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Top Violations Identified Through AEP 2014 Compliance Programs

Posted by Amber Berger on 2/19/14 10:20 AM
Amber Berger

Human nature ensures that we are constantly comparing our performance to others. The questions on all of our minds are...Am I normal? Are my organizational issues the same as others? To support our clients in answering these questions with regards to top violations of CMS Marketing Guidelines in the 2014 AEP season, we’ve listed the common threads that we saw below. Were these the issues you saw in your organization?

During the 2014 AEP season, TrendSource conducted ~4,000 compliance audits and we wanted to share with you the top deficiencies we uncovered for our clients.

*Deficiencies not listed in any particular order.

1. Events (Formal and Informal)

  • Plan-specific enrollment kits were not provided, OR they were missing some of the required items
  • Step Therapy was not explained
  • The plan’s Overall Star Rating was not discussed
  • It was not clear whether or not sign-in sheets were optional
  • Agents didn't clearly explain the difference between preferred and network pharmacies

2. 1:1 Appointments

  • Election periods were not fully explained
  • Step Therapy was not explained
  • Scope of Appointment was not completed according to requirements
  • The Coverage Gap was not explained in full
  • Agents didn’t explain the difference between paying the plan premium versus paying the Part B premium

3. Prospective Member Accuracy of Information Calls

  • Calls were disconnected
  • It took longer than 7 minutes to receive an answer to the first Accuracy of Information question
  • Calls failed based on accuracy of information given
  • Call Center Reps did not answer questions confidently
  • Hold times were longer than 2 minutes (to reach a live person)

Identifying deficiencies as they occur allow our clients to take corrective action and stop trends before they snowball into larger issues. Also, our findings tend to corroborate with what CMS is seeing in the field. This allows our clients to proactively make changes to potentially avoid larger compliance infractions.

Don’t forget to read TrendSource’s AEP 2014 in Review for more detailed insights on last year’s compliance audits.

For more information on how TrendSource can assist you with execution of compliance monitoring programs to help prevent violations, visit our CMS services page.

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Topics: Market Research, Featured, CMS Compliance

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