Lesson 3: Allegation Outcomes

Welcome to lesson three, allegation outcomes. There’s a lot of different verbiage and phrases that you may see when you’ve submitted an allegation response and the carrier comes back with their outcome. You can see things just as simple as closure, closure notifications, but generally you’re gonna see something that kind of indicates what the carrier found and what the outcome of that allegation is. So unfounded or unsubstantiated generally means that either the information that you provided in the course of the response has shown them proof that you, as the agent, did not do anything wrong, and it was maybe just a misunderstanding on behalf of the beneficiary, unsubstantiated or inconclusive kind of use. Sometimes interchangeably means either they didn’t quite have enough information to go on to truly market unfounded, but there also wasn’t any information or positive proof that is going to lead this to being a substantiated or founded allegation. So, we see a lot of inconclusive outcomes where the member said one thing, the agent says another thing, and there’s just no hard proof to figure out either way where that allegation falls. The kind of third bucket, which is a substantiated or founded bucket, means that there has been something said or something provided that has indicated that the beneficiary was correct in their complaints, and that the agent did do something you know, incorrectly throughout the sales process. Now, substantiated or founded doesn’t necessarily mean that it’s egregious in nature. It could be a mistake on behalf of the agent. It could be a, a simple misinterpretation of the rule. So, don’t think that just because you do get an allegation in that is substantiated or founded, it’s gonna lead to something like termination of your contract. I’m sure for those of you who have worked in the Medicare Advantage space, you know, for, for years and years and years, you’ve probably had an allegation and you may even have had a substantiated allegation somewhere along the way. Now, allegation outcome actions are a little bit different. So, you always have an outcome, you know, founded, inconclusive, unsubstantiated, but sometimes you might have an action that as a result of the outcome itself. And actions can range from coachings or re-training all the way up to suspensions or held commissions, or even terminations depending on what that allegation actually is. One thing to keep in mind is that some of these suspensions held commissions or terminations will come not from the allegation itself, but from a lack of response. So, the primary thing to remember here is if you do get an allegation, make sure that you submit your responses along with that corresponding documentation, if applicable to the carrier, get it into them before the due date. If you need an extension for some reason, most carriers are gonna be extremely reasonable. So, let’s say you’re, you know, out of the country and you don’t have access to some of your files, just respond back to them. Let them know the situation. Ask them if you can have a few extra days or sometimes even, you know, an extra week. And that will kind of push that due date back. So, make sure that you are getting those responses in. If you get an outcome and you don’t understand what it is, the carriers will be very happy to communicate that with you. And if you do have an action such as coaching or retraining make sure that you are also following those instructions as well. So, whether that’s completing a course or completing re-training with the carrier themselves, make sure you’re paying attention to the details of that email and that you’re making sure that that is also fulfilled before any due dates. Thank you for joining us, and let’s get started with a final exam so that you can get your certificate for finishing this course.