Conversely AI

Top 3 Medicare Compliance Challenges (+ How to Solve Them Before AEP)

AEP Compliance & QA Monitoring

The Medicare Annual Enrollment Period (AEP) is just around the corner. And as the busy season approaches, Medicare Advantage Organizations (MAOs) must prepare not only for the increase in sales and marketing efforts but for heightened compliance expectations this year. 

The Centers for Medicare & Medicaid Services (CMS) released its 2023 Final Rule—outlining recommendations and requirements for marketing and communications oversight, with an emphasis on greater transparency. 

The new rule and recent guidance require MAOS to adopt comprehensive best practices including: 

  • Strengthening oversight of third-party marketing organizations to detect and prevent the use of confusing or potentially misleading activities to enroll beneficiaries in Medicare Advantage and Part D plans.
  • Reviewing marketing and enrollment calls between beneficiaries and agents to ensure compliance under 42 CFR Subpart V.

But adapting to these new standards and ensuring compliance across thousands of calls and sales in your organization this year is a big task—made all the more difficult amidst a tight labor market, increased turnover, and heightened scrutiny. 

That’s where AI technology can make a difference. 

Artificial intelligence (AI) and other technological innovations are transforming the compliance landscape and making it easier for MAOs to monitor and improve compliance at scale. 

Below we’ll review some of these top challenges to mitigating risk and achieving compliance—plus how new AI technology can help you overcome them. 

Challenge 1: Hiring staff in a competitive market with high turnover 

Monitoring compliance manually across hundreds of sales calls is time-intensive and increasingly costly in today’s tight labor market. MAOs and third-party marketing companies need a staff of licensed agents—a skilled role that is difficult to fill these days. 

Today, the average agent attrition rate is approximately 42%. So with 11.4 million job openings and roughly 56 workers for every 100 job openings, finding and retaining a skilled quality assurance team is a challenge. And even when you can find qualified candidates, the cost of replacing an employee is as much as 2x their annual salary. 

Even if you can keep a full staff, the sheer scale of calls to monitor means you’ll only be able to sample and QA a small portion of those calls for compliance purposes. This leaves your organization open to greater risk for noncompliance for missed mistakes and makes it difficult to uncover key opportunities for improvement.

Solution: Analyze compliance risk within seconds

Manual spot checks for QA take time and can only cover a portion of your sales calls. But AI tools for Medicare compliance can scan and transcribe 100% of calls within seconds, tagging words, phrases, and behaviors that may indicate risk.

With an AI solution, you can analyze each conversation for sales and compliance adherence to uncover insights into performance and identify exceptions so you can take immediate corrective action. 

This efficiency enables organizations to act more quickly to resolve red flags and mitigate risk during enrollment. In fact, with real-time monitoring enabling fast-tracked review, any red flags that occurred in the enrollment period could easily be fixed before the January 1 effective date.

Challenge 2: Less experienced staff = more mistakes and missed opportunities

Trust is key to building good relationships with customers and securing sales. But when organizations struggle to communicate with transparency and compliance that impacts consumer trust and satisfaction. This is especially a concern for MAOs that have high turnover and are regularly training new, less experienced staff. The less experience agents have, the higher the risk of uncompliant practices.

When employee turnover is high, organizations are stuck in a high-cost recruiting and training loop that leads to a drain on resources and talent. And newer, less experienced staff are more likely to make mistakes that increase the risk of non-compliance and miss key sales opportunities that could improve revenue and customer satisfaction. 

Solution: Improve the legitimacy of the Medicare sales process 

An AI solution improves trust and builds legitimacy in the sales process by not only monitoring keywords and phrases but also behaviors.  For example, AI systems can detect confused callers, negative sentiment, and forced sales—and can block the sale in real-time for management review and approval.

AI can also listen to conversations, detect if the right thing is being said at the right time by the agent, and alert the agent in real-time so they can correct the issue before the call comes to an end.

Challenge 3: Managing new and expanded compliance requirements 

With the new standards for 2023, MAOs and marketing companies need to pivot fast to implement updated best practices and procedures, train agents on the new rules, and monitor compliance across the organization. Managing these changes reliably at scale is difficult, especially as organizations need agility to keep up with evolving standards—and manual compliance QA is limited in agility and efficiency.   

Solution: Rapidly scale your compliance capabilities with confidence 

AI enables sales organizations of any size to rapidly scale their QA efforts while remaining up-to-date on compliance requirements so agents can make calls with confidence. A robust AI solution enables agents and organizations to review calls in near time to identify compliance issues as they happen so agents can take immediate action to fix the problem—instead of taking weeks or months to review calls. This not only reduces compliance risk but also improves sales and customer experience.

Unlock the power of AI in your compliance management solution

Manual QA and compliance management is no longer sufficient for today’s healthcare landscape. To meet the needs of customers and agents, while maintaining high compliance standards, modern sales organizations need agile solutions that can deliver results.   

Enter: Conversely AI.

Specifically designed for Medicare call centers, Conversely AI has analyzed the sales processes of some of the largest Medicare sales providers in the country, uncovering what sales techniques drive lift and what don’t so you can replicate the best behaviors while ensuring full compliance before, during, and after enrollment. 

Conversely is purpose-built for rapid deployment at scale so you can achieve compliance in a fraction of the time. And it’s not too late to get started this year. 

Get 100% visibility into your sales practices and your compliance with Conversely AI.

Schedule a demo today.

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