Welcome to CMS Compliance Counsel Welcome to CMS Compliance Counsel Welcome to CMS Compliance Counsel Welcome to CMS Compliance Counsel

Medicare Sales and Marketing

CMS has taken a very hard line in reviewing the marketing materials utilized by licensed providers in offering coverage to consumers, and requires pre-approval of marketing materials. Since the permissible marketing time period constitutes a relatively narrow window, timely submission of these materials, and timely approval of the same, is critical to a successful marketing effort. The firm is available to review and assist in this submission process, in order to seek approval as rapidly as possible.

Once the marketing materials are approved, they must then be distributed, and agents must be trained appropriately to present the materials exactly as prepared and approved, with no material deviations. Again, this process requires careful attention, since CMS has engaged "secret shoppers" to attend seminars/presentations where the marketing information is disseminated, to test whether or not the approved script is followed. Failure to adhere to these pre-approved marketing materials, and to adhere to the limitations imposed by CMS, will almost certainly result in severe administrative consequences. Therefore, the insurance company/provider must maintain a rigorous training program with strict enforcement in order to protect itself and safeguard against regulatory sanctions. The firm is available to assist in designing and implementing such programs.

Providers are further required to maintain reporting of agent complaints and disenrollment figures so that CMS can monitor the methods by which programs are being marketed, and the effectiveness of the agent training and supervision. Excess complaint levels, or abnormally high disenrollment figures that are out of line with industry averages will undoubtedly result in administrative scrutiny which may even escalate to the point of requirement for promulgation of a Corrective Action Plan.

The difficulties to be encountered in conducting effective marketing are many, but may range from outright fraud or deception by unscrupulous agents, a hopefully rare occurrence, to misunderstandings by unsophisticated consumers, which ideally would be minimized by carefully prepared marketing materials, and may often by triggered by inadequate geographic or specialty scope of providers who have agreed to coverage under the specific plan, resulting in cancellation by unhappy consumers who find out that they either cannot find a specialist for the care that they need, or that there is no physician or facility within easy geographic access. Again, these issues can hopefully be minimized by careful and thorough advance planning and development, but all too often can still arise as problems after the fact requiring immediate remedial attention. The firm is ready to assist with these matters.

Finally, even when the licensed provider has obtained proper advance approval of its marketing materials, and even where there is adequate agent training and supervision, there still must be carefully monitored implementation of audit policies and procedures to manage internal review of performance and monitor complaints and disenrollment/cancellation. Since CMS will require reporting of these on a regular basis, it is the responsibility of the provider to monitor its own performance and attempt to head off any major regulatory problems resulting from substandard performance.

These dynamics of ongoing auditing, monitoring, corrective action, and reporting are all potential areas of regulatory problems which require careful attention by the provider, and the firm is ready to assist in these difficult matters.