Lake Wobegone Exchanges
One of the most frequent questions I've been getting on the health reform speech circuit has been what our expectations are for enforcement activity in the exchanges in Year 1 -- and the answer is just about none.
For the 16 states launching their own exchanges this Fall, much of the focus will be on basic administrative functions involved in getting the millions expected to enroll through the system. For the 27 states where the Federally-Facilitated Exchange will be operating, the answer is really nothing. The Feds are painting a picture of "Lake Wobegone Exchanges", where all of the plans are strong, all of the brokers and agents are good looking, and all of the stakeholders are above average.
Year 1 of the Exchanges was always going to be about getting the "pig through the python" of the enrollment and eligibility process. It was basic fulfillment functions like verifying "clean" enrollments, entering and reconciling new members into plans' systems, and issuing membership cards that tripped up the launch of Medicare Part D in 2006. The rollout of the Exchanges will see the same struggles. But CMS's latest rule points to an enforcement "hall pass" for participating plans in Year 1.
CMS's latest exchange regulation estimated that there will be more than 250,000 agents and brokers registered in the Federal Exchange -- and went on to say it expected to suspend or terminate 2. Not a typo. CMS seems to be saying that their agent oversight role is limited since states have primary responsibility for broker licensing and monitoring -- but still, 2 out of 250,000? Really? CMS further estimated there will be 409 Qualified Health Plans (QHPs) in the Federal exchanges, but only 1 civil money penalty and only 1 plan termination. Talk about a paper tiger.
CMS will not do much but play "whack-a-mole" with anything egregious that comes up in QHPs. There will be little to no unilateral state enforcement in the first couple years of the Exchanges. And there won't be any kind of organized compliance process for plans in the exchanges like we see in MA until at least year two or three. So bottom line: the plans don't have to worry about the hammer coming down in Year One -- unless they kill someone with an administrative screw-up. Lake Wobegone for sure.
Resources
Listen to a three-part podcast series where GHG Executive Chairman, John Gorman discusses the Importance of a Readiness Checklist for the Exchanges for Sales Marketing Enrollment and Risk Adjustment.
Learn how Gorman Health Group's web-hosted modular software solution, Sales Sentinel, makes sales agent training, credentialing, onboarding and ongoing oversight a smooth and seamless process.
When reconciling Plan data to CMS' records, you have to deal with a number of issues. Listen in as Gorman Health Group's Senior Consultant Chris Groves discusses these issues and the importance of reconciling member data.
Choosing a Call Center? Five Must-Ask Questions
This fall promises to be one of the busiest in history for health insurers with the flurry of Health Insurance Exchanges (HIE), Annual Election Period (AEP) and the implementation of the Affordable Care Act (ACA).
Unanswered calls to insurance companies by potential customers will become forfeited opportunities that may never be reclaimed. Many companies will rely on call centers to handle their call overflow, many for the first time. Consider these five questions when selecting a call center:
1. TECHNOLOGY: Does their technology meet your needs?
The complexity of the insurance industry calls for innovative technology solutions: practical solutions that improve the process for agents and customers alike, and proactive solutions that are flexible enough to handle diverse responsibilities in intuitive ways. Can their call center directly connect your callers with agents in the field instantly? Can they track responses at the individual record level? Do they offer dashboards and reporting in real time?
2. TRAINING EXCELLENCE: Are their CSRs well-trained on Medicare and your plan's protocols?
Harper Lee wrote in To Kill a Mockingbird, "We're paying the highest tribute you can pay a man. We trust him to do right. It's that simple." Like Atticus Finch, trust in the training call center agents receive is a key consideration in a partner. After all, they represent your Medicare plan(s), your brand and your relationships. Could your call center partner handle the scrutiny of a CMS audit?
3. AGENT EXPERIENCE: How experienced are their CSRs?
Exerience is critical in the insurance industry. Experienced agents could mean the difference between a successful sales campaign and a failed one. Because AEP is condensed, inexperienced agents shouldn't gain the necessary experience on the fly.
4. QUALITY & COMPLIANCE Is a robust quality and compliance program with metrics reporting in place?
Quality and compliance go hand-in-hand. Everyone's accountable to CMS. A good compliance program protects clients, plan members and prospective members alike.
5. ADAPTABILITY: How much flexibility and input is permitted?
Flexibility and adaptability are the bread & butter of a vendor partnership, particularly when responsibilities are outsourced. Will you have access to a support team when needed? Such access ensures seamless support of day-to-day campaign challenges. A high-quality support team is agile, adaptable and attentive to detail. Partnering with an experienced call center helps you stay competitive, provides excellent caller experiences, and helps grow your membership.
Resources
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
Every OEV Call Should Be a Welcome Call
In the world of insurance sales, making the right call during a sales presentation and getting the call right for compliance purposes is critical. Outbound Enrollment Verification calls (OEV) calls are not just for an applicant's protection — they're the insurance industry's version of instant replay!
Verification calls are "welcome calls" with a new member. A verification representative should be on every OEV call. Just because OEV calls are a CMS requirement does not mean verification specialists should just "check the box" and read the questions in a Ben Stein-monotone.
Remember, all plan sponsors are required to conduct OEV calls for enrollments originating from both independent and employed agents/brokers to ensure applicants understand the plan's rules.
Here are some other tips to ensure a plan sponsor makes the most out of every OEV call:
- WRITE YOUR OWN SCRIPT: The OEV call is your first call with a new member following enrollment. It's important to create a natural, personable script to make a favorable first impression. A good OEV script should flow comfortably.
- STAY POSITIVE, WARM AND ENGAGING: Verification calls are often a customer's first point of contact since their enrollment. It's important that OEV agents help to put their company's best foot forward. Verification agents should use a warm tone and shouldn't shy away from emphasizing their company's brand. Use the opportunity to engage the member.
- EMPLOY A COHESIVE PROCESS: Some plans face challenges with OEV calls because their process is disjointed. Instead, work to create internal automation that pushes the calls and letters when necessary, or partner with a vendor that can do it for you.
- CONDUCT OEV CALLS ASAP: Make CMS-mandated OEV calls as soon after the enrollment as possible. (OEV calls must be made to an applicant after the sale; they cannot be made at the point of sale.) Make the call sooner rather than later.
- ARM OEV AGENTS WITH RESOURCES: Plan sponsors should ensure their verification agents have a strong knowledge base of plan details like doctors and hospitals in the network (if applicable), the co-pays for different prescriptions and the maximum out-of-pocket. In short, verification agents should be well-trained and have access to resources.
- IT ALL STARTS AT ENROLLMENT! The enrolling agent can help the OEV process by setting expectations. Our Bloom phone and field agents explain applicants what the OEV process is, when to expect the call and what to expectduring a call. Enrolling agents should stay connected with OEV agents to ensure a healthy level of coordination and cooperation.
Remember, you get only one chance to make a first impression -- and that impression begins with the OEV call!
Resources:
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
To learn how you can put Bloom's Call Center agents to work for you, visit our website.
Exchanges: Sales Agent Certification
CMS has released a notice seeking comments on their plans for training and certifying sales agents who could enroll persons into the federally facilitated exchanges. To be exact, the notice is about collection of data about the sales agents who are trained and certified for selling coverage offered by qualified health plans on the exchange. It just so happens that the vehicle for doing the collection is the training and certification program that is mandated by the law and the final regulations published last March. So, CMS does not want comments about the requirement to be trained and certified but they do want comments about what information is collected and maintained about individual sales agents.
In the process of telling us what they want to collect, CMS is also letting us know something about the training and certification program. First, they expect that approximately 250,000 agents will take the FFE training and certification program. They note that this excludes all states where a state operated exchange will function. If agents (approx. 240,500) are allowed to sell QHP coverage in state operated exchanges, the states need to develop and offer their own certification program. CMS also notes that captive agents (approx. 110,500) are expected to enroll persons through their QHP. This means any training for these sales agents must be conducted by the health plan and must follow required enrollment processes through the exchange.
CMS will collect basic identifying information such as name, location, and state license as the agent accesses the system. There is no paper process so agents without electronic access need not apply. After providing basic information, the agent will take the training course and complete the exam to be certified. CMS expects the agent to spend 4.75 hours to complete training and testing in the first year allowing for re-taking and re-testing for those who fail to complete it in the first try. For succeeding years, the expected time requirement falls to 3.25 hours. During this process, CMS can identify particular issues about the test such as time required or troublesome questions and concepts. In addition, CMS will know the individual test taker's training history and their relative success. There is no prohibition on retakes or how often an agent can re-take the training and test. Agents who are certified though the process will be listed on the FFE website so that interested persons can contact them for information and assistance.
CMS notes that they will use collected data for oversight and monitoring. CMS will take follow-up actions whenever they identify questionable activity. Also, from time to time, CMS will ask agents to make their records available for oversight and compliance purposes but does not make clear what records are involved in these requests or actions will occur. Finally, agents will be required to sign an agreement that allows all of this to occur plus documents their commitment to periodically updating information.
Access to the portal will begin around July 1. There is no indication of a fee for taking the training and CMS does provide an outline of the training program that covers the basic components of exchange operations and eligibility determinations.
No doubt there will be questions since any data collection efforts with federal implications for the agent call big brother into question. Clearly, sales agents will have concerns about another body getting complaints about their sales activity and CMS will counter that it has over 25 years of experience with sales agent mischief dealing with vulnerable populations in the Medicare Advantage program.
Click here for information on how to submit comments on this notice.
Click here for a description of the data collection program and some of the processes that will be used to train, certify and collect information.
Resources
Senior Vice President for Public Policy, Jean LeMasurier, summarizes the February 7, 2013 notice from CMS regarding Agency Information Collection Activity.
Download a podcast on the key components of OEV calls and get advice on how to handle rapid disenrollment — and other common challenges.
Learn how Gorman Health Group certifies, trains and manages sales agents with our Sales Sentinel software.
250,000 Agents in the Federal Exchanges???
In a Federal Register notice out yesterday CMS officials are projecting 254,095 health insurance agents and brokers will sign up to sell the "metal plans" in the new federal health insurance exchange (HIX) system. Quarter. Million. Agents. OMG. And the scary part: they face a fraction of the regulatory requirements Medicare sales agents do.
"Federally facilitated exchanges" will operate in some two dozen states next year -- largely in Red States with a significant presence of independent brokers, such as Florida, Texas and Arizona. The final regs on the Federal exchange issued last May included a surprise provision allowing agents to sell exchange products to eligible individuals -- designed to get more enrollment into the program faster through this huge distribution channel.
CMS plans to collect information about producers through a registration process, and by verifying a producer's licensure status and issuer appointments. Once the agents get through the registration process, they will be able to get any required training and take any required exams on the CMS Learning Management System site.
In addition to using the producer data to run the exchange training process, "CMS will use the collected data for oversight and monitoring of agent/brokers." Exchange agents would probably have to register with the system annually, and getting through the entire process could take each agent an average of 4.7 hours, CMS estimated.
Here at Gorman Health Group, we certify, train and manage over 30,000 agents selling Medicare products. And I can tell you that less than 5 hours' training and a bare-bones certification process means there are going to be plenty of sleezeballs selling the "metal plans" to the chronically uninsured. And that will only serve to confuse and exploit huge numbers of them, diminish support for health reform, and bring complaints down upon sponsors. We need a tougher system than CMS outlines here to ensure these vulnerable Americans don't fall prey to predatory salespeople.
Resources
Senior Vice President for Public Policy, Jean LeMasurier, summarizes the February 7, 2013 notice from CMS regarding Agency Information Collection Activity.
Download a podcast on the key components of OEV calls and get advice on how to handle rapid disenrollment -- and other common challenges.
Learn how Gorman Health Group certifies, trains and manages sales agents with our Sales Sentinel tool.
Selling Season is Nearly Here, Now what?
Most plans are in the process of onboarding their agents and preparing them to sell. Meanwhile, they've invested marketing dollars across various channels and different media. Now it's time to turn marketing dollars into members. With another AEP just around the corner, here are a few GHG best practice tips to keep in mind this season to help get the most bang for your buck out of those incoming leads.
- Cut down on lead distribution times as much as possible. This is one area that cannot be stressed enough; beneficiaries are not waiting for follow ups, if leads are not quickly & efficiently being converted into appointments another carrier could potentially get that all-important first meeting on the schedule faster. The industry is much too competitive, and the cost per lead is far too expensive to let any leads sit in today's marketplace. Statistics show that close ratios improve the faster the lead can be converted to an appointment and the quicker that meeting can be conducted by the agent. In an industry where the little details can matter, if this process is managed effectively there are additional members to be had.
- Once agent in-home appointments are in full swing, make sure to collect and document a disposition from the agent for EVERY meeting. A lot of good information can be collected about why a potential beneficiary chose to enroll or not enroll in a particular plan. That information doesn't only apply to the sales team. Share it with the benefit design team too, it will provide a real world perspective on why beneficiaries join, or more importantly, why they don't. Most plans are good at tracking dispositions for their employed sales force, but lack integrated systems to capture this for some independents. Consider adopting a mobile technology to capture the rest of the picture from the independent agents.
- Make every possible enrollment avenue available for potential beneficiaries. This means having a telesales unit, deploying a nimble sales force in the field, and finally in today's world, utilizing (hopefully creating one if not) the online enrollment process. The aging in Baby Boomer population requires us to provide a diverse number of channels for prospects to enroll. Missing one avenue could be detrimental to your sales numbers!
- Learn from your successes….and your mistakes! Improvement in years to come is only possible if there is an understanding of the effectiveness of current marketing campaigns, where enrollments are coming from, what return on investment various channels have yielded, and many more variables in play. Track…measure…assess….adjust…repeat!
As always, stay tuned to the GHG Blog and to the Point for more selling season tips later this month.
Sales Oversight & Thoughts on CMS Updated Agent Training Guidelines
As you likely noticed, CMS recently released its updated Guidelines for Agent Broker Training and Testing for CY 2013 on August 21. Our in-house compliance experts have cross-walked the new regulations with the old ones from last year and here's our take: for the most part, the updated guidelines should be business as usual. However, it is interesting to take note of where CMS is going to greater lengths to provide additional clarity or requirements.
Here's our take on a few additions:
- Under the Beneficiary Protections section, new requirements were added on the education of agents on Aggressive Marketing. More specifically, you'll see requisites on things like what the potential consequences will be for engaging in Aggressive Marketing activities, report requirements, plan disciplinary actions, termination rules, and compensation forfeiture guidelines. Again, while this isn't new, it's now part of the training requirements and necessitates additional preparation, as plans now need to inform the agents about their specific disciplinary process up front. Agents now need to be educated on scenarios that clearly define, "if agent does X, the penalty is X." Plans should take the time to create an offense ranking matrix and a disciplinary scale that escalates based on number of infractions or severity, and educate their agents ahead of time. Of course there will always be new situations that pop up, but this is not a process that should be created on the go.
- There are quite a few updates focused on "do's and don'ts". We saw these added under Marketing for things such as scripts, health screenings, and contact information and again under a new section on Rewards and Incentives. This is in place to educate agents on what the process should look like in order to help identify any plans that try to get a little too "creative" in some of these areas.
Both of these additions are all about starting to compare processes across some of the (historically) more challenging areas for sales & marketing and compliance departments to manage. CMS fully encourages plans to forge their own respective path when it comes to agent oversight. They recognize it's not a one-size-fits-all solution, but with information like this now more accessible, it also allows them to start identifying more instances of what's working and what's not.
Stay tuned for the latest analysis on the updated training and testing guidelines. As always, contact us with questions and be sure to check out the Point -- launching in October.
Sales Force Oversight Ain't Easy
Selling season is nearly upon us, so with that in mind, here are some thoughts to help plans prepare. In this post, I'll detail some sales oversight and reporting best practices we've seen applied with success in a number of plans.
When creating an effective agent oversight program, keep in mind that agent oversight requires a program, not a process. There is really no single indicator that can identify all outliers. A successful agent oversight program requires a collection of metrics that - when combined - paint a clear and concise picture of an agent or group of agents' performance.
Some of the data we often see included in effective oversight programs includes:
- OEV Calls
- Secret Shopping
- SOA Audits
- Rapid Disenrollment
- Ride-alongs
- Sales Call Monitoring
One of the most challenging aspects of agent oversight is often that the data needed to execute powerful reports can originate from a number of different sources. For larger plans, this task is even more challenging because of divisions between departments. Therefore, don't try to reinvent the wheel when designing these reports; plans can create and track a number of different oversight metrics from data that is readily available from enrollment.
There are quite a few potent reports that can be developed to assess agent/broker risk, (at both the plan level and individual level). These can be created using just a monthly enrollment report (TRR & MMR) combined with various data points from the activities listed above that your sales management should be tracking. Keep in mind - whichever reports are developed — use them in unison: tracking by one data point must become a practice of the past.
Here are some simple best practice reports we suggest:
- Percentage of Direct Oversight activities not met (combined pass/fail from secret shops, OEV calls, SOA audits, etc.)
- Rapid Disenrollment Rate (set benchmarks)
- Complaints vs. Agent Assisted Enrollments (create acceptable thresholds)
Finally, once the oversight program is in place and agents are in the field actively selling, make an effort to run two self-perpetuating oversight processes. The first involves pulling a random selection of active oversight activities from the population to identify potential outliers. Then, once outliers are identified from either the random sampling process, or through adverse behavior, plans can administer more focused activities.
I hope these strategies were helpful. Stay tuned to the GHG blog for more tips for successful selling this season!
"Lean and Clean" is Key to Survival for Medicare Plans -- Join the exclusive GHG Compliance Forum November 2-4 in Las Vegas
New regs every other week. 500 HPMS notices a year. RADV audits and Star Ratings surveys. Intermediate sanctions and the threat of termination for poor Stars performance. And now a new, uncoordinated CMS Central Office/Regional Office audit approach that could result in multiple government reviews in a calendar year. "Lean and clean" must define a cultural and management revolution among Medicare plans. If you aren't on the compliance train in these next several years, you're going to be under it.
Tell your compliance staff about our latest Gorman Health Group Compliance Forum. This exclusive GHG event is designed for Medicare Advantage health plans and will provide an intensive examination of the state of compliance in MA, with focus on the changing regulatory environment surrounding both Parts C and D. The meeting is limited to GHG client health plan staff ONLY. No vendors, no CMS representatives, to ensure a frank and open discussion about the way forward.
You'll want your team to be in the room to hear the latest from GHG's compliance experts on:
- Practical tips for implementing a fully-integrated compliance program
- Best practice Sales Oversight strategies that have cross-functional impact
- Part D pitfalls and action steps for oversight and monitoring
- Lessons learned from risk areas in compliance, including sales/marketing, enrollment reconciliation and risk adjustment
For registration information and more details, click here.
To check out the preliminary event agenda, click here.
Have a question? You can always reach our team at ghg@ghgadvisors.com.
I'll look forward to seeing you and your team in Las Vegas.
Help take the "salesguy" out of your sales force
With CMS sure to maintain their focus on agent conduct, plans must demonstrate adequate oversight of their ever-changing sales force.
The Gorman Health Group Sales Sentinel organizes oversight data from multiple sources into one easy-to-use dashboard. Identify risks sooner and make decisions more quickly and decisively. From tracking compliants to gathering enrollment data, this is a tool to help you get there before CMS does. Learn more about Sales Sentinel here.
Watch a short demo video.
Learn more here. Feel free to leave comments, questions and feedback.
Medicare Sales Sentinel short demo video
Medicare Sales Sentinel fact sheet.