other training, education, and 

Note: The total does not include New York. 

26 
APPENDIX C 

Activity AZ CA CO FL GA IL LA MA MO NJ NY OH OR PA TN TX VA WA TOTAL 

C. Activities of ORT trainees 

1. # of ORT trainees currently 

promoting 

awareness and reporting of health 

care 

fraud and abuse 

96 1,112 DK 60 4 0 16 400 89 0 6,932 165 DK DK 63 56 80 DK 2,141 

2. # of education and training sessions 

by ORT trainees for staff and 

volunteers 

58 7 15 0 0 2 6 0 0 0 240 0 9 5 3 3 0 DK 108 

3. # of staff and volunteers attending 

these 

sessions 

128 1,400 450 0 0 43 58 0 0 0 5,670 0 DK 560 285 68 0 DK 2,992 

4. # of sessions by trainees for 

beneficiaries, 

family members, care givers, and 

others 

75 DK 30 52 3 45 1 0 1 0 758 0 DK 40 0 4 0 DK 251 

5. # of beneficiaries, family members, 

care 

givers, and others attending these 

sessions 

1,801 1,000 856 4,120 97 1,071 22 0 20 0 9,184 0 DK 1,585 0 155 0 DK 10,727 

II. Health Care Fraud and Abuse 

Complaint Receipt and Referral 

A. Types of calls received 

1. # of calls concerning billing for services 

not received 

6 DK DK DK 2 DK 0 DK 0 0 31 DK DK DK 0 DK 7 10 25 

2. # concerning double billing 3 DK DK DK DK DK 0 DK 0 0 48 DK 1 DK 0 DK 11 DK 15 

3. # concerning suppliers compiling CMN 

for 

physician 

0 DK DK DK DK DK 0 DK 0 0 0 DK DK DK 0 DK 0 DK 0 

4. # concerning services not needed 2 DK DK DK 2 2 0 DK 0 0 131 DK 1 DK 0 DK 4 DK 11 

Note: The total does not include New York. 

27 
APPENDIX C 

5. # concerning poor quality of care or 

limitations in needed care 

7 DK DK DK DK 3 0 DK 0 DK 111 DK DK DK 0 DK 8 1 19 

6. # concerning other health care fraud and 

abuse 

6 DK DK DK 3 1 0 DK 0 0 0 3 1 DK 0 DK 5 6 25 

7. # concerning other health-related matters 3,653 DK DK DK DK 2 0 DK 0 DK 160 3 DK 8 0 DK 10 26 3,702 

8. # concerning non-health issues 0 DK DK DK DK DK 0 0 0 DK 20 22 DK DK 0 DK 8 DK 30 

Total 3,671 DK DK 43 7 8 0 2,302 0 0 501 28 3 8 0 152 53 43 6,318 

Note: The total does not include New York. 

28 
APPENDIX C 

Activity AZ CA CO FL GA IL LA MA MO NJ NY OH OR PA TN TX VA WA TOTAL 

B. Complaints referred for action 

1. # referred to the HHS TIPS Hotline 26 6 DK 19 4 DK 6 DK 0 0 0 DK DK DK 0 29 DK 1 91 

2. # referred to the Medicare Carrier 3 123 DK 21 DK 5 0 DK 0 5 52 2 2 4 0 DK 15 3 183 

3. # referred to the Fiscal Intermediary 2 DK DK 14 DK DK 0 DK 0 0 0 DK DK DK 0 DK 12 DK 28 

4. # referred to the Regional DME Carrier 1 DK DK 0 DK DK 0 DK 0 3 DK 1 1 DK 0 DK 7 DK 13 

5. # referred to the State Medicaid Fraud 

Control Unit/ Attorney General’s office 

0 51 DK 5 DK DK 0 DK 0 0 DK 1 DK DK 0 DK 11 DK 68 

6. # referred to other fraud and abuse 

agencies 

2 DK DK 2 3 1 0 DK 0 0 DK DK DK DK 0 DK 7 DK 15 

7. # referred to other health care agencies 0 26 DK 11 DK 2 0 DK 0 DK DK 24 DK DK 0 DK 8 DK 71 

8. # referred to the Eldercare Locator 0 DK DK 0 DK DK 0 DK 0 0 0 DK DK DK 0 DK 0 DK 0 

Total 34 206 DK 72 7 8 6 DK 0 8 52 28 3 4 0 29 60 4 469 

C. Complaint outcomes 

1. # of referrals accepted for investigation 

by 

complaint-handling agencies 

8 DK DK 1 7 1 DK DK 0 0 11 1 DK DK 0 1 DK 3 22 

2. # of convictions or other punitive actions DK DK DK DK DK DK DK DK 0 0 0 DK DK DK 0 0 DK DK 0 

3. Dollar amounts recouped (including fines 

and restitutions) 

DK DK DK DK DK DK DK DK 0 0 3,000 DK DK DK 0 0 DK DK 0 

4. # of other actions DK DK DK DK DK DK DK DK 0 0 22 DK DK DK 0 39 DK 1 40 

Note: The total does not include New York. 

29 
APPENDIX C 

Activity AZ CA CO FL GA IL LA MA MO NJ NY OH OR PA TN TX VA WA TOTAL 

III. Building Partnerships 

A. Contacts with agencies and 

organizations concerning the design and 

operation of ORT 

1. # of contacts with the Medicare Carrier 84 5 14 14 20 1 2 12 5 1 81 4 0 12 10 2 33 DK 219 

2. # with the Financial Intermediary 27 DK 0 4 25 1 0 5 5 1 12 4 0 4 DK 2 21 0 99 

3. # with the Regional DME Carrier 18 DK 0 2 2 1 0 9 1 1 67 5 0 4 10 2 10 4 69 

4. # with the State Medicaid Fraud Control 

Unit/Attorney General’s office 

21 4 1 15 8 5 2 5 3 1 78 1 10 4 2 2 21 30 135 

5. # with the State insurance counseling DK DK 0 58 10 7 2 DK 17 DK 2 20 10 DK 2 DK 29 DK 155 

6. # with the LTC Ombudsman program DK DK 2 17 DK 2 1 10 DK DK 0 17 10 DK 5 DK 79 20 163 

7. # with other agencies/organizations 34 33 5 25 12 6 2 13 3 DK 93 6 10 12 30 DK 74 150 415 

Total 184 42 22 135 77 23 9 54 34 4 333 57 40 36 59 8 267 204 1,255 

B. Results of partnership-building 

activities 

1. # of training materials these agencies and 

organizations helped develop 

6 8 2 1 5 1 2 0 0 0 71 1 5 3 2 2 3 4 45 

2. # of training sessions in which they 

participated as trainers 

21 4 20 4 2 2 2 0 14 0 55 1 DK 5 5 1 1 35 117 

3. # of ORT task force or other meetings in 

which they participated 

39 8 13 30 10 2 0 0 3 0 30 1 10 4 3 3 3 20 149 

4. # of written procedures developed with 

them to coordinate ORT activities 

10 4 5 0 1 1 0 1 0 0 25 3 0 1 1 1 0 11 39 

Total 76 24 40 35 18 6 4 1 17 0 181 6 15 13 11 7 7 70 350 

Note: The total does not include New York. 

30 
APPENDIX C 

Activity AZ CA CO FL GA IL LA MA MO NJ NY OH OR PA TN TX VA WA TOTAL 

IV. Staffing and Management 

A. Uses of ORT funds 

1.. # of SUA staff supported in whole or in 

part with ORT funds 

6 0 1 2 1 0 0 0.5 0 0 0.75 2 0 0 1 0 0 0.17 14 

2. # of AAA staff supported in whole or in 

part with ORT funds 

0 0 0 5 0 0 DK 0 0 0 3 DK 0 0 0 0 0 0 5 

3. # of other agency/organization staff 

supported in whole or in part with ORT 

funds 

2 3 2 0 0 1 DK 0 1 0 1 DK 1 1 2 0 3 0 16 

Total 8 3 3 7 1 1 0 1 1 0 4 2 1 1 3 0 3 0 35 

B. Leveraging of ORT resources 

1. # of network on aging staff supporting the 

ORT program who are paid for with 

other funds 

24 99 1 17 30 13 1 19 1 5 27 12 0 30 0 54 0 34 340 

2. # of volunteers supporting the ORT 

program 

88 1,400 3 65 0 DK 46 400 0 400 1,500 DK 42 58 0 1,123 0 395 4,020 

Total 112 1,499 4 82 30 13 47 419 1 405 1,527 12 42 88 0 1,177 0 429 4,360 

Note: The total does not include New York. 

31 
APPENDIX C 

Operation Restore Trust Program Performance Report

Instructions and Definitions

Training and public information activities: Section I A and B of the report cover the initial materials development and train-thetrainer sessions conducted by or on behalf of the ORT grantee. Trainees consist of the network on aging and other staff and 

volunteers, including personnel from State and Area Agencies on Aging and service providers, and staff and volunteers from the 

Long Term Care Ombudsman and insurance counseling programs, among others. These activities also include other outreach and 

informational efforts, such as presentations to professional groups and public service announcements (PSAs) to inform the public 

about ORT and how to identify and report cases of health care fraud and abuse. A major purpose of the ORT training activities 

described in Section I B is to create a cadre of knowledgeable individuals who, in turn, educate beneficiaries and others who work 

with them to identify and refer potential cases of health care fraud and abuse to appropriate federal or state agencies. 

Activities of ORT trainees: Section I C covers the activities of these trainees after they return to their respective agencies and 

organizations. In many respects, this subsequent activity is the most important contributor to ORT success by promoting 

beneficiary awareness and reporting of fraud and abuse in the Medicare and Medicaid programs. Reporting this information, 

however, requires the grantee to establish and maintain ongoing communication with trainees on ORT activities. 

Complaint receipt and referral activity: While the activities in this section are voluntary, AoA is encouraging all HIPAA grantees to 

build on or develop a state-level capacity to receive and screen calls about potential cases of health care fraud and abuse from 

Medicare and Medicaid beneficiaries, their family members or care givers, and others. Receiving these calls at the state level will 

allow screening for, and directly addressing, simple billing questions or other non-fraud and abuse cases that the state insurance 

counseling programs routinely handle. 

This also permits referral of the remaining calls to the most appropriate fraud and abuse agency, including the new HHS TIPS 

Hotline number for use by the ORT grantees. Section II covers the receipt of these calls, the referral of these calls to the particular 

fraud and abuse agency, and the results or outcomes of these referrals, including the specific action these agencies took. Given the 

initial stages of ORT program implementation and the length of time it takes to resolve a complaint, call volume and resolution 

figures may not be high. 

32
APPENDIX C 

Definitions (Continued)

Building partnerships: The ORT legislation calls for developing partnerships with other state and local agencies and organizations 

responsible for combating health care fraud and abuse. The purpose of these partnerships is to provide for a logical link between 

ORT grantee activities and the work of other entities, including those that receive and investigate complaints. Please identify the 

agencies and organizations you have contacted and the results of your partnership-building activity during the reporting period. 

Staffing and management: ORT grantees vary in how they allocate their funds among the State Unit, Area Agencies, and others 

responsible for program implementation and operation. In addition, many grantees are using the ORT award as seed money to 

stimulate the use of other resources to promote identification and reporting of health care fraud and abuse. Identifying the number 

of staff and volunteers engaged in ORT activity, beyond the limits of the grant, helps demonstrate the extent to which ORT funds 

have leveraged other resources. 

33
APPENDIX D 

Comments

34
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