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5 Keys to Running a Successful Medicare Compliance Program

Posted by Amber Berger on 4/10/13 9:22 AM
Amber Berger

As the Account Manager for our Secret Shopper Medicare Compliance Programs, I currently manage 20+ programs for healthcare insurers, most of which are Medicare Advantage/Prescription Drug organizations. Through the course of working with so many different companies, I’ve noticed several trends and gained a lot experiential knowledge, so I have a pretty good handle on what makes a Medicare compliance program successful – and unsuccessful for that matter. We aim to support the healthcare insurance community with compliance efforts in order to get the highest possible value out of the programs. We genuinely see these programs as more than simply a CMS requirement; there is a major opportunity to use these programs as a means to grow and improve as a company.

All that being said, I put together five keys for running a successful program. Enjoy!

1. Create a collaborative culture of compliance within your organization
I know – easier said than done, right? However, we find that the most successful compliance programs tend to come from organizations where the compliance team and sales/marketing team are both on board with the program. There’s the tendency to see compliance (and mystery shoppers) as “the bad guys”. It’s important that everyone understands the role of compliance, because when it comes down to it, they (and we!) are there to help. Transparency about the intent of the program, and how the data will be used, is key. Our motto at TrendSource is, “We’re not here to grade you. We’re here to help you get an A.”

2. Give your sales team the tools to succeed
Whether it is a DVD presentation covering required health plan/CMS topics, or a sales agent summit to ensure everyone is on the same page, it’s important to maintain constant communication with your sales force. Requirements and CMS dictations are constantly changing, so it’s important for organizations to be nimble and have a plan in place to quickly disseminate information with those that are ultimately responsible for communicating important information to potential beneficiaries.

3. Understand that every sales person poses some risk
There’s a tendency to assume that certain individuals don’t pose marketing compliance risks. However, even an experienced, captive agent poses some sort of risk. It’s easy to go off script, and even if it’s just for a moment, there is always the chance that one statement is misinterpreted and/or gets blown out of proportion. Maybe CMS is at that marketing event; maybe a beneficiary takes the statement out of context. Either way, it’s important to even the playing field and understand that some degree of monitoring (secret shopping) is good to have in place, even for those experienced agents. It doesn't mean that all agents must be shopped all the time, but we find that even just knowing that there is the possibility of a shop can significantly influence positive changes in behavior.

4. Maintain the appropriate internal resources to manage a compliance program
Typically compliance/mystery shopping programs start with the best intentions. There are people to spearhead the project and get it up and running. Resources are budgeted and available. Then things get busy, and the project can easily be put on the backburner. Even once the program is up and running, it’s important to have dedicated resources to review and disseminate the information. Much of the data that we collect is actionable, as well as somewhat perishable. During AEP season when call volumes spike, and sales agents hold events and appointments in short succession from one another, it’s especially important to have a plan in place to quickly share information and take corrective action. This allows you to ensure that the same mistakes are not made over and over. Having a dedicated point person to assist in the management of both corrective action as well as positive reinforcement goes a long way in maximizing the value of the program.

5. Sustain high levels of communication with your mystery shopping vendor
Now hear me out on this one…I’m well aware that people in compliance tend to wear many, many hats, and schedules are quite demanding, especially leading up to and during AEP, but we find that in order to maintain a smooth running, successful program, regular and open communication is key. We recommend short reoccurring meetings with your secret shopping vendor in order to keep that time budgeted and available to discuss any potential questions, issues, or areas for opportunity. What trends are we seeing? Where can we do better? These short meetings tend to decrease the need for larger discussions on the backend. The goal should be to do things right the first time, and to address minor concerns as they arise, so they don’t snowball into major issues.

Topics: Featured, CMS Compliance

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