Protecting Your Medicare: The Senior Medicare Patrol Program

Medicare fraud is one of the most expensive crimes in America. The National Health Care Anti-Fraud Association estimates that healthcare fraud costs the United States $68 billion to $230 billion per year, with Medicare and Medicaid bearing a disproportionate share of those losses. Fraudulent billing schemes range from simple errors—a provider accidentally bills for the wrong procedure code—to elaborate criminal enterprises that bill Medicare millions of dollars for services never rendered, equipment never delivered, and patients never seen.

The victims of Medicare fraud are not abstract budget line items. They are real people: the 78-year-old widow who receives a bill for a wheelchair she never ordered, the cancer patient whose medical records are compromised by identity theft, the veteran whose Medicare benefits are exhausted by charges for phantom services, leaving less coverage for legitimate care. And ultimately, every taxpayer is a victim, because Medicare fraud drains the Trust Fund that finances healthcare for 67 million Americans.

The Senior Medicare Patrol (SMP) program, funded by the Administration for Community Living (ACL) and part of the broader federal effort to combat healthcare fraud, empowers Medicare beneficiaries to be the first line of defense. Operating in all 54 U.S. states and territories through a network of over 5,000 trained volunteers, SMP educates beneficiaries about how to detect fraud, reviews Medicare statements to identify suspicious charges, and assists beneficiaries in reporting fraud, errors, and abuse to the appropriate authorities.

Since its inception in 1997, the SMP program has identified over $346 million in potential savings from healthcare fraud, errors, and abuse. But the program’s true value extends far beyond dollar figures—it protects individual beneficiaries from financial harm, medical identity theft, and the compromise of their healthcare, while fostering a culture of vigilance that deters fraud across the entire Medicare system.

Opportunity Snapshot

What Medicare Fraud Looks Like

Understanding Medicare fraud starts with knowing what to look for. Common fraud schemes that SMP helps beneficiaries identify include:

Billing for services not rendered: A provider submits claims to Medicare for services, tests, or procedures that were never actually performed. This is the most common form of Medicare fraud.

Upcoding: A provider bills Medicare for a more expensive service or procedure than what was actually provided. For example, billing for a comprehensive office visit when only a brief visit occurred.

Unbundling: A provider breaks a single procedure into multiple component parts and bills each separately at a higher combined cost than the bundled rate Medicare would normally pay.

Phantom billing: Clinics, labs, or equipment suppliers submit claims for patients who never visited the facility or received any services.

Kickback schemes: Providers receive payments for referring patients to specific labs, clinics, pharmacies, or equipment companies—the costs of which are passed on to Medicare through inflated billing.

Medical identity theft: Someone uses your Medicare number, Social Security number, or personal health information to fraudulently bill Medicare for services you never received. This can affect your medical records, compromise your care, and exhaust your benefits.

Unnecessary services: Providers order and bill for tests, procedures, or equipment that have no medical justification—driven by profit rather than patient need.

Durable medical equipment (DME) fraud: Companies deliver equipment that was never ordered by a physician, bill for equipment more expensive than what was delivered, or continue billing Medicare after a patient has returned or no longer needs equipment.

How SMP Helps You

Medicare Statement Review

The foundation of SMP’s work is helping beneficiaries understand and review their Medicare Summary Notices (MSNs) and Explanation of Benefits (EOBs). These documents—sent by Medicare after each healthcare service—list every service billed to Medicare on your behalf, including the provider, date of service, procedure description, amount billed, Medicare-approved amount, and your financial responsibility.

Most beneficiaries either ignore these statements or find them too confusing to understand. SMP volunteers are trained to review statements line by line with beneficiaries, identify charges that don’t match the services you remember receiving, spot patterns that may indicate fraud (such as billing for services on dates you didn’t see a provider), explain confusing terminology and billing codes, and help you determine whether a charge is a legitimate service, an honest error, or potential fraud.

Fraud Education

SMP conducts extensive community education to help beneficiaries protect themselves before fraud occurs. This education covers how to read and understand Medicare statements, the most common types of Medicare fraud and how to recognize them, how to protect your Medicare number and personal health information, the dangers of “free” medical services offered door-to-door or by phone, how to recognize Medicare-related scams (phone calls, emails, letters), how to avoid medical identity theft, and your rights and responsibilities as a Medicare beneficiary.

Education is delivered through community presentations at senior centers, libraries, faith communities, and other gathering places, one-on-one counseling sessions, printed materials and consumer alerts, webinars and online resources, health fairs and community events, and partnerships with local media to spread awareness.

Reporting Assistance

When a beneficiary identifies a suspicious charge or potential fraud, SMP counselors help navigate the reporting process. Depending on the nature of the issue, SMP can help you contact the provider directly to resolve billing errors, file a complaint with your Medicare plan or Medicare contractor, report suspected fraud to the HHS Office of Inspector General (OIG) hotline at 1-800-HHS-TIPS, report suspected fraud to the Medicare hotline at 1-800-MEDICARE, file a complaint with your state’s Department of Health or Attorney General, and work with law enforcement if criminal activity is suspected.

SMP counselors understand the different reporting channels and can guide beneficiaries to the most appropriate resource for each situation. They can also help beneficiaries document their concerns in a clear and organized way that facilitates investigation.

Complex Case Assistance

For beneficiaries facing serious fraud situations—medical identity theft, large-scale billing fraud, or complicated disputes with providers or plans—SMP staff and volunteers provide more intensive assistance. This may include coordinating with the HHS Office of Inspector General, working with Medicare Administrative Contractors to resolve billing disputes, assisting with Medicare appeals when claims are denied due to fraud-related complications, connecting beneficiaries with legal assistance (through Legal Services Corporation or other resources), and following up to ensure that fraudulent charges are removed and benefits are restored.

The SMP Volunteer Network

SMP’s effectiveness depends on its volunteer network. Over 5,000 trained volunteers serve as SMP counselors, community educators, and peer mentors across the country. SMP volunteers typically are retirees who bring professional expertise from healthcare, law, accounting, education, social work, and other fields. They undergo specialized training in Medicare policies, fraud detection, counseling techniques, and privacy protections. They serve at senior centers, libraries, healthcare facilities, community organizations, and faith-based institutions. They often work alongside SHIP (State Health Insurance Assistance Program) counselors, combining fraud prevention with insurance counseling for a comprehensive service.

SMP is always seeking new volunteers. If you have a few hours a week and want to help protect your community from healthcare fraud, contact your local SMP program to learn about volunteer opportunities.

Protecting Yourself: SMP’s Key Messages

SMP distills its fraud prevention guidance into several key messages that every Medicare beneficiary should know:

Protect your Medicare card like a credit card. Your Medicare number is valuable to fraudsters. Never share it with anyone who contacts you unsolicited—by phone, email, text, or door-to-door. Medicare will never call you to ask for your Medicare number (they already have it).

Review your Medicare statements carefully. Check every Medicare Summary Notice and Explanation of Benefits you receive. Look for services you don’t remember receiving, providers you don’t recognize, dates that don’t match your records, and charges for equipment you didn’t order.

Report suspicious activity immediately. If something doesn’t look right, don’t ignore it. Contact SMP, your provider, or 1-800-MEDICARE. Early reporting is critical—the sooner fraud is detected, the sooner it can be stopped.

Be skeptical of “free” offers. Be wary of anyone offering free medical services, equipment, or supplies in exchange for your Medicare number. If it sounds too good to be true, it probably is.

Keep records of your healthcare. Maintain a simple log of doctor visits, tests, and procedures—including dates, providers, and what was done. This makes it easy to cross-reference your Medicare statements and identify discrepancies.

The Scope of Medicare Fraud

The financial scale of Medicare fraud is staggering. The Medicare program processes over 1.2 billion claims per year—a volume that makes it impossible to review every claim before payment. The “pay-and-chase” model, in which Medicare pays claims quickly and then investigates fraud after the fact, creates opportunities for criminals. Conservative estimates place annual Medicare fraud losses at $60 billion; some experts believe the true figure exceeds $100 billion.

In recent years, the Department of Justice has prosecuted Medicare fraud cases totaling billions of dollars. In 2023 alone, DOJ’s Healthcare Fraud Strike Force charged hundreds of defendants in fraud schemes totaling over $1.4 billion. These cases involved every type of fraud imaginable—from phantom clinics in Miami billing for non-existent services to international criminal organizations using stolen patient identities to bill for compounding pharmacy medications.

SMP’s role in this ecosystem is both preventive and detective. By educating beneficiaries to review their statements and report anomalies, SMP creates millions of additional “auditors” who can catch fraud that might otherwise go undetected.

Frequently Asked Questions

Will I get in trouble for reporting fraud that turns out to be an honest error? Absolutely not. SMP encourages beneficiaries to report anything that looks suspicious. Many reports turn out to be billing errors rather than fraud, and that’s perfectly fine—errors need to be corrected too.

Can I report fraud anonymously? Yes. You can report suspected fraud anonymously to the HHS OIG Hotline at 1-800-HHS-TIPS or online at oig.hhs.gov. Your identity will be protected.

What if I participated in fraud unknowingly? If someone used your Medicare number to bill for services you didn’t receive, you are a victim, not a perpetrator. Contact SMP immediately for assistance. If you knowingly allowed someone to use your Medicare number, contact an attorney—but still report the situation.

Does SMP investigate fraud directly? No. SMP educates, counsels, and assists with reporting. Actual fraud investigation is conducted by the HHS Office of Inspector General, the Department of Justice, and other law enforcement agencies.

Is SMP the same as SHIP? No, though they often work together. SHIP (State Health Insurance Assistance Program) provides comprehensive Medicare counseling—plan comparison, enrollment, billing help. SMP focuses specifically on fraud prevention and detection. Many communities co-locate SMP and SHIP services.

How to Get Started

1. Call the SMP National Hotline at 1-877-808-2468
2. Visit smpresource.org to find your local SMP
3. Report suspected fraud to 1-800-MEDICARE (1-800-633-4227)
4. Report to the HHS OIG Hotline at 1-800-HHS-TIPS (1-800-447-8477)
5. Contact your local SMP through your Area Agency on Aging
6. Attend a free SMP community presentation at a senior center or library near you

Your Medicare benefits are a precious resource—one that you’ve earned through a lifetime of work and contributions. Don’t let fraud steal what’s rightfully yours. Review your statements, protect your Medicare number, and when something doesn’t look right, call SMP. Together, we can protect Medicare for this generation and the next.