Sales Agent Corrective Action

Policy Number: SLS-022

PURPOSE:

To ensure Care N’ Care (CNC) addresses and administers appropriate corrective action for Sales Agents.  Corrective action is designed to correct and ensure compliance with all Centers for Medicare & Medicaid’s (CMS) rules and guidance regarding corrective action needed and create the framework by which sales corrective action is taken as warranted.

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.

POLICY:

CNC follows the Centers for Medicare & Medicaid’s (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.

Care N’ Care has developed policies, rules, and regulations designed to assure compliance with CMS and Company requirements. CNC responds to reported or suspected compliance or deficiency concerns by reviewing the matter to fully understand the issue and by taking appropriate corrective action when warranted. Whenever the CNC Sales Leadership and Compliance Officer determines that an individual has acted in violation of CNC compliance requirements, the Compliance Officer, in conjunction with Sales Leadership, may implement or recommend corrective action designed to address the particular violation and to assure that the violation does not recur. Corrective action will be proportional to the potential risk of harm to CNC. Consequently, corrective action imposed will vary based on the severity of the violation.

  1. Applicability – Each individual is responsible for having knowledge of CNC requirements.
  2. Scope – The CNC Compliance Officer and Sales Leadership will review all potential compliance and deficiency concerns raised, initiate an investigation as appropriate, and when warranted impose corrective action. Sales Leadership authority impose corrective action extends to CNC Sales Agents. The provisions of this Policy supplement existing CNC policies and procedures.

This policy and the related procedures apply to all Sales Agents employed, contracted, or otherwise representing Care N’ Care Company, Inc., and its subsidiaries that represent and are authorized to sell CNC Medicare Health Plans.  This includes, but is not limited to all internal Sales Agents and External Sales Agents contracted by CNC, including independent Agents, and Sales Entity (Agency, General Agency (GA) or Field Marketing Organization (FMO)).

PROCEDURE:

  1. Investigation Process – Sales Leadership will review all potential concerns and follow procedure detailed below:
  2. Corrective Action
    1. Compliance Violation Confirmed – If a compliance violation is confirmed, Sales Leadership may impose one or more of the following corrective actions:
      1. Provide additional education.
      2. Implement a Focused Compliance Review of the Sales Agent’s activity.
      3. Restrict or suspend the Sales Agent’s activity.
      4. Recommend termination of the Sales Agent in accordance with this Policy.
      5. Initiate sanctions against or the termination of a CNC employee.
      6. Other corrective actions as necessary to address the compliance violation and preclude the violation from recurring.
  1. Documentation – Sales Leadership will maintain documentation of corrective action imposed on an individual.
  1. Summary Action During Investigation
    1. Decision to Implement Summary Action – Sales Leadership may implement immediate corrective action when appropriate to avoid continuing violations during the investigation, up to and including the immediate suspension of an individual’s sales activities or authority. Summary action is effective throughout the investigation unless otherwise specified by Sales Leadership.
    2. Notice – If summary action is taken, Sales Leadership will notify the Compliance Officer, and the Sales Agent.
  2. Notice to the Sales Representative – If Sales Leadership imposes corrective action against a Sales Agent, the CNC Compliance Officer will provide written notice to the Sales Agent. Such notice will include the following:
    1. A summary description of the conduct giving rise to the corrective action.
    2. The standard violated;
    3. The date that the corrective action is effective;
    4. A description of how the Sales Agent may request review of the corrective action by Sales Leadership; and, if appropriate
    5. The potential sanctions that may be applied if the Sales Agent fails to comply with CNC Compliance Requirements in the future.
  3. Review of Non-Termination Corrective Action Involving a Sales Agent– The Sales Agent may request review by Sales Leadership when the CNC Compliance Officer imposes non-termination corrective action.
    1. Request for Review – The Sales Agent must submit a written request for review within 15 days of the date on the notice of the corrective action. Requests for review, and all accompanying information, are submitted to Sales Leadership. A Sales Agent may request an in-person meeting with Sales Leadership.
    2. Termination Action
      1. Written Notice – The CNC Compliance Officer will provide written notice of the recommendation for termination to the Sales Agent. The notice will include a summary description of the basis for the recommendation to terminate and may also include conditions for rescinding the termination.
      2. Effective Period – The termination will be effective throughout any review period.

CORRECTIVE ACTION PLANS (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 in to 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 Agent fraud will result in immediate termination and is subject to reporting 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.