Agent Oversight Committee

Policy Number: SLS-013

PURPOSE:

To ensure Care N’ Care (CNC) is compliant with all Centers for Medicare & Medicaid’s (CMS) rules and guidance regarding consistent oversight of CNC Sales Agents/Entities with the creation of an agent oversight committee.  Furthermore, this policy helps establish adequate oversight of sales and marketing activities conducted by CNC Sales Agents/Sales Entities and furthering CNC’s adherence to all federal and state laws, regulations and guidance.

DEFINITIONS:

Centers for Medicare and Medicaid Services (CMS):  The federal agency within the Department of Health and Human Services that administers the Medicare program.

Sales Agent – Licensed insurance agents that are employed by CNC and/or external agents who are licensed, contracted and are certified to sell CNC Medicare Advantage Plans.

Sales Allegation:  A beneficiary complaint of a potential marketing problem.  A beneficiary,      family beneficiary, advocate, Power of Attorney, provider or CMS may initiate sales allegations either verbally or in writing.  Sales allegations may originate from communication obtained during an outbound verification call, inbound telephone calls, as well as outbound quality control calls.

Sales Entity:  Field Marketing Organization (FMO), General Agency (GA) or Agency.

POLICY:

CNC Sales Agents/Sales Entities are subject to a continuous oversight program, conducted by CNC Sales Leadership and CNC Compliance, to ensure the agents are marketing and selling CNC products in accordance with all applicable federal and state laws, as well as Centers for Medicare and Medicaid Services (CMS) regulations, policies, and marketing guidelines.

To ensure consistent and measurable oversight, the Agent Oversight Committee will oversee these matters. The Agent Oversight Committee will be responsible for review of adherence to various statutory and regulatory requirements as well as CMS Marketing guidelines of Agent activities for Medicare health plans; institutes needed actions and ensures follow-up, as appropriate. This committee will:

  • Provide performance monitoring and oversight of the Agents
  • Provide a mechanism for interdepartmental participation and collaboration in agent activities
  • Demonstrate quantifiable improvement in care and services
  • Afford Care N’ Care the opportunity to ensure that agents are not engaging in coercive or aggressive marketing tactics

The Agent Oversight Committee will be comprised of both voting and non-voting members. There will be five voting members and a majority quorum will be necessary for meetings to be held and any decisions to be made.

Non-voting members are permitted to participate in these meetings as well as provide additional background information that may be relevant to the issue being discussed.

PROCEDURE:

Compliance will facilitate quarterly meetings in regards to agent oversight. If there is an urgent issue then Compliance will schedule an ad-hoc meeting.

The following rating scale assigns points for violations on a scale of 1-7 with the points being assigned in the following manner:

  • 1 point – A sales allegation is filed that results in evidence of no wrongdoing by the agent. This category is also used for any deficiency noted by a CMS Secret Shopper as well
  • 3 points – This is a sales allegation where it is a “he said/she said” situation where no harm or malice to the client was found
  • 5 points – This is a sales allegation where the agent did not act in the best interest of the beneficiary, including lack of due diligence or misrepresentation. Some form of harm was place upon the beneficiary
  • 7 points – A sales allegation that resulted in proof of some form of fraud

Once a Sales Agent accumulates 6 points, the Director of Product Management will be responsible for presenting the Sales Agent to the Agent Oversight Committee.

In addition, all sales agents will be placed on a probationary period that will continue from their date of contract through the last day of December of the year they contract the first time. In this probationary period, any sales agent that accumulates three (3) points will be presented to the committee.

Ex: Sales Agent Smith contracts with CNC on June 18, 2013, his/her probationary period would end on December 31, 2013. 

These points do not reset over a period of time, however, if a sales agent is brought to the committee and the committee votes to allow the agent to continue to market Care N’ Care products, their point total will be reset.

QUALITY ASSURANCE:

Overall responsibility for monitoring and oversight process of Care N’ Care Sales Agents rests with the Director of Product Management.