Responding to Sales Allegations

Policy Number: SLS-100

PURPOSE:

To ensure Care N’ Care (CNC) is compliant with all Centers for Medicare & Medicaid’s Services (CMS) rules and guidance regarding sales allegations filed against CNC Sales Representatives and create the framework by which sales allegations are properly investigated and corrective action taken as warranted.

DEFINITIONS:

Agency:  An individual/company that allows Agents to write underneath them.

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

Field Marketing Organization (FMO):  An FMO is an agency contracted to provide broad  coverage for the marketing and sales of a health plan. Areas of support will include, but are not limited to, Marketing / Lead Generation, Call Center capabilities, and Administrative functions.

General Agency (GA):  A GA is an agency contracted to provide sales of a health plan.  Typically  its focus is on Agent recruitment and sales.  Areas of support will include, but are not limited to, Agent Certification, Sales Training, Product Training and Compliance Oversight.

Gorman Health Group (GHG):  Company contracted by CNC to administer the CNC Sales Agent certification program, including collection of required documentation (i.e. state licensing, AHIP certification, background checks) and facilitation of online sales certification training and examination.

Medicare Managed Care Manual:  Chapter 3 Medicare Marketing Guidelines:  Manual written and published by CMS for use by Medicare Health Plans and Agents to use to ensure compliance in regards to marketing to potential plan enrollees. It sets guidelines for communication and enrollment for these entities.

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 follows the Centers for Medicare & Medicaid’s Services (CMS) requirements contained in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines and in the applicable regulations, in regard to the activities of Sales Agents, to ensure that they do not mislead, confuse, or misrepresent the organization.

CNC is committed to ensuring that all CNC Sales Agents follow the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) and in CNC policies when representing CNC plans and products.  When CNC is informed of a possible allegation of inaccurate or improper sales activity or inappropriate conduct by a CNC Sales Agent, the issue is investigated thoroughly and reviewed through the grievance process with oversight on each case through Sales Management.

Sales Agents may NOT engage in any of the following activities when conducting marketing activities (please see the Care N’ Care Sales and Marketing Code of Ethics Career and Delegated Agents) on the Gorman Health Group CNC web page for a complete list as well as detailed information on the below activities:

  • Engage in activities which mislead, confuse or misrepresent the plan
  • Engage in discriminatory marketing practices
  • Offer gifts or payments as an inducement to enroll or solicit referrals
  • Solicit door-to-door for Medicare beneficiaries or through other unsolicited means of direct contact, including calling a beneficiary without the beneficiary initiating the contact or giving express permission
  • May not claim recommendation or endorsement by CMS or that CMS recommends that the person enroll in a CNC plan
  • May not make erroneous written or oral statements including any statement, claim or promise that conflict with, materially alters, or erroneously expands upon the information contained in CMS approved materials
  • May not use providers or provider groups to distribute printed information comparing benefits of different health plans, unless the materials have concurrence of all Medicare Advantage (MA) plans involved or the materials have received prior approval from CMS
  • May not cross-sell any non-health care related products (such as annuities, life insurance, etc.) during any sales or marketing activity or presentation conducted with respect to an MA plan or Part D plan
  • May not provide meals of any sort, regardless of value, at any event at which plan benefits are being discussed and/or plan materials are being distributed
  • May not conduct sales or marketing activities at educational events
  • May not conduct sales or marketing activities in areas where patients primarily intend to receive health care services or where health care is delivered

PROCEDURE:

Sales Management will work with Compliance to monitor and track complaints from beneficiaries or their representatives regarding Sales Agents on an ongoing basis. Complaints may come in from, but are not limited to, the following sources:

  • The CMS Complaints Tracking Module (CTM) in HPMS
  • The CMS Regional Office
  • The Member Service call center
  1. Beneficiary sales allegations are received by CNC via the member call centers, member correspondence, CMS correspondence, State Department of Insurance or other communication to anyone within CNC
  2. When a beneficiary sales allegation is received, CNC conducts a thorough investigation of the issue
  3. The Sales Agent is asked to respond to the investigation inquiry within two (2) calendar days. It is critical that Sales Agents respond in a timely manner
  4. Sales Management reviews the sales allegation and the Sales Representative response and makes a determination of whether the agent acted in any manner not in alignment with CNC’s Policies and Procedures or Medicare’s guidelines found in the Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines
  5. Sales Management will input allegation information into Salesforce and assign a score to the allegation based on the model developed for the Agent Oversight Committee. Refer to SLS-013 on Agent Oversight Committee for point definitions.
  6. Corrective actions will be implemented as needed and could include but are not limited to:
    1. No Action
    2. Coaching/Immediate Need Training
    3. Ride Along
    4. Verbal Discp Action
    5. Written Discp Action
    6. Suspension
    7. Suspension – Discp Action
    8. Termination
    9. Termination – Discp Action
    10. Report to State Department of Insurance

In the event sales allegation is not responded to by the Sales Agent as required, CNC has a right to take any of the above actions.  Note: all Sales Agent/Sales Entity contracts/agreement contain language requiring that all sales allegations require a timely response.

Corrective Action Plan (CAP)

In assessing any corrective action plans for a Sales Agent/Sales Entity, Sales Management will review the Agent/Entity’s Compliance file to verify or determine any patterns in their behavior.

The history of the agent/entity will be taken into account to determine what corrective measures need to be implemented, if any.

The final determination for a Corrective Action Plan will be recorded on the Sales Agent Complaint Resolution Form, signed by the Sales Management Member making the recommendation, and both forwarded to Compliance and filed in the Agent/Entity’s Oversight File.

Fraud

  • Any documented incidence(s) of Sales representative fraud will result in immediate termination and is subject to reporting to the State Department of Insurance

Direct Violation of Medicare Managed Care Manual – Chapter 3 Medicare Marketing Guidelines

  • Immediate termination occurs for a verifiable claim if an agent directly violates any part of the CMS marketing guidelines including, but not limited to:
    • Door to Door sales
    • Unsolicited outbound telemarketing, which violates the CMS regulations

Termination of a Sales Agent

If the Sales Representative’s insurance license is terminated by the State, due to a founded CMS/TDI violation, Care N’ Care will electronically file with NIPR (National Insurance Producers Registry) to terminate the Sales Representative’s Appointment with Care N’ Care.