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AEP 2016 Findings: Top Violations Per Audit Type

Posted by Dean Robertson on 2/29/16 3:13 PM
Dean Robertson

Every year, TrendSource executes Secret Shop programs with over 30 Medicare Advantage plans during the Annual Enrollment Period to ensure their sales agents are meeting CMS Marketing Guidelines. Based on over ~4000 Secret Shops completed, we were able to identify the top violations per audit type that occurred during AEP 2016. Some of these violations were an issue last year; however, some of these violations are new issues we were able to relay to our clients for corrective action.*

Events

  • Agents did not clearly explain the difference between network and preferred pharmacies
  • Step Therapy was not always clearly explained during events
  • The difference between the plan premium and Part B premium was not clearly explained by some of the Sales Agents
  • The transition process for prescription drugs was not always clearly explained by Sales Agents
  • Sales Agents did not always discuss the coverage gap in detail
  • Sales Agents were not always onsite and ready for the event at the scheduled start time

Appointments

  • The Scope of Appointment was not completed, or was completed at the incorrect time
  • Sales Agents did not always discuss enrollment periods, or were explained incorrectly. This includes the Late Enrollment, Disenrollment, and Special Enrollment Periods.
  • Sales Agents did not always discuss Step Therapy during appointments
  • The transition process for prescription drugs was not explained clearly by Sales Agents
  • Sales Agents did not always clearly explain the difference between network and preferred pharmacies

Call Center Monitoring

  • Some call center reps were not answering questions confidently
  • Disconnections occurred at some point during the call
  • The time from when the Call Center Rep answered the call to the time they started answering the first question related to plan-specifics (“Hard Skills”) exceeded 7 minutes.
  • Some call center reps were answering plan-specific questions incorrectly

Check out TrendSource’s AEP 2016 in Review for further insights on this year’s AEP season.

*Deficiencies are listed in no particular order.

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

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