Customer Service Etiquette
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Questions and Answers

Which of the following actions should be avoided during a call with a beneficiary? (Select all that apply)

  • Engaging in conversation with coworkers during the call (correct)
  • Placing the beneficiary on hold for unnecessary reasons (correct)
  • Interrupting the beneficiary without explanation (correct)
  • Documenting details without listening to the beneficiary (correct)

    • It is appropriate to place a beneficiary on mute for personal discussions?

    False

    What should an agent do if the consumer's communication is difficult to understand?

    Exercise empathy and provide necessary assistance.

    Periods of unexplained ______ negatively impact the consumer’s experience.

    <p>silence</p> Signup and view all the answers

    Match the following issues with their corresponding descriptions:

    <p>Placing on mute = Engaging in discussions unrelated to the call Interrupting without reasoning = Not allowing the beneficiary to provide complete information Distractions = Engaging in activities like web browsing during the call Unexplained silence = Periods during the call where no communication occurs</p> Signup and view all the answers

    Did the agent ask to save prescription data for enrollment?

    <p>Yes</p> Signup and view all the answers

    Did the agent ask for Digital Onboarding permission?

    <p>Yes</p> Signup and view all the answers

    Did the agent ask and properly document the PTE question?

    <p>Yes</p> Signup and view all the answers

    What is the minimum requirement for Needs Analysis Technique?

    <p>$2 Points</p> Signup and view all the answers

    What is the minimum requirement for Presenting a Solution?

    <p>$2 Points</p> Signup and view all the answers

    What is the minimum requirement for Call to Action?

    <p>$2 Points</p> Signup and view all the answers

    What is the minimum requirement for understanding and addressing the gaps/barriers/concerns?

    <p>$2 Points</p> Signup and view all the answers

    What is the minimum requirement for expanding AOR relationship through Humana support/initiatives?

    <p>$2 Points</p> Signup and view all the answers

    What is the minimum requirement for demonstrating active listening skills throughout the call?

    <p>$2 Points</p> Signup and view all the answers

    Did the agent review the Summary of Benefits prior to completion of the enrollment?

    <p>Yes</p> Signup and view all the answers

    Did the agent offer to review provider network status, current prescriptions for plan coverage, preferred hospital network status, and preferred facility network status?

    <p>Yes</p> Signup and view all the answers

    Did the agent explain how enrolling will affect current coverage including being disenrolled from their current plan?

    <p>Yes</p> Signup and view all the answers

    Did the agent read all required disclosures for the determined plan of interest?

    <p>Yes</p> Signup and view all the answers

    Did the agent confirm the beneficiary was ready to complete his/her enrollment including stating the plan name and effective date?

    <p>Yes</p> Signup and view all the answers

    Did the agent accurately complete the consumer's application and review contact information, payment options, language preference, and alternate format election?

    <p>Yes</p> Signup and view all the answers

    Did the agent follow the appropriate steps to obtain a compliant signature?

    <p>Yes</p> Signup and view all the answers

    Did the agent claim to be endorsed or work for Medicare?

    <p>False</p> Signup and view all the answers

    Did the agent ask health-related questions that can be used for targeting a subset of members?

    <p>False</p> Signup and view all the answers

    Did the agent engage in high-pressure sales tactics?

    <p>False</p> Signup and view all the answers

    Did the agent disclose health PI information to the wrong party?

    <p>False</p> Signup and view all the answers

    Did the agent cross-sell non-health plans on a Medicare plan call?

    <p>False</p> Signup and view all the answers

    Did the agent conduct cold calling for MA/MAPD/PDP interest without established EBR or permission?

    <p>False</p> Signup and view all the answers

    Did the agent provide compliant call closing?

    <p>Yes</p> Signup and view all the answers

    Did the agent collect the applicant’s email address?

    <p>Yes</p> Signup and view all the answers

    Did the agent discuss Humana Care Highlight Program to help the applicant select a primary care provider?

    <p>Yes</p> Signup and view all the answers

    Did the agent ask permission for Centerwell Pharmacy outreach?

    <p>Yes</p> Signup and view all the answers

    Did the agent complete the HRA with an authorized party?

    <p>Yes</p> Signup and view all the answers

    Did the agent accurately document their CRM database?

    <p>Yes</p> Signup and view all the answers

    Did the agent ask if additional parties are seeking assistance?

    <p>Yes</p> Signup and view all the answers

    Did the agent use the required call opening?

    <p>Yes</p> Signup and view all the answers

    Did the agent follow guidance from CMS as it relates to the Scope of Appointment (Telephonic)?

    <p>Yes</p> Signup and view all the answers

    Did the agent identify the name of the primary beneficiary?

    <p>Yes</p> Signup and view all the answers

    Did the agent determine if the beneficiary is able to make their own healthcare decision?

    <p>Yes</p> Signup and view all the answers

    Did the agent obtain and document permission from the beneficiary prior to accessing MARx?

    <p>Yes</p> Signup and view all the answers

    Did the agent determine valid election period eligibility?

    <p>Yes</p> Signup and view all the answers

    Did the agent fully qualify each interested party?

    <p>Yes</p> Signup and view all the answers

    Did the agent determine the reason the beneficiary is inquiring about a different plan?

    <p>Yes</p> Signup and view all the answers

    Did the agent determine which benefits are a priority for the beneficiary?

    <p>Yes</p> Signup and view all the answers

    Did the agent review the Summary of Benefits prior to completion of the enrollment?

    <p>Yes</p> Signup and view all the answers

    Did the agent offer to review provider network status, current prescriptions, and hospital network status?

    <p>Yes</p> Signup and view all the answers

    Did the agent explain how enrolling will affect current coverage?

    <p>Yes</p> Signup and view all the answers

    Did the agent read all required disclosures for the determined plan of interest?

    <p>Yes</p> Signup and view all the answers

    Did the agent confirm the beneficiary was ready to complete their enrollment?

    <p>Yes</p> Signup and view all the answers

    Did the agent accurately complete the consumer's application?

    <p>Yes</p> Signup and view all the answers

    Did the agent follow the appropriate steps to obtain a compliant signature?

    <p>Yes</p> Signup and view all the answers

    Did the agent refrain from claiming to be endorsed or work for Medicare?

    <p>Yes</p> Signup and view all the answers

    Did the agent refrain from asking health-related questions that could be viewed as cherry-picking?

    <p>Yes</p> Signup and view all the answers

    Did the agent refrain from engaging in high-pressure sales tactics?

    <p>Yes</p> Signup and view all the answers

    Did the agent avoid disclosing health PI information to the wrong party?

    <p>Yes</p> Signup and view all the answers

    Did the agent refrain from cross-selling non-health plans on a Medicare plan call?

    <p>Yes</p> Signup and view all the answers

    Did the agent refrain from cold calling for MA/MAPD/PDP interest without established EBR?

    <p>Yes</p> Signup and view all the answers

    Did the agent provide compliant call closing?

    <p>Yes</p> Signup and view all the answers

    Study Notes

    Document Overview

    • Focuses on MarketPoint Call Quality requirements for DMS agents managing calls about Medicare Advantage (MA), Medicare Advantage Prescription Drug (MAPD), or Prescription Drug Plans (PDP)
    • Intended for DMS agents conducting inbound and outbound sales calls

    Compliance and Business Process

    • Developed as a resource for evaluators to provide feedback to Licensed Sales agents
    • Evaluators include Call Quality Managers, Sales Leadership, and Compliance Professionals
    • Document highlights necessary actions but does not cover all call scenarios due to diversity in interactions

    Scoring and Evaluation Mechanics

    • Compliance and business process components evaluated using Yes, No, or Not Applicable
    • Scoring for compliance:
      • 85%-100% indicates agents are on target; review and coaching recommended for any missed elements
      • Below 85% signifies need for immediate attention, with discussions on violations and remediation

    Consumer Experience Evaluation

    • Consumer experience scored by effectiveness on specific call behaviors, with a range of 0-3 points for scored components
    • Exceptional (3 points), Full (2 points), Inconsistent (1 point), and Did Not Demonstrate (0 points) ratings
    • Scores categorize agents as either requiring attention or demonstrating acceptable behavior

    Compliance Definitions and Questions

    • Key compliance questions addressed include:
      • C1: Required call opening procedures
      • C2: Adherence to Scope of Appointment mandates
      • C5: MARx disclosure requirements
      • C17: Refraining from claiming Medicare endorsement
      • C19: Avoiding high-pressure sales tactics

    Business Process Questions

    • Key questions include:
      • BP1: Collecting applicant’s email address for communication
      • BP2: Discussing Humana Care Highlight Program for primary care provider selection
      • BP4: Completing member care assessments with authorized parties

    Consumer Experience Focus

    • Focuses on enhancing customer interactions through techniques such as:
      • CE1: Needs Analysis Technique
      • CE3: Call to Action emphasis
      • CE6: Active listening as a critical component

    Key Elements Summary

    • Compliance section includes 23 questions, each weighted differently based on importance
    • Business process section includes 9 questions, also tailored to ensure thorough engagement
    • Consumer experience section presents 6 questions aimed at refining agent-customer interaction dynamics

    Important Regulations

    • Compliance with 42 CFR requirements is essential for agents conducting telephonic enrollments
    • Scopes of Appointment must be secured and documented before engaging prospective enrollees

    Conclusion

    • Continuous monitoring and feedback are crucial for improving DMS agents' call handling and ensuring compliance with Medicare guidelines
    • Emphasis on understanding the consumer experience is critical and contributes to successful sales interactions.### Enrollment Process Guidelines
    • Agents must affirmatively inquire about caller's interest in plan options and tailor presentations accordingly.
    • Conversations regarding enrollment do not affect current or future health coverage unless an enrollment occurs on that call.

    Beneficiary Identification

    • Agents must obtain the full name of the primary beneficiary and the caller.
    • If the caller differs from the beneficiary, the agent should establish the relationship to the beneficiary.

    Decision-Making Capability

    • Agents must determine if the beneficiary can make their own healthcare decisions and identify if a Power of Attorney (POA) or authorized representative is necessary.
    • Prior to accessing beneficiary information, agents must obtain explicit consent and explain the purpose of the access.
    • Required eligibility information includes Medicare ID, name, birth date, and social security number, alongside a disclaimer regarding CMS’s final eligibility determination.

    Valid Election Period Verification

    • Agents are responsible for confirming valid election periods for enrollment, per established guidelines to ensure effective dates of coverage are accurate.

    Qualifying Interested Parties

    • Full qualification of all interested parties is required; agents must verify Medicare eligibility, current coverage, and assess additional health-related inquiries for specific needs.

    Understanding Beneficiary's Needs

    • Agents must identify the reasons beneficiaries seek new plans and assess their current plan's benefits to understand unmet needs.

    Prioritized Benefits Discussion

    • Fundamental to the conversation is determining which benefits the beneficiary prioritizes in their desired plan.

    Review of Summary of Benefits

    • Agents must review the Summary of Benefits (SOB) prior to enrollment, including monthly premiums, deductibles, copayments, emergency services, and coverage limitations.

    Provider Network Status Review

    • Agents should evaluate the network status of Primary Care Providers, specialists, pharmacies, and hospitals to help beneficiaries understand their options and any impacts of out-of-network services.

    Explanation of Enrollment Impact

    • Assess the implications of enrolling in a new plan, particularly how it may lead to disenrollment from existing coverage. This includes discussing the nature of IDV/OSB products compared to supplemental plans.

    Required Disclosures

    • Agents are obligated to read all necessary disclosures relevant to the plan of interest, ensuring beneficiaries fully understand the product being offered.

    Resource References

    • A variety of resources are referenced for training and compliance, including Medicare presentations, disclosures, job aids for sales integrity, and specific documentation related to enrollment practices and eligibility verification.### Intent/Purpose Overview
    • Regulations require MA organizations to provide accurate and clear information to beneficiaries.
    • Agents must disclose their representation status clearly within the first minute of a sales call.
    • MA organizations need a system to confirm beneficiaries understand their plan.

    Enrollment Requirements

    • Agents must confirm beneficiaries' readiness to complete enrollment including stating the plan name and effective date.
    • Accurate completion of consumer applications requires reviewing: contact information, payment options, language preference, and alternate format election.
    • Telephonic signatures must comply with outlined standards and procedures.

    Compliance and Agent Representation

    • Agents cannot misrepresent their affiliation with Medicare or CMS.
    • Refraining from health-related inquiries is essential to avoid targeting specific subsets of potential members, referred to as "cherry-picking."
    • High-pressure sales tactics are prohibited; agents should provide information based solely on beneficiaries’ needs.

    Privacy and Disclosure

    • Agents must safeguard protected health information, disclosing it only to authorized individuals.
    • Cross-selling non-health plans during Medicare discussions is prohibited.
    • Cold calling without prior established business relationships or documented permissions is not allowed.

    Communication and Documentation

    • Agents must provide beneficiaries with carrier information and application confirmation after enrollment.
    • Collecting email addresses is critical to engage beneficiaries and support retention through digital communications.
    • The Humana Care Highlight Program aids in selecting primary care providers, emphasizing quality and efficiency without steering beneficiaries.

    Outreach and Assessments

    • Permission must be obtained for outreach by Centerwell Pharmacy, enhancing member experience through additional benefits.
    • Completion of Health Risk Assessments (HRAs) with authorized parties is part of addressing community health needs.

    Documentation Practices

    • Accurate documentation in CRM databases is vital for compliance and maintaining effective communication with beneficiaries.
    • Providing incorrect beneficiary details can lead to privacy risks and issues in marketing strategies.

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    Description

    This quiz assesses the knowledge of customer service representatives on appropriate behaviors during calls with beneficiaries, including communication strategies and etiquette.

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