2022 risk prevention

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Risk Prevention

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This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other us is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

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Introduction

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Welcome to the Risk Prevention course.

This module will encourage awareness among sales professionals, regarding some of the most misunderstood sales practices that cause questions on the part of our beneficiaries. This module will be required annually at a minimum, as part of the certification process to encourage compliant sales practices. During this training, you will learn what the most common inquiries can be, and how to avoid errors in the scenarios offered. For this module, you will be required to achieve a score of 100% on the assessment to earn a passing grade. This module will be updated annually or as needed to reflect changes in consumer and sales trends.You will be required to re-take this module, and possibly other modules if a complaint is received regarding your sales practices. Additional modules may be assigned as a method of re-training depending upon the nature of the inquiry, if one should be received at the plan.


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Learning Objectives

• What constitutes “Marketing Misrepresentation?”• Where do inquiries and allegations come from?• How is an inquiry initiated?• Allegations Process• Common Mishaps to Avoid• Prohibited Activities• Terminology and Disciplinary Actions• What to do if you receive notice of an allegation?

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Marketing Misrepresentation

What is considered marketing misrepresentation?Intentionally or unintentionally presenting something in a false way, or with partial accuracy, causing others to have a false or incorrect impression of the true information. While there are many forms of marketing misrepresentation, the sales agent facilitating the enrollment is often the subject of an inquiry.

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In the industry or throughout this presentation, you may see the following terms, which all refer to a single occurrence of marketing misrepresentation:

• Allegation

• Sales Complaint, or simply, Complaint

• MMR = Medicare Marketing Misrepresentation

• Investigation

• Case

• Sales Incident

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What types of activities could be classified as marketing misrepresentation?

• Only explaining parts of the health plan

• Not explaining the required parts of an enrollment form

• Omitting required information from a sales presentation

• Misstating providers as being in the plan’s network

• Conduct that is questionable and/or unethical

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Where do inquiries and allegations come from?

Complaints can originate from any individual suspecting a wrongful activity on the part of an agent or the plan, including:

• Beneficiaries or their families• Other Agents or Internal staff• Compliance • State regulatory agencies• CMS• Other entities or agencies

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Beneficiaries can voice their complaints in several ways:• “I was told my doctor was in the network.”• “I did not intend to enroll.”• “My agent told me I had no copays.”• “Someone showed up at my door without

calling in advance.”• “I have a premium? I wasn’t told this.”

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How is an inquiry initiated?

Inquiries are most commonly initiated by these areas:• Appeals and Grievances

• Complaint Tracking Module (CTM)

• Customer Service

• Compliance

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Allegations Process

This process allows us to:

• Clearly evaluate claims of marketing misrepresentation

• Ensure compliance with CMS guidelines by reinforcing appropriate behavior and processes

• Ensure a positive beneficiary experience and protect their best interests

• Properly document investigations and their outcomes

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Common Mishaps to Avoid

Let’s examine areas of compliance where focus is needed to avoid “real-time” hazards when in the sales environment.

These include, but are not limited to:

• Marketing Materials

• Prohibited Activities

• Unsolicited Calls

• Formulary Verification

• Marketing at Events

• Referrals and Gifts

• Provider Network Verification

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Use of Marketing Materials

Materials Use and Requirements

ONLY use marketing materials provided and/or approved by the plan.

Agents may not change or alter the plan-provided and/or approved materials.

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Use of Marketing Materials (cont.)

Confirm your materials are approved for use. The material identification number must be on the document and is found in the lower right or left-hand corner on the first or last page.

Example of a material ID (taken from an application):Y0114_21_124975_T_C_0149 CMS Approved 8/18/2020

Example of a code (taken from a Summary of Benefits):Y0114_21_123775_U_M_0232 Accepted

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Prohibited Activities

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Agents and Brokers are NOT permitted to…• Conduct outbound telemarketing (cold calling), unless beneficiaries

initiated and/or previously provided permission for the contact (e.g., signed business reply card)

• Market to former members who have voluntarily disenrolled or current members who are in the process of disenrolling

• Contact a beneficiary outside of a public social media forum without express permission for contact; if an individual comments, likes or follows an agent/broker on social media, this does not constitute agreement for contact


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Prohibited Activities (cont.)

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Agents and Brokers are NOT permitted to…• Market door-to-door, including leaving marketing materials, such as a

flyer, at a residence (single family home, senior housing, assisted living facilities, etc.)

• Approach beneficiaries in common areas (e.g., parking lots, hallways, lobbies, or sidewalks)

• Send email without providing an “opt-out” feature

• Send text messages without prior permission


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Referrals and Gifts – Do’s and Don’ts

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Referrals: Agents and Brokers ARE allowed to….

• Ask for referrals from active members (mailing addresses only)

• Accept referrals from a provider upon completion of a business reply card (or similar), signed by the beneficiary, providing permission for contact

Referrals: Agents and Brokers are NOT allowed to…

• Offer cash promotions

• Offer gifts as a condition of enrollment


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Marketing at Events

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Be certain you are clear about the difference between a sales and an educational event.

The discussion or distribution of any material with plan-specific information (including plan-specific premiums, copayments, or contact information) is prohibited at educational events.


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Misrepresentation Allegations Mishaps: A Closer Look– Benefits

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Some common types of allegations or inquiries pertain to a misquotation of benefits, especially when there is unexpected cost to the beneficiary.

Costs can include such items as:

• Deductible

• Coinsurance

• Copayments

• Services misstated as being covered under preventive care

Use the Summary of Benefits to help you find the information the beneficiary needs to know.


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Misrepresentation Allegations Mishaps: A Closer Look– Providers

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Beneficiaries want to be sure their doctors, including specialists will be covered under the plan they select. Verifying a provider’s network status accurately is very important.

Provider Networks may be accessed through these methods:

• Online at our web site

• Calling the plan directly to confirm a provider’s network status

• Paper copies of the directory (limited markets)

Know how to use the directory tools properly before meeting with any beneficiaries.


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Misrepresentation Allegations Mishaps: A Closer Look– Providers (cont.)

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When a member asks if they will be “covered” when going to an out of network provider, they are really asking you, “Will everything be paid for?”

Simply saying, “yes, you will be covered” if you go to a doctor outside of the network, is not a sufficient response.

REMEMBER:

• HMO plan members can generally only go to providers in the plan’s network except in an emergency

• PPO plan members obtaining services from providers outside the network will incur additional costs, unless the services are classified as an emergency

You MUST tell your PPO plan clients they will have to pay more when seeking non-emergent eligible services outside of the network.


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Key points to remember:

In some cases, providers may be in-network for some plans, but not all. Specifically, look under the Medicare section of the plans accepted list, or similar, to verify the provider accepts the plan.

Providers must have a PCP indicator in order to serve as a primary care physician (PCP). Use the online tool to find and verify the PCP indicator information.

Network status can change at any time. Plans are required to provide notice of start and termination dates for providers where applicable.



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Example: Ms. Smith currently sees a geriatric specialist, Dr. Jones, for her preventive care. Can she select this provider as her PCP?

Response: Depends on the following factors:

• Is Dr. Jones contracted with the plan?

• Is Dr. Jones contracted as a specialist?

• Is Dr. Jones contracted as a PCP?

Only if Dr. Jones is contracted and designated in the directory to serve as a PCP can the selection occur.


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Misrepresentation Allegations Mishaps: A Closer Look– Quoting Drug Coverage

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You must confirm the beneficiary’s drugs are listed on the plan formulary; specifically, dosage, type (like liquid versus tablet) and quantity.

In addition, are the drugs listed on a specific tier and/or do they require a prior authorization?

Lastly, confirm the drug’s status and cost during the “donut hole.”


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Formularies change, and a drug covered last year may not be covered the next year or may not be covered at the same level. It is important to verify the beneficiary’s prescriptions, even if they are an existing client.

Ask and confirm what coverage they may already have – so any current creditable coverage (such as VA benefits or employer group plan) is not compromised.

If a beneficiary has creditable coverage, they should be receiving an annual notice telling them so. Remind them to keep these notices if they later choose to enroll in a plan that includes drug coverage.


Misrepresentation Allegations Mishaps: A Closer Look– Quoting Drug Coverage (cont.)

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Misrepresentation Allegations Mishaps: A Closer Look– Enrollment

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Key points to remember:

Clearly explain enrollment in the plan will automatically end their enrollment in another Medicare Advantage health plan, or prescription drug plan.

Remind the beneficiary it is their responsibility to inform the plan of any prescription drug coverage that they currently have or may get in the future.

You are responsible for knowing and explaining the differences between product types, and the scenarios that may cancel a beneficiary’s existing coverages should they enroll into a new plan.

Clearly explain the Part D late enrollment penalty.


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Misrepresentation Allegations Mishaps: A Closer Look– Enrollment (cont.)

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Enrollment Disclaimers

Please be certain you are familiar with the disclaimers as part of the enrollment process. All applicable disclaimers are found on the beneficiary enrollment form. Disclaimer language will vary depending on the product represented on the form.

Use the Pre-Enrollment Checklist or approved telephonic enrollment script to review and obtain acknowledgement of the applicable

disclaimers prior to enrollment.


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Misrepresentation Allegations Mishaps: A Closer Look– Application Errors

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Timely Submission of Enrollment Forms

• Our plan requires all agents and brokers to immediately submit applications and required supporting documentation upon receipt and not hold them in their possession

• Do not hold the application – if a beneficiary wants you to hold an enrollment application, you must explain that you can either submit or cancel the enrollment application following established procedures

• Taking additional time to deliver an application due to a holiday and/or submitting the application to their sales agency (or upline), are not valid reasons to delay submission of the application to the plan


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Remember the following:

• The application and other documents must be for the correct plan year and correct service area

• Avoid submitting duplicate applications

• P.O. Box may be used as a mailing address but NOT as a permanent address

• If you are faxing the application, ensure all pages are transmitted

• Ensure the application is signed


Misrepresentation Allegations Mishaps: A Closer Look– Application Errors

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Write legibly! Commons application submission errors include:

• Entering the number “zero” instead of the letter “O” and vice versa

• Information entered in the wrong field

• Missing information, including date fields

• Inaccurate Medicare Beneficiary Identification Number (MBI) or Medicaid number

MBI Format:

C – Numeric 1 through 9 A – Alphabetic character (A, B, C , etc., excluding S, L, O, I, B, Z)N – Numeric 0 through 9 AN – Either Alphabetic or Numeric

Example of new MBI: 1EG4-TE5-MK73

Position 1 2 3 4 5 6 7 8 9 10 11

Type C A AN N A AN N A A N N


Misrepresentation Allegations Mishaps: A Closer Look– Application Errors (cont.)

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Proper Handling of Beneficiary Information

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Part of your responsibility as an agent is the proper and secure handling of beneficiary information. At a minimum, the following security measures must be taken:

• Keep beneficiary information in a locked office, drawer or car (hidden out of sight!)

• Do not open multiple client files during an appointment

• Do not repeat beneficiary ID numbers in areas where you may be overheard

• Do not re-use old beneficiary documents

• Do not post any sales or beneficiary information to social media


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Proper Handling of Beneficiary Information (cont.)

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Items to be destroyed must be properly disposed of via crosscut shredding and not re-used or placed into regular recycling or trash containers. This includes:

• Files at the end of the mandatory record retention period (the end of the year in which they have been retained for 10 years), or

• Withdrawn, incomplete or incorrect applications with complete or partial beneficiary information


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Mishaps with Allegations: Agent Preparedness

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How can an agent or broker be prepared in the event of an inquiry?

• Maintain proper documentation of beneficiary interactions and any CMS or plan-required documents (such as SOA and Pre-Enrollment Checklist)

• Take notes and keep them secure! For example: • Keep a list of the items discussed during sales appointments,

materials reviewed and/or left behind with the beneficiary• Note the providers or medications discussed• Any questions the beneficiary asked during the appointment

• Practice proper personal conduct and good etiquette

Keep all documentation readily available.


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Mishaps with Allegations: Agent Preparedness– Proper Guidance for Beneficiary Complaint

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Beneficiaries may have concerns that come up after they enroll in a plan, and they may come to you for help.

Instruct your clients to call the Plan first with questions.

Remember:

• The plan can handle most types of inquiries

• A beneficiary is always welcome to call 1-800-Medicare, however all plans are encouraged by Medicare to solve member inquiries


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Terminology and Disciplinary Actions– Types of Discipline

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When investigating an allegation of marketing misrepresentation, sometimes multiple infractions may be cited. Compliance has discretion to address all elements as deemed necessary. The agent will be informed regarding the outcome of the investigation and next steps (if necessary).

Frequent allegations may result in escalated disciplinary action. Disciplinary action can include:

• Coaching

• Verbal warning

• Written warning

• Agent termination


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If I receive an inquiry or allegation, what do I do?

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1. You will be sent a questionnaire and must respond within 48 hours.

• Include any pertinent notes from your sales appointment, event, etc. that may apply to the allegation

• Address all concerns presented in the allegation

2. The outcome will be communicated to you, and your manager or director.

3. If disciplinary actions are assigned, they must be completed within 10 days.


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What do I do when I have questions or issues?

If you have questions or concerns with the Medicare Advantage or Part D plan, please contact the plan directly for assistance, including:

• Sales support

• Sales director or regional sales manager

Also, be sure to take advantage of the guides in the Resources section of this certification site and the "Producer Online News."

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Risk Prevention Assessment

An assessment will be given to test your knowledge on the information presented. A score of 100% on the assessment is required to successfully pass this module. If a score of 100% is not obtained, the assessment can be attempted again immediately.

Please click the link to access the assessment.

After completing the assessment for this course, refer to your online training summary for your certification progress.

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CLICK HERE FOR ASSESSMENT


https://anthem.uat.coursestage.com/course/view.php?id=40&pageid=45

2022 risk prevention

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