smp counselor training
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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.
5
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
8
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
13
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
16
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
Three Types of Questions
One-on-One
Counseling
Complex Issue
Simple
Inquiry
18
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
19
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
20
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!
22
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
Three Types of Questions
One-on-One
Counseling
Complex Issue
Simple
Inquiry
24
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.
28
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?
30
* 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
32
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 ?
33
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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
35
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
36
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
37
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!
38
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 ?
40
Steps to Effective CounselingStep 1: Set the StageStep 2: Listen ActivelyStep 3: Respond Appropriately
Tips for Effective CounselingWhat to Say, What Not to Say
41
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
42
Make a good first impression
Greet the beneficiary
Explain how you can help
43
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
44
Step 1:
Set the Stage
Step 2: Listen
Actively
Step 2: Listen
Actively
Step 3: Respond Appropriately
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
Step 3: Respond Appropriately
Going through the motions
Interrupting brusquely
Skimming the surface
Doing all the talking
Don’t Fall Into the Trap of Poor Listening!
46
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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
48
Point of View Practice Makes Perfect Professionalism and Respect
Reflection Storytelling Understanding
49
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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.
56
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
58
Use SMP Resources
SMP BrochuresPersonal Health Care JournalsFact SheetsState-specific Materials
Consideration 12
Before you Start… Be Prepared
During the SessionAfter the Session:
Tracking and More
59
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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?
64
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!
66
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!
68
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.
70
See Handout 9: Personal Health Care Journal and your copy of the PHCJ
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.
How do I use my PHCJ?May turn in to more than a one-
on-one counseling session!
71
CAUTION!
I’m confused about a charge on my MSN. I think it might be
fraud… can you help me figure it out?
72
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
73
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
74
Why is Medicare Paying for a Service that I Don’t Know About?
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.
Confusion related to suspected fraud, error, and abuse…
May turn in to more than a one-on-one counseling session!
75
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.
79
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.
83
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.
85
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”
87
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
One-on-One Counseling
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.
90
Complex Issue
Simple Inquiry
One-on-One Counseling
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
91
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.
92
Complex Issue
Simple Inquiry
One-on-One Counseling
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
One-on-One Counseling
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.
95
I received this postcard in the mail asking me to sign up for a new health care
program.
Complex Issue
Simple Inquiry
One-on-One Counseling
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
One-on-One Counseling
ANDOR
Before you Start… Be Prepared
During the SessionAfter the Session: Tracking and More
97
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
99
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
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