Case Studies

During AEP, CMS Event Audits Rapidly Report Compliance Issues

Posted by TrendSource on September 11, 2018

Background and Client Objectives

A Medicare Supplement provider needed to ensure it remained compliant with Center for Medicare/Medicaid Services (CMS) regulations during the Annual Election Period (AEP). They were particularly concerned about in-person meetings between prospective customers and their agents, namely 1:1 appointments, informal events, and formal events, all of which connected licensed providers to potential customers.

The client knew that in these settings, certain informational materials must be provided to attendees, certain questions must be answered according to script, and that unpredictable situations arose that require agents to provide accurate information. 

Rather than find themselves on the wrong side of CMS regulations, which could result in punitive action and even contract termination, they came to TrendSource looking to establish an in-person compliance audits program.

Program Development and Methodology

With a decade of experience designing and executing in-field CMS compliance audits, TrendSource quickly worked with the client to design a program that both addressed their concerns and also looked to issues they had yet to consider. TrendSource built questionnaires for each meeting type to ensure all areas of compliance were addressed, and designed a sampling schedule to ensure all reps were audited at least once during the period.

With the client’s approval, TrendSource scheduled the audits across each region in which the client operated, utilizing its nationwide Field Agent database to ensure 100% coverage and completion.

Results and Analysis

TrendSource provided detailed reports to the client within 72 hours of the audited event, alerting them to urgent areas of noncompliance before they were detected by CMS. In 1:1 appointments, the most common issue was one that would seem quite preventable: often agents simply no called/no showed their appointments, missing the scheduled meeting with a prospective customer, in direct violation of CMS regulations. 

In formal events, the licensed agent often failed to provide the required materials including a Summary of Benefits, Plan Star Ratings, Multi-Language insert, and Enrollment Form. The same problem arose at informal events, which were also characterized by absentee agents not in their scheduled meeting place at the appointed times.

Other issues across all three event types included reluctance to answer hard skills questions as well as a failure to accurately outline the requirements of Medicare eligibility.  

Conclusion

By reporting these issues within 72 hours of their occurrence, TrendSource ensured the client had ample opportunity to make small scale corrective action before encountering punitive action from CMS. With regards to absentee agents in particular, the client was able to implement scheduling corrections and also reach out to their partners to ensure such misses did not occur.

A strong in-person audit program provides Supplement providers with the on-the-ground intelligence necessary to ensure compliance with stringent CMS regulations. This rapidly alerts them to their shortcomings in the field while also allowing them to fine tune training materials to address areas of concern moving forward.

Topics: CMS, Compliance, CMS Compliance, Mystery Shopping

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