AEP 2016 has come to a close. During our 7th successful AEP season, we ended up completing over 4,000 “Secret Shops” for our 30+ Medicare and Medicaid clients.
Below are the top trends we found to be the greatest compliance risks for providers:
Formal/Informal Events
- Transition Fills: Like last year, the transition fill process was not always explained clearly to potential beneficiaries. This means that if a beneficiary changes plans and the new plan does not cover their prescription drug, a beneficiary may not be aware of the next steps to get the medication they need, or the one-time aspect of the refill.
- Step Therapy: Step Therapy, which is beginning prescription drug therapy with a cost-effective and safe prescription, was also not explained clearly during events. Step Therapy allows patients to save money while receiving the treatment they need.
- Part B Premium: Sales agents didn’t always clarify the difference between the Part B premium and the Medicare Advantage plan’s premium. Even though the Part B premium is automatically deducted from beneficiaries’ Social Security checks, one must be made aware of the difference, or else a complaint can be lodged against the plan if the beneficiary feels misled.
Appointments
- Scope of Appointment: Sales agents need to provide the Scope of Appointment before the appointment begins to ensure beneficiaries know and agree to what will be discussed. If this protocol is not followed, it could be seen as the sales agent taking advantage of the appointment for their own benefit.
- Disenrollment Period: If election periods were discussed, more often than not, the sales agent forgot to mention the disenrollment period which runs from January 1 through February 14. If beneficiaries find that they do not need the Medicare Advantage plan and are unaware of the ability to un-enroll during this period, they will incur unexpected costs and can file a complaint again the Medicare Advantage plan.
Call Center Audits
- Hard Skills Questions: Many call center reps provided last year’s plan benefit information when our shoppers asked plan-specific questions. We are finding that as we enter the new year, items like Medication Therapy Management or the cost to leave the coverage gap are being missed by reps who are providing last year’s information. Since CMS will be auditing call centers between February and May, now would be a good time to test your rep’s knowledge!
TrendSource designs custom Medicare/Medicaid Secret Shopper Compliance Programs to help mitigate the extreme risks of non-compliance and evaluate overall customer service to internal standards. Secret Shops are customized for formal/informal events, one-on-one appointments and call programs (supporting all CMS focus languages for translation services).
