DMS 2024 Call Quality Definitions and Insights
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Questions and Answers

Did the agent use the required call opening?

Yes

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

Yes

Did the agent identify the name of the primary beneficiary?

Yes

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 to determine eligibility on their behalf?

<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

What is considered appropriate behavior during a call with a beneficiary?

<p>Limiting distractions and addressing the consumer's needs</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 with focus on experiences with current coverage?

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

It is appropriate to place the beneficiary on mute to discuss issues with other parties.

<p>False</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

What should agents be prepared to handle during a call?

<p>The needs of the beneficiary.</p> Signup and view all the answers

Periods of unexplained silence negatively impact the consumer's experience, often leading to questions like, 'Are you still ______?'

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

What example indicates a negative impact on a beneficiary during a call?

<p>The agent answers a secondary call.</p> Signup and view all the answers

Interrupting the beneficiary to obtain information is acceptable without reasoning.

<p>False</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 technique should agents use to analyze consumer needs?

<p>Needs Analysis Technique</p> Signup and view all the answers

What is important when presenting a solution to consumers?

<p>Focusing on addressing the consumer’s needs and wants</p> Signup and view all the answers

What does a call to action entail?

<p>Direction for immediate action from the beneficiary</p> Signup and view all the answers

How should agents address gaps, barriers, and concerns?

<p>Proactively and with clear communication</p> Signup and view all the answers

What is a way to expand the AOR relationship through Humana support?

<p>Communicating how initiatives enhance the relationship</p> Signup and view all the answers

How can agents demonstrate active listening skills?

<p>By personalizing the conversation and responding to consumer cues</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, 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 plan name and effective date?

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

Did the agent accurately complete the consumer's application including 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 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 refrain from cross-selling non-health plans on a Medicare plan call?

<p>True</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 collect the applicant’s email address?

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

Did the agent discuss the 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

Study Notes

Document Overview

  • Job aid outlines MarketPoint Call Quality requirements for DMS agents managing inbound and outbound calls regarding MA, MAPD, or PDP products.
  • Document revised on February 1, 2024, by Humana Inc.

Compliance and Business Process

  • Evaluators include certified associates like Call Quality Managers and Sales Leadership Teams.
  • Focus on situational sales requiring adaptive approaches based on interaction dynamics and beneficiary needs.
  • Compliance section scored using Yes, No, or Not Applicable, with an emphasis on minimum requirements.

Scoring Dynamics

  • Compliance score range:
    • 85%-100% indicates agents are on target; review and coaching recommended for any missed elements.
    • Below 85% requires immediate review and documentation of coaching steps.

Consumer Experience Evaluation

  • Consumer experience section scores components on a scale of 0-3, focusing on effectiveness rather than minimum expectations.
  • Score ranges:
    • 15-18 points: Exceptional/Modeling
    • 11-14 points: Full/Demonstrating
    • 6-10 points: Inconsistent/Learning
    • Below 6 points: Immediate Attention Required

Key Compliance Questions and Elements

  • C1: Required call opening must include agent identification in compliance with regulations.
  • C2: Scope of Appointment must be secured and documented before marketing efforts.
  • C3: Identifying primary beneficiary requires accurate documentation.
  • C5: MARx disclosure necessitates beneficiary permission before eligibility assessment.

Consumer Experience Elements

  • CE1: Utilize needs analysis techniques to ascertain beneficiary requirements effectively.
  • CE2: Clearly present solutions tailored to beneficiary needs during calls.
  • CE4: Address and understand gaps or concerns raised by beneficiaries to enhance service experience.
  • CE6: Demonstrate active listening skills throughout the call process.

Important Compliance Regulations

  • 42 CFR § 422.2274(b): Requires agent licensing and identification.
  • 42 CFR § 422.2264(c)(3)(i),(iii): Stipulates securing a Scope of Appointment prior to engagement.

Training Resources

  • Use internal resources such as All Scripts and Voicelogs for guidance on presentational techniques and compliance protocols.### Enrollment Process Guidelines
  • Ensure all telephonic enrollment requests are made by the beneficiary or their authorized representative.
  • Collect the full name and relationship to the primary beneficiary when the caller is not the beneficiary.

Determining Decision-Making Capacity

  • Establish if the beneficiary can make healthcare decisions independently.
  • Verify the necessity of a Power of Attorney (POA) or authorized representative during discussions.
  • Obtain documented consent from the beneficiary before accessing MARx for eligibility checks.
  • Inform beneficiaries that consent is optional but assists in determining eligible plans.

Valid Election Periods

  • Verify that enrollment requests occur within valid election periods established by CMS.
  • Educate beneficiaries on the election period relevant to their enrollment.

Qualification of Interested Parties

  • Ensure all interested parties meet eligibility requirements for Medicare.
  • Assess current medical coverage and benefits impacting enrollment options, including health-related questions for specific needs.

Understanding the Beneficiary's Needs

  • Establish reasons for changing plans by understanding experiences with current coverage.
  • Determine what benefits are prioritized by the beneficiary during the plan consideration process.

Summary of Benefits (SOB) Review

  • Clearly communicate the details of the Summary of Benefits to the beneficiary, including premiums, deductibles, and coverage specifics.
  • Ensure understanding of the product rules and cancellation rights before finalizing enrollment.

Network and Coverage Review

  • Discuss provider network status, including primary care physicians, specialists, pharmacies, and hospitals.
  • Clarify any consequences of using out-of-network providers and conditions for referral requirements.

Impact of Enrollment on Current Coverage

  • Explain how enrolling in a new plan may result in disenrollment from current coverage options.
  • Emphasize the benefits of the new plan compared to existing coverage.

Required Disclosures

  • Read all mandated disclosures regarding the specific plan of interest before proceeding with enrollment discussions.### Enrollment and Communication Guidelines
  • MA organizations must avoid inaccurate or misleading information per 2 CFR § 422.2262 and 42 CFR § 422.2268.
  • Agents are required to confirm if they represent all available plans within the first minute of sales calls as per 42 CFR § 422.2267.
  • Policies mandate that MA organizations establish systems confirming beneficiaries understand their product and plan rules (42 CFR § 422.2274).

Enrollment Process Requirements

  • Agents must verbally confirm readiness to enroll by stating the plan name and effective date (42 CFR § 422.2262, 42 CFR § 422.2268).
  • Accurate completion of consumer applications includes verifying contact information, payment options, language preference, and alternative format requests.
  • Proper documentation of all enrollment processes, including verbal attestations of intent to enroll, is required.

Signature and Misrepresentation Protocols

  • Agents must adhere to compliant signature processes, utilizing electronic or verbal methods consistent with MMCM guidelines.
  • Misrepresentation of affiliation with Medicare is prohibited; agents must clarify their licensed agent status (42 CFR § 422.2262).

Health Status Guidelines

  • Prohibition on health-related questions unless necessary for suitability assessments (42 CFR § 422.2262, § 422.2264).
  • MA organizations can only collect limited health information relevant for eligibility during enrollment, with broader assessments permissible post-enrollment.

Sales Tactics and Practices

  • High-pressure sales tactics are expressly forbidden; presentations must emphasize the beneficiary's needs without intimidation (42 CFR § 422.2262).
  • Disclosure of protected health information must only occur with authorized individuals (45 CFR § 164.502).

Cross-Selling Restrictions

  • Discussions of non-healthcare products during MA or Part D sales activities are prohibited (42 CFR § 422.2262, § 422.2264).
  • Agents should provide beneficiaries with a toll-free number if inquiries about non-health products are made.

Cold Calling and Contact Regulations

  • Cold calling without an established business relationship or prior permission is prohibited (42 CFR § 422.2264).
  • Unsolicited contacts regarding CMS-regulated products must not occur without documented consent.

Closing Procedures

  • Agents must include the carrier name, customer service number, and confirmation number during call closing (42 CFR § 422.111, § 422.2274).

Email Collection and Communication

  • Agents should collect email addresses to facilitate communication and retention through digital engagement.
  • Discussing the Humana Care Highlight Program helps beneficiaries select informed healthcare providers without leading them to specific options.

Centerwell Pharmacy and Health Risk Assessment

  • Conversations about Centerwell Pharmacy benefits should establish permission for future outreach.
  • Completing Health Risk Assessments (HRAs) requires agent confirmation for participation, contributing to improved health outcomes and addressing social needs.

Documentation and Compliance

  • Accurate CRM documentation is vital for communication and compliance, ensuring that beneficiary information is correct to avoid HIPAA violations and ineffective strategy implementation.

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Related Documents

Humana 2024 DMS Definitions and Insights PDF

Description

This quiz provides guidance on MarketPoint Call Quality requirements for DMS agents handling inbound and outbound calls related to MA, MAPD, or PDP products.

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