Lesson 2: Allegation Families & Best Practices

Welcome to lesson two, Allegation families. In this lesson, we’re gonna walk through the main families or buckets that we see sales allegations generally fall into as we go through this lesson, you may notice that some allegations can fall into more than one bucket. So, you may have an allegation that touches on an operational component as well as a plan and product component. The, the allegation families that we’re gonna go over in this lesson include lead and permission to contact plan and product prohibited activities, risk to beneficiary, operational, and point of sales. Let’s get started with lead and permission to contact.

In this bucket, we see things such as misleading marketing materials or non-compliant leads. Failure to capture permission to contact and specific permission to contact for Medicare Advantage or the plan types. You’re going to be speaking with them about using outdated permission to contact and using churned leads, which we talked about in lesson one. So, some best practices that you can engage in to avoid sales allegations in this allegation family. Number one, confirm you’re partnering with a reputable lead vendor. If you’re purchasing leads, asking some basic initial questions on the front end, such as, can you share with me some examples of leads that I may be using? Are you able to provide me with the lead material or a trusted form such as Jornaya? if I get a sales allegation, they should be answer, able to answer yes to all of those. And if not, you may wanna look for a different lead partner. Second, confirm. All materials used to generate leads are compliant, whether you’re generating those on your own and creating that collateral, or whether you’re purchasing leads. And it doesn’t matter what medium either. So, it could be social media, email, print, mail, direct mail, whatever it is, you wanna make sure that it’s compliant with current CMS and carrier guidelines. If you’re not sure if you need a little bit of help, please make sure that you’re engaging your upline or carriers to take a second look at your materials. Third, confirm leads are not misleading and that you’re very clear in your lead material what you’ll be speaking to them about. So, if it’s a Medicare Advantage plan, if it’s Medicare health plans, including Medicare Advantage and Medicare supplement options, or maybe something as specific as a dual special needs plan, you wanna make sure that that is very clear in your marketing materials so there’s no confusion from the beneficiary on the backend. Next, confirm that you’re using a permission to contact, um, form or permission to contact from the beneficiary that has been given in the past six months and is specific to what you’re going to be contacting them about. If you have permission to contact that’s older than that you know, we recommend that you try to capture new permission to contact. Maybe you send them another letter or a mailer. If they haven’t opted out to email, you can reach out to them via email as well. And lastly, confirm all purchase leads are exclusive to you and not churned, as we discussed in lesson one. The next allegation family we’re gonna talk about is plan and product in outside of lead and permission to contact. This is probably the second most common bucket that we see in regards to sales allegations coming in from the carriers and CTMs. Some items that are generally bucketed out into this allegation family are going to include providing inaccurate or incomplete benefit information to the beneficiary, failing to check all providers, pharmacies, hospital networks, providing inaccurate premium information, inaccurate plan descriptions. So maybe you did not fully explain to them how an HMO plan works, that they may need referrals, that there may be network limitations. So, just failing to provide a complete and accurate plan description of the plan that they’re going to be enrolling into. And this kind of bleeds over into the last one, which is not clearly explaining or not ensuring that the member understands that this is a Medicare Advantage plan and not a Medicare Supplement plan.

So, a few best practices that can help you out in this allegation bucket. First, make sure you’re reviewing a full compliant sales presentation with each beneficiary. It doesn’t matter if you’re selling in person, if you’re selling over a video or if you’re selling over the phone. There are tons of tools to help you with the specific talking point right here. So, carriers provide a lot of great flip charts and PowerPoint presentations you can use, you can use that in person and over zoom calls if you’re selling over the phone, if you’re in a call center, of course you’re gonna have scripting that makes sure that you’re hitting all of the points of a compliant presentation. If you’re a field agent selling over the phone. There’s also a lot of great scripting tools available for you as well to ensure you’re covering all baseline benefits as well as all other components of a full and compliant sales presentation. Next, you wanna make sure that you’re confirming that all providers, hospital networks, specialists, and pharmacies that the member uses or prefers to use are going to be in the provider directories in the formularies. And you wanna make sure that you’re, you’re using online versions of these and not something that’s been printed out. We all know as soon as they’re printed, they’re probably outdated. So you wanna make sure you’re using those online tools to provide the most accurate information. Next, make sure you’re fully explaining all of the rules that the plan has that goes along with it. So if it’s an HMO that you’re explaining again, the referral requirement, any sort of network limitations if, if it’s a PPO  you wanna make sure that they understand that there may be lower cost sharing if they stay in network versus going outside of the network. And last but not least, definitely make sure that they understand that they are enrolling into a Medicare Advantage plan and that it’s not a Medicare supplement plan. And that if they’re already currently enrolled in an MA plan or Part D plan, enrolling into the new plan will terminate any of their current plan enrollments and be replaced by the new plan.

Our third allegation family that we’re gonna talk about in this lesson is prohibited activities. This is where you’re gonna find things like your violations orfailure to follow CMS or carrier guidelines. We’re gonna see things like unsolicited contact, non-compliant cross-selling at Medicare Advantage appointments, engaging in sales activities at educational events, or engaging in prohibited activities at sales events, or the misuse of private health information or personally identifiable information. So, PHI or PII, those are gonna be some of the things that fall into this allegation family or bucket. So a few simple best practices to avoid these types of sales allegations. First, make sure you’re not engaging in unsolicited contacts such as cold calling or door knocking. This also includes things like you’re not permitted to leave behind materials at someone’s door, even if you’re not knocking, unless you had an appointment scheduled with them and they didn’t show up for it. Don’t engage in offering non-health related products at Medicare Advantage meetings. So you can talk to them about healthcare related items such as dental, vision, hearing. You can talk about Medicare Advantage versus Medicare supplement plans, but you can’t talk about non-health related products such as life insurance, annuities, property, and casually, anything that would fall in that bucket requires a 48 hour cooling off period. So, those appointments need to be scheduled at a separate time from your Medicare meetings. Third, don’t engage in sales activities at educational events. Educational events are meant to be just that educational in nature. So topics such as Medicare 101 and you wanna make sure that you’re not talking to individuals about specific benefits, plan specifics that you’re not talking to individuals about their specific scenario and different, you know, plan recommendations that you may give them. Under current rules and regulations, you can schedule appointments to follow up with them at a later time. You can also capture a scope of appointment there, but just make sure that you’re not engaging in the actual sales activity portion of it at educational events. This also follows suit for not engaging in inappropriate activities at sales events. So, a really common example is, you know, you get folks to a sales event, you can’t provide them with a full meal. You can only provide light snacks, coffee, donuts, something like that. So make sure that you are aware of the rules and regulations for both sales events and educational events that you’re following those and for sales events that you are filing them with any carrier that may still wanna see those ahead of time. And lastly, make sure that you always take measures to safeguard PHI and PII at all times. Doesn’t matter if you’re capturing this in paper form or if you’re doing it digitally, you wanna make sure that if it’s paper you are you know, keeping that confidential and secure that you’re storing it behind either a locked filing cabinet or a locked door if you need to dispose of it, that you’re not throwing it in the trash can, but you’re using some sort of shredding service. And then if it’s digital or if it’s online, just making sure that your laptop’s encrypted it’s password secured, and that it’s not just out there on a main server where anybody and everybody in your office could have access to it.

The next allegation family we’re gonna talk about is risk to beneficiary. This allegation family will include sales allegations that cover things like beneficiary does not recall enrolling or beneficiary did not give consent to be enrolled, that they were unable to comprehend. And this could be either, um, they were mentally, you know, had diminished capacity or they had some sort of language barrier. In either case, it’s a failure of the agent to not engage the power of attorney or authorize representative or utilize translation services. Also, in this allegation family are things like intimidating sales practices or scare tactics. And then again, not, uh, failure to clearly capture permission to enroll into the plan and the specific plan in which you have presented to them best practices in this allegation family, first of all, make sure that the beneficiary fully understands that they are enrolling into a new plan, the plan that they are enrolling into, and that by proceeding with the call or the appointment, they will become enrolled into that plan and that their current plan will terminate. Next verify with the beneficiary if they have a power attorney or an authorized representative. This should be asked in, in every single appointment that you have. Do you have a power attorney authorized representative or someone that helps you make healthcare decisions? You also wanna be paying attention to things like red flags for failure to understand or having difficulties being able to comprehend either benefits or plan details. If you see any of that sort of behavior that may indicate they have diminished capacity, you should again ask if they have a power of attorney authorized representative or someone who helps them make healthcare decisions. If they still say no and they’re still having difficulty comprehending, you may wanna look at either stopping the, the appointment at that particular time, trying to reschedule it for maybe another day. Maybe they’re just having some difficulty with some new medication or something like that. If they’re still having difficulty comprehending and they don’t have anyone that can attend that meeting with them such as a family member, then you’re gonna wanna just, you know, stop proceeding with the appointment. Maybe try to get them connected with Medicare or the carrier directly and see if they may be able to help. If you’re working with someone who is having difficulty comprehending from a language standpoint and they don’t have a translator available, there are translation services that you as the agent can utilize. Again, you can also connect them with Medicare or directly with the carrier. They all have translation services that can be used as well. In other words, do not proceed with the enrollment. If you identify any red flags or difficulties, the beneficiary has comprehending benefits or plan information. And lastly, don’t engage in intimidating or inappropriate sales practices, including scare tactics. Sometimes this can be just a change in how you’re wording something. So, there’s a big difference between the annual enrollment period ends tomorrow. If you don’t make a plan selection before then you may not have the opportunity to enroll into another Medicare Advantage plan until the next AEP versus if you don’t enroll in this plan with me today, you won’t have health coverage for the next year. You can see how the meaning is the same, but the way in which you word things in the second instance is really intended to scare or intimidate or push the beneficiary. So, make sure you’re carefully choosing your words and that you’re not engaging in those intimidating or inappropriate sales practices.

This next allegation family is gonna talk about the operational things that can be driving factors of sales allegations. Most of the things in this bucket are not going to be intentional in nature. They may just be a mistake on behalf of the agent, but they can still lead to sales allegations, nonetheless. So some things we see in this bucket are the agent not being fully ready to sell. So, they’re not appropriately licensed, appointed, and certified. They’ve enrolled the individual in the incorrect plan, and this means an error. So not that they didn’t pick the right plan for them and present the right plan to them, but that they actually presented the appropriate plan. They talked to them about their needs and their, you know, wants from a healthcare plan, but when they actually went to enroll, maybe they checked the wrong box on a paper form or they picked the wrong dropdown in an online form and they accidentally enrolled the person into an incorrect plan. The third thing that we see in this is using the incorrect election period, or more specifically an incorrect SEP code. You know, again, not usually intentional in nature. Sometimes it’s just an incorrect box checked or, you know, dropdown field or just not understanding which election periods should be used. If they have maybe a couple that overlap. Choosing the incorrect effective date, same thing. Generally, this is not going to be that you intentionally picked the incorrect effective date or didn’t understand what they were asking for. It’s that the incorrect effective date was just applied in error to the application form. We see this a lot during the annual enrollment period. If you’re enrolling somebody who is maybe turning 65 and they are needing an 1/1 effective date or a 12/1 effective date we know a lot of times with those online forms it can default to the current or to the future plan year. And so you may actually be looking at 2024 plans and a 1/1 effective date instead of a 2023 plan with a 2023 effective date. And last is failure to follow scripting. And this is not necessarily like a blatant lack of following scripting. If you’re in a call center, sometimes you may just accidentally skip over a section and miss an important part of the sales process in light of doing that. So, it’s some best practices with this allegation family. First of all, make sure you’re fully licensed, appointed, and certified for all states and all products prior to selling. Now I know that a lot of carriers are going to just in time appointments and that’s fantastic, but you still wanna make sure that you’re licensed in all of those states before engaging in business and that you have a full understanding of which states are just in time versus which states are pre-appointment and that you’re appropriately appointed in each of those states. And lastly, of course, just make sure that you’re certified for all products for the current year that you’re going to be selling in. Use a quote, an enrollment platform. There’s a lot of great ones out there. This not only helps you capture sort of everything that you need to conduct a compliant sales presentation from quoting to enrolling to doc find, to pharmacy lookups, but it also can help manage your ready to sell permissions and, you know, throw up some red flags and potentially prevent you from enrolling someone into a plan that you’re not ready to sell for. Make sure you double check that you selected all of the correct plan and effective date information. If you’re using anything outside of the AEP that you’ve made the correct special election period IEP, ICEP, that you have the correct election period down. And if you aren’t sure, give the carrier a call, give your upline a call, ask them to help. You make the correct  selection for enrollment periods. There’s also a lot of great tools out there from the carriers that serve as kind of like a guide or a grid that you can print off and take with you. You can save to your laptop and reference as needed. And lastly, make sure you’re following telephonic scripts fully and reading all required disclaimers. This is a, a requirement for anybody that’s operating out of a call center, but there’s also a lot of great scripts, again for field agents out there that can help you follow along and ensure that you’re checking off all sections of a compliant sales presentation.

The last allegation family we’re gonna talk about today is point of sale. Now, you may see some things in this allegation family that seem to overlap some with operations but there’s some slight variances that, um, push them into this bucket versus operational. So first, the agent did not provide their contact information to the beneficiary. You always wanna make sure that they have your contact information because if they don’t, they’re more likely to call the carrier or even Medicare in 9 times out of 10, If they do that, it’s gonna end up with a sales allegation. Next, the agent didn’t select a suitable plan. So, unlike operational where the incorrect plan was selected from maybe a clerical error, in this case, the agent didn’t actually select the correct or appropriate plan for the beneficiaries current needs. We see this a lot. One very common example is the part B, give back plan. So part B give back sounds really flashy beneficiaries see that they think they can get money back on their part B, which is fantastic. However, generally we see the benefits in these plans degraded. So if you have an individual who uses the plan a lot, maybe they go to a lot of doctor’s office visits, they use the pharmacy benefits, a lot of times their cost sharing is going to be higher and they’re gonna see degraded benefits from what they would get in in a normal regular Medicare advantage plan to the point where what they’re getting in that part B give back really doesn’t offset everything that they’re seeing from the actual plan itself, and it’s not a suitable plan selection for them. Next, the agent didn’t confirm eligibility. So sometimes this can be as simple as not confirming that the individual has Medicare, both parts A and part B. More common it’s gonna be that you didn’t confirm that the agent had eligibility to be able to enroll into one of those special needs plans. So dual eligibility, chronic qualifications or institutional qualifications. And sometimes, just that miscalculation can lead them to not be able to enroll into that plan and maybe the election period has ended and now they don’t have the opportunity to get into another plan unless they call Medicare file a complaint and hope to get a special election period through that channel.

And lastly, the agent didn’t engage in active listening. They just weren’t listening or weren’t hearing or weren’t picking up on the beneficiaries needs and wants as they go through the discussion and the sales process. So, some best practices to avoid allegations in this family. First of all, make sure your beneficiary has your contact information. The first thing that you should do after you enroll somebody is give them a business card, send them an email, send them a magnet. Whatever means you have to make sure they have your contact information, have them write it down. It doesn’t matter. You want to be the person that they call if they have questions or issues with their plan. And then if you can’t help them resolve it, you can work with the carrier directly. What you don’t wanna do is give them an opportunity to call the carrier or call Medicare for something that you could have helped them with. Again, more often than not, that’s gonna wind up in a sales allegation for you. Utilize active listening skills. This starts from the moment the conversation begins all the way through the through the end. Sometimes a beneficiary may mention something so subtly in passing, but if you’re really engaging in those active listening skills, if you’re taking notes, if you’re paying attention, when you start walking through the benefits of a plan, you may hit one that really is a callback to something that they talked about either in their family or that they had a concern about that you can talk about very specifically throughout that sales practice. Just reinforcing that you have heard them and that you’re making the correct plan, selection, or recommendation for their needs. Next, make sure you’re utilizing all of the tools that we talked about earlier inside of carrier portals, inside of your online quote and enroll tools to confirm eligibility, specifically LIS or dual eligibility. You also wanna make sure that the member has part A and part B and that you’re aware of what those effective dates are. You also wanna make sure that you never change a beneficiary’s plan if their current one is the best plan to fit their needs. You may not get the sale today, but there is nothing that breeds trust with a beneficiary more than speaking to a new agent via that agent doing a full plan review and really saying to them, you know what? Your current plan is the best one for your needs right now. However, here is my contact information. If anything changes, give me a call and I’ll be happy to kind of look at other plans for you. Also, is it okay if I continue to give you a call and check up on you throughout the year just to make sure nothing’s changed with your healthcare needs? Beneficiaries love it, and you’ll have a client and probably some referrals for life. Now, before we move on to the next lesson, let’s take a brief quiz to test your knowledge on this one.