Plan Advisors Blog

Most common compliance allegations and ways to avoid them

Posted by Lance Hoeltke on Fri, May 17, 2019 @ 04:11 PM

As agents, we are sometimes faced with the challenge of protecting our good name. If you receive an allegation, it is required that you respond back to the appropriate carrier in writing within 5 business days. This can easily put you on the defensive, but try to keep the emotion out and focus on the facts when preparing your response. Also, get your agency leadership involved to help you best represent and protect yourself. We use attorneys and tax professionals when we need help in certain areas, think of your agency leadership in the same manner vs keeping it from them. We’re here to help.

The number one allegation made against agents is: Misrepresenting Provider Networks.

This can happen if a member uses non participating providers, or in the case of an HMO plan, network providers without first consulting with their Primary Care Physician.

Agents must take the time to explain the rights AND responsibilities associated with a network based plan. Perhaps correlating the value of the plan with the importance (or necessity) of using the network properly and responsibly is what allows us to enjoy such benefit rich plans in the first place! Network use and continuity of care is not about control or limitations, it’s about quality outcomes, communication and transparency across all providers giving care, and reducing waste and inefficiency.

It may also help the beneficiary understand that misuse of the plan may lead to being on the hook for the total cost of the service received! It’s a reasonable trade off the member must agree to in order to gain the benefits and cost savings that come with their chosen Medicare Advantage plan. Whenever I explain this I always remind folks that emergency and urgently needed care are always covered, without network restriction. Any life threatening issue should result in an ER visit to the nearest facility, period. Any unforeseen illness or injury should be tended to by the nearest urgent care clinic or available provider at the time (a good time to plug any 24 hour Nurse lines available if the plan provides this).

Obviously those with past experience in a network based plan should have a better grasp than those previously on a traditional Medicare plan, but providing full disclosure to every new enrollee is the best policy in order to avoid these issues altogether, or at least have a strong case in response to an allegation.

Another tip...when certain specialists are the priority in selecting a plan, be sure to confirm that the primary care physician selected refers to those particular specialists. Being listed in the network directory does not guarantee the member open access to any specialist. Confirm with with the appropriate provider(s) before selecting a PCP to avoid challenges later.

Printed vs Electronic Directories: To ensure prospects are given the most detailed and accurate information, agents should not rely on printed directories alone, as they can become inaccurate shortly after production. The most reliable resource is carrier’s online provider search tool. Taking screenshots or printing appropriate pages upon enrollment for your records, similar to how many agents print a copy of the Rx plan finder results, may serve you well should an allegation arise.