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Top Violations Found in AEP 2015 Secret Shopper Compliance Programs

Posted by Chris Bellesia on 2/26/15 4:17 PM
Chris Bellesia

Supporting over 30 health plans nationwide in their compliance towards CMS Marketing Guidelines, TrendSource is in a unique position to identify the top violations that occurred during AEP 2015. Based on over 4,000 completed secret shop compliance audits during the 2015 AEP season, we found the following to be the top violation trends.

Most of these violations were not trending during AEP 2014. Across the board, health plans improved their performance by addressing violations identified during AEP 2014.

Events and Appointments
Deficiencies not listed in any particular order.

  • Transition Fill – Sales Agents did not always clearly explain the transition process when a new plan member’s current medication is not on the plan Formulary.
  • Exception Process - Sales Agents did not always clearly explain the prescription drug coverage exception process when a new plan member’s current medication is not on the plan Formulary.
  • Election Periods – Specifically, the Medicare Advantage Disenrollment Period (MAPD) was not always discussed.
  • Preferred vs. Network Pharmacies – Sales Agents did not always explain the difference between preferred and network pharmacies. This violation was also seen in the top trends of AEP 2014.
  • Provider Network Resources – Sales Agents did not always explain how or where to find providers in the provider network.

Appointments (Only)
During One-on-One Appointments with potential beneficiaries, an additional violation trend was found.

  • Medicare Advantage (MA) Eligibility - Sales Agents did not always inform potential members that they must live in the plan’s service area to be eligible. This is important because potential beneficiaries may move out of the plan’s service area, and therefore would no longer be eligible.

Call Center
Deficiencies not listed in any particular order. During phone conversations with potential beneficiaries, the following key experience metrics were seen as top violations.

  • 7 Minute Threshold Exceeded – 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.
  • Disconnections – Calls were disconnected an average of 5% of the time (ranging from 2-10%) across health plans.
  • Licensed Rep Availability – As was the case last year, there were issues with availability of Licensed Reps due to high call volumes.
  • Hold Time for a Translator – When it came to connecting callers to a Translator, it took over 7 minutes to connect to a Translator, causing callers to wait for a long period of time to receive the information they were seeking.

Don’t forget to read TrendSource’s AEP 2015 in Review for further insights on this year’s AEP season.Click Here to Contact Us

Topics: Market Research, Featured, CMS Compliance

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