Medicare Ethics and Compliance

If you haven’t thought about compliance, put it on your radar. NCC’s agents don’t typically get complaints (more on that later) because we help them keep compliance in mind at every step.

If you do receive a complaint, don’t panic. Mistakes happen, and there are systems in place to resolve these issues. That said, the best way to handle compliance complaints is to avoid receiving them in the first place.

Avoiding Medicare Compliance Complaints

Here are a few of the most common compliance complaints and how to avoid them.

1. The beneficiary is unhappy with the selected plan

Your job as an agent is to keep your clients’ best interest in mind, so if a beneficiary ends up with a plan that doesn’t meet their needs, that’s on you.

Avoid this situation by going over every detail of the selected plan with your clients. Once the plan has been selected and the client is ready to apply, go over the details again to be certain there’s no confusion. Ask the client to read the plan details back to you and confirm they understand the policy completely.

After completing these steps and your client’s application, you still have another chance to avoid a potential plan selection complaint. Most beneficiaries will know that they want to change plans within the first week, so make a habit of calling new clients a week after their application to confirm they’re still happy with their choice.

2. The beneficiary’s application was not submitted on time

This one is easy to avoid. Submit all applications within 24 hours of completion. If you want to be extra certain not to miss a deadline, set a reminder on your phone as you’re finishing a meeting with a beneficiary.

3. The beneficiary’s prescriptions or providers either aren’t covered or cost more than expected

Whether it’s quoting drugs at the wrong pharmacy or failing to verify specialists, a lack of attention to detail can result in higher-than-expected costs for your clients. They’ll complain, and rightfully so.

When you check drug and provider coverage for a client, be sure to use the most up-to-date and accurate information available. Tools like Enrollment Central, NCC’s quoting and enrollment platform, give you access to regularly updated information.

Confirm the client’s prescriptions and providers multiple times before submitting their application. If you aren’t already, you should also use a detailed Medicare Needs Assessment to record the beneficiary’s drug and provider info for later reference. As with other types of Medicare compliance complaints, you can avoid these misunderstandings with careful attention and due diligence.

Resolving Medicare Compliance Complaints

Don’t be stressed if you’ve received a complaint. It may simply be a misunderstanding, either by you or the beneficiary. In either case, you will be given a platform to respond with details of the event.

If you contract through NCC, your first step after receiving a complaint should be to contact your Marketing Specialist. Each carrier has unique complaint resolution requirements, and our team can help you understand what steps to take next.

Depending on the carrier, you may need to complete training modules online or sign an attestation, but you will definitely be required to offer your version of events in writing. Use as much detail as possible in your response. More detailed responses have a much higher chance of a positive resolution.

When you feel your response is ready to submit to the carrier, send it to your Marketing Specialist first. NCC’s Compliance Department will give it a thorough review and make sure it meets the carrier’s requirements.

If a complaint is the result of an error on your part, we’ll help you avoid those errors in the future with additional Medicare compliance training and support. Regardless of the circumstances or resolution, our Compliance Department is here to help you respond to complaints appropriately and accurately.

Medicare Compliance Audit: NCC’s Agents Are A Compliance Success

At NCC, our Compliance Department is responsible for staying knowledgeable about Medicare compliance guidelines and tracking agent complaints filed through CMS or a carrier. In the interest of transparency, they’ve provided details from our recent internal audit.

The majority of complaints NCC’s agents receive come from carriers. Rarely does a beneficiary make a complaint directly to CMS, but in those instances, they are investigated and responded to like any other carrier complaint.

NCC’s Complaint Rate is .01%

Our audit found that of all applications completed by NCC’s agents, only about one in 1,000 resulted in complaints. The top three types of complaints received were related to the timely filing of applications, followed by plan satisfaction, with drug coverage and enrollment issues tying for third.

This reflection shows that our agents understand their products and explain the plan details appropriately and accurately. It also must be noted that almost all agents who received a complaint received only one.

A Happy Resolution for some NCC Agents

Early in 2020, we received many complaints related to Scope of Appointment from one specific carrier. After a thorough investigation, it turned out to be an error with the carrier’s forms containing an outdated fax number. We discussed this with the carrier, and they agreed to remove the complaints against the agents. With that issue resolved, the number of complaints related to SOAs dropped to only one for all of 2020.