SMP Counselor Training

1

Provide SMP volunteers and staff with the necessary skills and resources to ◦Hold one-on-one

counseling sessions and

◦Answer simple inquiries consistently across the country.

2

Training Goal

Upon completion of this training, you will be able to:◦Identify the various types of questions

received by the SMP

◦Determine the appropriate response for each type of SMP question

◦Use effective counseling skills and SMP resources when handling SMP questions

3

Objectives

Chapter 1: Types of SMP Questions Chapter 2: Determining the Appropriate Response

Chapter 3: SMP Counseling Skills Chapter 4: Handling SMP Questions

4

See Handout 1: About the SMP Counselor Training

About this Training

What Can I Expect from SMP Counselor Training?

New to answering questions?

Learn new counseling skills.

Some experience answering questions?

Review and practice skills you have used in the past.

Expert counselor?Help mentor those who are newer to counseling.

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6

Let’s Get to Know Each Other

See Handout 2: Counseling Experience

Round 1:How did you get involved in the SMP?

What is your level of experience as a counselor?

Round 2:If you are new, what questions or concerns do you have?

If experienced, share a method for providing good counseling.

Simple inquiries and one-on-one counseling sessions

Provide a valuable service to Medicare beneficiaries in your state

Help your SMP achieve their goals

7

Consideration 1

What Can I Expect as an SMP Counselor?

See Handout 3: State and Local Considerations

Overview SMP vs. Other Counseling Programs Simple Inquiries One-on-One Counseling Sessions Complex Issues Identifying Types of SMP Questions

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9

Why Worry about Types of Questions?

The SMP Mission:To empower and assist Medicare beneficiaries,

their families, and caregivers to prevent,

detect, and report health care fraud, error, and

abuse through outreach, counseling, and

education. 10

11

Sometimes SMP staff and volunteers wear other “hats” (not just their SMP “hat”)◦SHIP: State Health Insurance

Assistance Program

◦AAA: Area Agency on Aging

◦ADRC: Aging and Disability Resource Center

◦Etc.

If you wear multiple “hats”, consider which “hat” you are wearing! This will help you know:◦What to enter in SMART FACTS

◦What to report to other counseling programs

12Consideration 2

Three Types of Questions

One-on-One

Counseling

Complex Issue

Simple

Inquiry

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14

A simple inquiry is a brief contact initiated by a

consumer and/or beneficiary that is resolved with minimal

time, research or review.

They are simple! Many are related to the SMP mission,

but some are not Do not require the review of personal

identifying information, information about a medical condition, or financial account information

15

Tip: If you wear multiple “hats”, remember to consider which “hat” you are wearing when answering

questions.

Examples of simple inquiries that ARE related

to the SMP mission

Examples of questions that are NOT related to the SMP

mission

A request for information about an upcoming SMP presentation

A question about which Medicare plan is best for the beneficiary

A request for a copy of a publication that your SMP recently released

A request for assistance in filing a Medicare appeal

A request for information about becoming an SMP volunteer

A question about whether Medicare or Medicaid will cover a nursing home stay

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OIG Report (Office of the Inspector General) ◦Simple inquiries received

◦Simple inquiries resolved

1997 – 2010◦261,878 simple inquiries received

nationwide

◦249,007 simple inquiries resolved nationwide

17

Consideration 3


One-on-One

Counseling

Complex Issue

Simple

Inquiry

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More in-depth than simple inquiries Additional research or review may

be needed by the SMP Related to the SMP mission You may need to review personal

identifying information/documentation

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Help identify potential fraud, error, or abuse Take place with one individual (or a family) Occur in a variety of settings◦After a group education session

◦At an SMP exhibit at a health fair

◦At the SMP office

Typically held in person, but can be over the phone

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Basic, individualized education about how to ◦Read an MSN

◦Recognize fraud, error, and abuse

Fraud, error, or abuse is suspected but review of their MSN confirms standard Medicare billing practices

After reviewing the beneficiary’s MSN with them, you identify potential error or fraud ◦Send to someone at your SMP who handles

complex issues

21

If you spend time educating and counseling the beneficiary

beyond the level of a simple inquiry, on a topic related to

the SMP mission, it’s a one-on-one counseling

session!

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The total number of one-on-one counseling sessions is included on the OIG Report.

1997 - 2010◦1,112,887 one-on-one

counseling sessions nationwide

23

Consideration 4


One-on-One

Counseling

Complex Issue

Simple

Inquiry

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Related to the SMP mission

Time-consuming

Involve research, including collection of detailed information and documentation

Often require the SMP to act on behalf of the beneficiary

May be identified as part of a simple inquiry or one-on-one counseling session

May result in an “SMP referral”

Require extensive training!

25

26Consideration 5

If a question is related to the SMP mission, and

follow-up is needed by the SMP (i.e. collecting

beneficiary documentation for further research and review), it’s a complex

issue!

A report of a potential error that the provider is unwilling to acknowledge or resolve.

A report of solicitation for equipment that has not been ordered by the beneficiary’s physician.

A beneficiary reports having been called and asked for their Medicare number by someone claiming to be from Medicare or Social Security.

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A report of Part C or Part D marketing violations.

A beneficiary calls to report a scam that they avoided.

A beneficiary sees a charge on their Explanation of Benefits for a service they never received.

Residents from a senior housing complex are being offered money or gifts as incentives to utilize specific providers or services.

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Overview SMP vs. Other Counseling Programs Simple Inquiries One-on-One Counseling Sessions Complex Issues Identifying Types of SMP Questions

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Is the question related to the SMP mission?

No. No.

Simple Inquiry*Simple

Inquiry*

Yes. Yes.

Does the answer require review of personal identifying information

and/or documentation?

No. No.

Is this a brief contact resolved with minimal time, research, or review?

Yes. Yes.

Simple Inquiry Simple Inquiry

No. No.

Can the question be resolved by providing education or information?

Yes. Yes.

One-on-One CounselingOne-on-One Counseling

No. No.

Complex IssueComplex Issue

Yes. Yes.

Maybe.The question is too complex to be sure!

Maybe.The question is too complex to be sure!

Complex Issue?

Complex Issue?

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* If you are wearing more than just your SMP “hat”, see State Consideration #2 and/or the SMP Counselor Training Manual, Chapter 1, Page 2 for more information.

Let’s review highlights to help you determine whether each question is a: ◦Simple inquiry

◦One-on-one counseling session

◦Complex issue

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See Handout 4: Identifying Types of SMP Questions

Answer the Question Yourself Have Someone Else Answer the Question

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Answer the question

yourself, now

Get an answer and call the person back

Send the person to

someone else inside the SMP

Send the person to

someone else outside of the

SMP

Which response is

appropriate ?

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It is a good idea to use the Tracking Form (Appendix E)

during the session to take notes.

This will help you remember the details of your

conversation, both for tracking purposes and in

case additional follow-up is needed.

Answer it now◦ If you know the answer, answer

it

◦ If you can get the answer quickly, ask the beneficiary if they will wait while you look the answer up

Get an answer and call back◦Make sure to get the

beneficiary’s name, phone number, and the best time to reach them

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Ask for help when you don’t

know the answer!

Never provide an answer if you aren’t 100%

confident that it’s accurate!

“Sending the person” to someone else (inside or outside of the SMP) ◦ Implies that the SMP is providing the necessary

contact information to allow the beneficiary, caregiver, or other complainant to act on their own behalf

An SMP “referral” ◦ Implies that the question is a complex issue, and

the SMP is contacting the outside agency on behalf of the beneficiary, caregiver, or other complainant

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Send the person to someone else INSIDE your SMPIf the question is related to the SMP mission but goes beyond the scope of a simple inquiry or one-on-one counseling session

If you are not sure if the question is a complex issue

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Send the person to someone OUTSIDE of your SMP◦ If the question is not related to

the SMP mission, empower the beneficiary to contact the outside organization themselves!

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Examples of services handled outside of the SMP include:

•Benefits counseling •Quality of care concerns•Medicare appeals •Change of address for Medicare / Social Security

What Are They?

Get into small groups

Research 2-3 partner organizations.

Write a question that a beneficiary might ask where the answer would be to refer them to that agency.

39

See Handout 5: SMP Partners and Appendix B

Tip: If you wear multiple “hats”,

remember to consider which “hat” you are wearing when

answering questions.

See Handout 6: Check Your Understanding

Answer the question yourself,

now

Get an answer and call the person back

Send the person to someone else

inside the SMP

Send the person to someone else

outside of the SMP

Which response is appropriate ?

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Steps to Effective CounselingStep 1: Set the StageStep 2: Listen ActivelyStep 3: Respond Appropriately

Tips for Effective CounselingWhat to Say, What Not to Say

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Step 1:

Set the Stage

Step 1:

Set the Stage

Step 2:

Listen Actively

Step 2:

Listen Actively

Step 3: Respond

Appropriately

Step 3: Respond

Appropriately

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Make a good first impression

Greet the beneficiary

Explain how you can help

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See Handout 7: Your Script

Step 1:

Set the Stage

Step 1:

Set the Stage

Step 2: Listen Actively

Step 3: Respond Appropriately

Invite the beneficiary to explain their question or issue

◦ “What can I help you with today?”

Focus on the beneficiary

◦ Stop. Listen. You can’t hear if you do all of the talking.

◦ Be patient. Give your undivided attention.

Take notes

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Step 1:

Set the Stage

Step 2: Listen

Actively

Step 2: Listen

Actively


Ask clarifying questions

◦ Don’t make assumptions

◦ Use open-ended questions

Confirm your understanding of the situation and the beneficiary’s needs

45

Consideration 6

Step 1:

Set the Stage

Step 2: Listen

Actively

Step 2: Listen

Actively


Going through the motions

Interrupting brusquely

Skimming the surface

Doing all the talking

Don’t Fall Into the Trap of Poor Listening!

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Step 1:

Set the StageStep 2: Listen

Actively

Step 3: Respond

Appropriately

Step 3: Respond

Appropriately

Assumptions Body Language Desire Feelings Interactive Communication

Patience

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Point of View Practice Makes Perfect Professionalism and Respect

Reflection Storytelling Understanding

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Medicare benefits and plan options

Answering questions not related to the SMP mission

Answering questions on SMP topics on which you have not received training

Providing too much information

Political opinions

Speaking negatively of Medicare and Medicaid

Endorsing specific products

Offensive jokes51

What Not to Say What to Say

I know it all! That’s fraud!

Your SMP may have some specific language you should use in every counseling session.

52Consideration 7

If you wear multiple “hats”, think about which “hat” you are wearing when answering questions. Even

doctors, lawyers, nurses, and social workers should not answer questions that are not related to the

SMP mission!

Before you Start… Be Prepared

During the SessionAfter the Session:

Tracking and More

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Do your Homework

Know the Process

Use SMP Resources

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Do your Homework

SMP Foundations Training Manual SMP Counselor Training ManualFAQs

Consideration 8

Read the questions and answers. If any answers (and/or questions) are different

for your state, take notes on the FAQ document.

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For example: if your SMP is also a SHIP, how will you handle questions for which

the suggested answer is “Send to: your

state SHIP”?

For example: if your SMP is also a SHIP, how will you handle questions for which

the suggested answer is “Send to: your

state SHIP”?

Consideration 9

If you wear multiple “hats”,

think about which “hat” you are wearing when

answering questions.

57

Know the Process

BeforeDuringAfter the Session

Consideration 10 & 11

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Use SMP Resources

SMP BrochuresPersonal Health Care JournalsFact SheetsState-specific Materials

Consideration 12


During the SessionAfter the Session:

Tracking and More

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Answer the question yourself.

Send the question to someone else.

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I need help understanding how to

read my MSN. Flow chart:

◦ Is the question related to the SMP Mission?

◦ Does the answer require review of personal identifying information and/or documentation?

◦ Can the question be resolved by providing education or information?

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MSN Resources

◦ MSN Fact Sheet – share with beneficiaries!

◦ SMP Foundations Training Manual

Additional Questions to Ask:

◦ Did the beneficiary receive the service, product, or test?

◦ Did the doctor order this service, product or test?

◦ Was the beneficiary billed for the same service, product, or test more than one time?

◦ Is the charge or service related to the beneficiary’s condition or treatment?

65

See Medicare Summary Notice Fact Sheet

If the review reveals questionable charges… send the beneficiary to

the person at your SMP who handles complex issues.

Remember, potential errors which require SMP research to resolve

are also considered complex issues!

I need help understanding how to read my MSN.

May turn in to more than a one-on-one counseling session!

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CAUTION!

What is Fraud, Error, and Abuse?

For more information: ◦Medicare Fraud Fact

Sheet

◦SMP Fact Sheets

◦SMP Foundations Training Manual

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See Handout 8: Identifying Fraud and Abuse and Medicare Fraud Fact Sheet

If your conversation with the beneficiary reveals potential

fraud, error, or abuse:

Send the beneficiary to the person at your SMP who handles complex issues.

What is Fraud, Error, and Abuse?May turn in to more than a one-on-

one counseling session!

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CAUTION!

I received this Personal Health Care Journal. What am I supposed to do

with it?

69

Take it to appointments.

Ask pertinent questions before your appointment.

Write down answers to your questions.

Write down what happens during your appointment.

Take this journal with you when you travel.

Use this journal when checking your Medicare and health care paperwork for accuracy.

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See Handout 9: Personal Health Care Journal and your copy of the PHCJ




How do I use my PHCJ?May turn in to more than a one-

on-one counseling session!

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CAUTION!

I’m confused about a charge on my MSN. I think it might be

fraud… can you help me figure it out?

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It could be fraud… or it may just be a lack of understanding about how Medicare works!

Answer the beneficiary’s questions and/or look at the MSN with them to help resolve their confusion.

If you do identify potential fraud, error or abuse, send them to someone at your SMP who handles complex issues.

This could be explained by services that are not performed in the beneficiary’s presence

◦ Beneficiaries can ask if other suppliers, labs, or doctors will bill Medicare for services related to the visit, and contact their provider to verify that the doctor authorized the charges

◦ You can help review the beneficiary’s MSN to make sure that Medicare was billed only for the services the physician performed or referred

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Why is Medicare Paying for a Service that I Don’t Know About?

If the beneficiary:◦ Is not comfortable contacting the provider

◦Contacts the provider but can’t get the answers they need

◦ Indicates that this is a service that they didn’t receive

Then send the beneficiary to someone at your SMP who handles complex issues so that they can follow up with the beneficiary and provider

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Why is Medicare Paying for a Service that I Don’t Know About?




Confusion related to suspected fraud, error, and abuse…

May turn in to more than a one-on-one counseling session!

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CAUTION!

Know When to Get an Answer and Call the Person Back!

Use the Tracking Form to note the person’s name, phone number, and

best time to reach them. Make sure to follow up.

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Answer the question yourself.

Send the question to someone else.

It all depends on the SMP mission!

Talk with the beneficiary to determine: ◦ If the question involves

potential Medicare fraud, error, or abuse

◦Where to send them for additional assistance if needed 78

Should you send the

person inside or outside of the SMP?

In some cases, complaints and concerns should be sent directly to someone at your SMP who specialized in that area.

Example: Questions about volunteering with the SMP should be sent to your coordinator of volunteers.

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Consideration 13

Tip: This is a simple inquiry.

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If the question is in addition to a complaint about fraud, error, or abuse...◦ It's a simple inquiry or one-on-one counseling

session AND may also be a complex issue

◦See the FAQs and/or flow chart to figure out if it's a simple inquiry or one-on-one counseling session

◦ If you’re not sure whether or not a question is a complex issue, ask for help from someone who handles complex issues

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Any questions that are not related to the SMP mission are simple inquiries. ◦Send these questions to someone outside the

SMP who can help.

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If you wear multiple “hats”, these types of questions may count towards one of

your other counseling program’s numbers. Think about which “hat” you

are wearing when answering and reporting questions.

What type of question is it? For each question, raise a card to show what

kind of question is being asked. On some questions, you may raise more than

one card.

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Simple Inquiry

One-on-one Counseling

Complex Issue

See Handout 10: What Kind of Question Is It?

Because this is a medical identity theft concern, it is considered to be an SMP-related complaint. Send them to someone who handles complex issues!

84

Complex Issue

Simple Inquiry

One-on-One Counseling

AND

OR

I’m afraid that someone has stolen my Medicare

card and is using it to get medications that are not

for me.

If the identity theft is not related to health care fraud, error, or abuse, it is not the role of the SMP to manage the resolution of identity theft. ◦ Send to someone outside

your SMP that can help with their concern, i.e. the Federal Trade Commission.

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I have identified charges on my credit card that I don’t

recognize. I’m afraid someone is using my credit card to purchase things.

If the consumer has Medicare and their Medicare number may have been compromised, treat this as a complex issue!

Complex Issue

Simple Inquiry

AND Simple Inquiry

In cases of consumer identity theft with no relation to the SMP mission:◦Provide the consumer with a

copy of the FTC’s “Deter, Detect, Defend” brochure

◦Recommend that they take the steps in the brochure

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See the FTC’s “Deter, Detect, Defend” brochure

Because the counseling request is the only concern, this is not within the SMP mission.

◦Your role as an SMP counselor is to put the beneficiary in touch with your state’s SHIP program

◦www.shiptalk.org Select “Find a State SHIP”

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Simple Inquiry

I need help choosing which Medicare plan is right for me. Right now is the enrollment period.

Can you help me?

Because this question includes a complaint about potential fraud, error, or abuse, send them to someone at your SMP who handles complex issues.

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Complex Issue

Simple Inquiry


AND

OR

I need help choosing which Medicare plan is right for me.

Right now is the enrollment period. I feel like under my current plan, I am getting

cheated. Can you help me?

Because the appeal is the only concern, this is not within the SMP mission. ◦ Your role as an SMP counselor is to put the

beneficiary in touch with the appropriate agency outside the SMP that can help with the appeal State Health Insurance Assistance Programs

(SHIPs) www.shiptalk.org State Legal Services Providers

http://www.nlrc.aoa.gov/nlrc/Services_Providers/index.aspx

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Simple Inquiry

I was denied a Medicare claim and I want to file an

appeal.

Because the appeal is in addition to a complaint of potential fraud, error, or abuse, send them to someone at your SMP who handles complex issues.

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Complex Issue

Simple Inquiry


AND

OR

I was denied a Medicare claim and I want to file an appeal. I think this is because of that

funny MSN I received a while back that said I had been

given a wheelchair, but that was not true.

Because the complaint is the only concern, this is not within the SMP mission. ◦ Put the beneficiary in touch with your state’s

Quality Improvement Organization (QIO)◦ American Health Quality Association’s

website: www.ahqa.org

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Simple Inquiry

I have been to see the same doctor three times now. I just don’t feel like she is listening to my concerns and is not giving me the

best care possible.

Because this concern is in addition to a complaint about potential fraud, error, or abuse, send them to someone at your SMP who handles complex issues.

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Complex Issue

Simple Inquiry


AND

OR

I have been to see the same doctor three times now. I just don’t feel like she is listening

to my concerns and is not giving me the best care possible. And to make it worse, I think I am being

double-charged!

Because the customer service issue is the only concern, this is not within the SMP mission. ◦ Instruct the beneficiary to

contact the customer service department for that provider

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If customer service issues

persist and accumulate, they become compliance

issues, which are related to

the SMP mission.

The case may become an

SMP complex issue. Simple Inquiry

I have tried contacting my

insurance company to resolve an issue with my Medicare bill, but I can’t get anyone to call me

back.

Because this issue is in addition to a complaint of potential fraud, error, or abuse, send them to someone at your SMP who handles complex issues.

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Complex Issue

Simple Inquiry


AND

OR

I have tried contacting my insurance company because

I think there are charges going through that don’t belong to me. But I can’t

get anyone to call me back. What should I do?

Because this may be legitimate, but could be fraudulent - additional research will likely be needed.

Send this issue to someone at your SMP who handles complex issues so they can investigate.

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I received this postcard in the mail asking me to sign up for a new health care

program.

Complex Issue

Simple Inquiry


AND

OR

If “other” questions are in addition to a complaint of potential fraud, error, or abuse, send them to someone at your SMP who handles complex issues.

If the “other” question is the only concern, this is not within the SMP mission.

◦Send the beneficiary to an information and assistance provider

◦Several options are available

96Consideration 14

Simple Inquiry

Complex IssueSimple Inquiry


ANDOR


During the SessionAfter the Session: Tracking and More

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After the session: Send the beneficiary any applicable materials. Get the answers for questions that you weren’t

able to answer, and call the beneficiary back! Notify the appropriate person at your SMP of

any complex issues so they can follow up. Complete the necessary paperwork and turn it

in.

98Appendix D: Process Checklist

Reporting is important to SMPs for several reasons:◦Provides required information to the OIG and AoA

(Administration on Aging)

◦Shows the media and the general public the hard work that is being done by the SMP to help beneficiaries prevent health care fraud

◦Helps support continued funding for the SMP program

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Consideration 15

You have learned how to effectively handle SMP simple inquiries and one-on-one counseling sessions

Talk with your SMP director and/or coordinator of volunteers about what you need to do to make sure you are ready to begin working as an SMP counselor!

100

(Name), SMP Director, (e-mail and phone)(Name), SMP Coordinator of Volunteers, (e-mail and

phone)(Name), (Other contact), (e-mail and phone)

101

Documents

SMP Counselor Training