Lesson 1: Types of Allegations & Root Causes

Hi, and welcome to lesson one, types of allegations and root causes. So, when we think about the different types of allegations, there’s really three buckets that those may fall into. You have carrier, you have a CTM or a call to Medicare, and you have agent agency, and we’ll talk a little bit about each one of those.

So, in a carrier allegation, it means the member has called into the carrier and said something or given some indication that there may be, a need for a sales allegation. Now, this could be a blatant kind of conversation that the beneficiary has with the carrier rep, such as, “I don’t remember enrolling to the plan”, or “My agent never went over that benefit with me.” It can also be a little more subtle where they’re really calling just to ask a general question, and they say something like, “I don’t remember going over that with my agent”, or, “I didn’t remember that I had that benefit.” So, there can be a lot of different factors that play into the reasons for the allegations, but generally it’s gonna be the member calling into the carrier and asking something about their plan.

Same thing with CTMS or calls to Medicare in this case, just like with the carrier ones, the beneficiaries calling in to either formally log a complaint or sometimes just generally ask a question. The difference is that in this case, the beneficiary didn’t call the carrier; they called directly into Medicare.

And then the third bucket, which we don’t see happen quite as often, but it can occur, is the agent or agency, meaning the beneficiary, has called directly into you or into your agency or your upline to file a complaint about something that occurred during the sales process. Now, this is not them just asking general questions and things like that, but if you do have somebody that calls into your office or calls you and says, “why did you enroll me in this plan? I didn’t know I was being enrolled”, or, “I told you I didn’t want this plan.” That’s something that, should be reported up to the carrier. And you know, if you don’t know how to do that, definitely reach out to your upline to seek guidance and they can help you through that process.

Now, the timeframe responses for allegations will also depend a little bit about where it came from or where it originated from. So, this is not kind of a, a, a black and white rule of thumb, but generally speaking, if it is a carrier allegation, you’re gonna have about 5-7 business days to get that response back into the carrier once an allegation is triggered. If it’s a CTM, we typically see those timeframes shortened a little bit. So, Medicare will send the allegation notice to the carrier. The carrier will send it to you as the agent, and you’ll have sometimes as short as, you know, two to three business days to get that response along with any corresponding documentation back into the carrier so they can prep their summary, um, findings and send that back to CMS.

Now, again, if it’s an agent or agency uncovered allegation, report that up to the carrier, and they’ll treat that like a carrier allegation if they feel a need to proceed with that. And when we talk about allegations, there’s a lot of driving factors that can, lead to an allegation.

We’ll get to that a little more in lesson two, but I wanna talk about some of the main root causes that we see, across the industry as well as the carriers see as being kind of the main driving factors for the increase in sales allegations that we’ve seen over the last couple of years.

The first one is lead source, and that can be as simple as using a non-compliant lead or working with non-compliant vendors. But we also see it from things like purchasing non-exclusive leads, which are leads that maybe you’re buying but are also being sold to, you know, 5, 6, 7 other agents at the same time. So, this beneficiary is just getting kind of hammered with calls all kind of around the same time. We also see something in the industry called churned leads. And what this means is you’re maybe you’re buying a lead from kind of a national vendor. A beneficiary sees a number on TV or gets something in the mail, and they call that number and the beneficiary is routed to you as the agent. But if that same beneficiary calls into that same number, the next time they’re not getting routed back to you to assist them as you did the first time. This time, they’re getting routed to a different agent or agency. And if that member calls into that number 10 times, they might get routed to 10 different agents. So, we see this not only as a driving factor of, of increased sales allegations, but also some of the trends that we’re seeing in the industry in regards to switchers and how we may have, you know, one beneficiary who may be enrolled in, you know, into 10 different plans or sometimes re-enrolled into the same plan by 10 different agents over the course of an AEP. Misleading content. This could be something such as you’re using a lead that advertises part B give back, and the member sees that receives that lead, but they’re not in an area that has a part B give back plan. So, the the content of the lead is misleading. They called in because they found it to be, something that they wanted to learn more about, and then they get enrolled into a plan that doesn’t have part B give back. You know, fast forward maybe 60 or 90 days and they kind of forgot that conversation and they’re, they’re trying to figure out why their plan doesn’t have that give back benefit involved into it. That can lead to sales allegations as well. And lastly, aged leads. And you know, we’re not talking about aged leads that are maybe 90 days old. We’re talking about aged leads that may be one, two years old. Where a beneficiary has given permission to contact, but a lot of time has passed since that’s happened. General best practice rule of thumb and something that we see in the proposed rule from CMS that came out towards the end of last year is making sure that you are not contacting beneficiaries unless they have given permission to contact in the last six months.

The second root cause of increased sales allegations is just insufficient training or knowledge or just a failure to follow CMS and carrier guidelines. You know, we know that these change pretty frequently these days. So, sometimes it’s just a simple misunderstanding or a misinterpretation of a new guideline that comes out that happens with all of us. But,  sometimes it’s just a failure to follow updated CMS or carrier guidelines or not understanding all of the sections of a compliance sales process that needs to occur, especially when selling over the phone.

Third, we have post-enrollment practices. So, you know, we all know that providing the beneficiary with your contact information so that they can call you if they have questions versus calling the carrier or calling Medicare directly is a great way to kind of help mitigate some of those sales allegations, but it goes a little bit further. So, maybe ask yourself, do you have a follow-up process? If so, what does that look like? Are you only contacting the beneficiaries, you know, the following year during AEP or do you have sort of a cadence to what that follow up process looks like? The second piece of that is having a solid member retention strategy. So, you know, you don’t wanna just follow up by calling the member and saying, Hey, is everything going okay? Fantastic, I’ll talk to you. And, you know, in 60 days you wanna have some sort of member retention strategy that when you call them or when you email them, you’re delivering value to them. Doesn’t always have to be about the plan or the benefit themselves. It could be something, you know, just topical from an industry standpoint that Medicare beneficiaries find useful. So, have a follow up plan and make sure you have kind of a built-in member retention strategy as well. And then the fourth is a lack of script adherence. So, of course we’re gonna see this primarily in the call center space, but we do have a lot of field agents now that are selling over the phone or primarily over the phone. You know, you don’t have the same exact type of script or scripting requirements currently in the call center space. But having a telephonic script, if that’s your primary mode of selling is helpful to make sure you’re hitting all of the components of a sales practice and a sales process. And of course, if you are in a call center, you do have to follow those telephonic scripts that are approved by CMS and the carriers almost verbatim. So, skipping any sections or failing to follow that can certainly cause you to miss important parts of the sales process leading to sales allegations. And last, but definitely not, not least, is regardless of how you sell, it’s not pausing to ask if the beneficiary has any questions or making sure that they are fully understanding the benefits that you’re reviewing with them.

Now, before we move on to the next lesson, let’s take a brief quiz to test your knowledge.