Sales Allegations — What is the best practice?

August 27, 2014
|In Compliance, Sales & Marketing, Agent Oversight
|By GHG Advisors

It’s just about that time of year again. Yes, you’ve got it — Sales Allegation time. During AEP, Organizations receive an influx of complaints of alleged sales misconduct “Sales Allegations”. And, every year we receive some of the same questions around how these allegations “should” be investigated and closed. The rub is, CMS is all but silent on the specific requirements around investigation and closure of Sales Allegations. So, here are a few critical pieces to keep in mind:

  • All Sales Allegations must be thoroughly investigated, even if it seems like a straight forward case.
  • All documentation such as a member interview and agent statement must be maintained by the Organization.
  • All cases must have a determination (e.g. Founded, Unfounded, Undetermined, Withdrawn).
  • The disciplinary action process must be different depending on the offence. For example, an issue of Fraud would not receive the same action as a less than comprehensive explanation of the fitness benefit.
  • All outcomes should be tracked and trended in order to identify issues with individual agents, as well as knowledge gaps throughout the entire Sales force.

Remember, you can’t prevent Sales Misconduct or Sales Allegations. But, ensuring that complaints are investigated and closed properly will reduce your Compliance risk and will impact the beneficiary’s experience in a positive way.

 

Resources

Now is the time to ensure your Plan – and your agents – are ready to sell while remaining compliant.  We invite you to learn how the Sales Sentinel™ suite of agent oversight tools can help demonstrate your organization’s commitment to compliance.

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