Case Studies

Medicare Provider Finds Corrective Action to Avoid AEP CMS Violations

Posted by Nick Bravo on February 07, 2017
Nick Bravo
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Background and Client Goals

A licensed Medicare Advantage and Medicare Supplement plan provider needed assistance monitoring their extended salesforce during CMS’s Annual Election Period (AEP). This included independent brokers selling their plans at events and appointments, as well as third-party phone representatives working at auxiliary call centers accepting the client’s overflow calls during peak periods. Specifically, they needed to know if these representatives followed the guidelines set forth by CMS; violations could result in costly fines for the client and even the possible revocation of their CMS contract.

Program Design and Methodology

An industry leader in CMS Compliance Management, TrendSource Trusted Insight determined a combination of mystery phone and sales event audits were fundamental to the client’s compliance management needs. Dispatching Secret Shoppers to the client’s formal and informal events, while also directing Secret Shoppers to schedule and attend 1:1 appointments with independent brokers, TrendSource Trusted Insight provided a robust, on-the-ground analysis. Furthermore, Secret Shoppers were directed to phone the client’s call center and similarly audit representatives as well as translators.

Results and Analysis

During three months of in-person and over-the-phone compliance audits, TrendSource Trusted Insight found that, more often than not, independent brokers and auxiliary call center employees were following CMS guidelines in their descriptions of and answers pertaining to Medicare Advantage and Supplemental Plans. Yet, certain violations did occur and some trended enough to warrant corrective action.

For instance, at events and appointments, brokers occasionally did not provide at least one copy of the enrollment kit (Summary of Benefits, Plan Star Ratings, Multi-Language insert, and Enrollment Form) as mandated by CMS. Further, while often adept at explaining the minutiae of Medicare, they sometimes forgot the basics and did not adequately delineate and explain the three requirements for Medicare eligibility. And, finally, some brokers showed up late for appointments or missed them entirely, signaling a particularly alarming trend requiring the client to follow up.

In call centers, disconnections were frequent enough to warrant concern and intervention. Furthermore, reps occasionally made absolute statements, and translators mistranslated important medical and plan-related details.

Recommendations to the Client

By being alerted to these deficiencies within 48 hours of their occurrence, the client was repeatedly able to implement small-scale corrective action, reaching out to independent brokers with coaching points while also registering long-term concerns moving forward. They similarly were alerted to potential violations at their auxiliary call center, providing them the necessary data to approach their call center partners and insist on corrective and preventative action through additional training.  TrendSource Trusted Insight further recommended regular audits to maintain the client’s standards and ensure continued compliance.

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Topics: CMS, Health Care, CMS Compliance, AEP, Health Care Compliance

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