Conversely AI

The Final CMS Rule: How Conversational AI Can Help Enhance Visibility Into Agent Behavior

conversational ai final rule cms

The Centers for Medicare and Medicaid Services (CMS) released its final rule for plan year 2024.  Among many other updates, it continues to provide guidance on how your agents can sell Medicare products in contact centers.

Below, we highlighted some of the areas where the deployment of a conversational AI tool can help you be part of the solution in the continuing effort of ensuring members have a great experience and are in a plan that serves them well. 

Conversely AI is an AI company that was specifically designed to understand and provide visibility into Medicare product sales conversations. 

#1: Lack of Oversight into Agent Behavior

CMS is concerned that MA organizations and Part D sponsors are being reactive instead of proactive in addressing inappropriate agent and broker behavior.  They are advising an oversight plan to be deployed to identify behaviors that are not compliant with CMS. 

In general, CMS is disappointed in how many instances they feel a customer was misled when reviewing telephonic enrollments.

How Conversely AI Can Help:

Offer confidence that the right process is being followed by analyzing and providing visibility into 100% of sales enrollment calls. Automatically tag key insights, phrases, and required statements for immediate scoring and corrective action through a closed-loop management process. 

This tool can customize an oversight plan specific to your compliance program and its workflow tool will automatically bucket flagged calls that can be reviewed by management and the agent to achieve corrective action quickly.

#2: Ensuring Adherence to the Updated Pre-Enrollment Checklist (PECL)

There are many references throughout the rule to the PECL.  Specifically, measures need to be taken to ensure enrollees understand what effect enrolling will have on their current coverage.  Additionally, the rule details what needs to be explained (and understood by the enrollee) in regard to the Summary of Benefits.  It also reinforces there is a certain order in the Summary of Benefits that needs to be read.  

How Conversely AI Can Help:

Conversely AI has built AI classification models that automatically capture moments in which the agent discusses the elements of the pre-enrollment checklist (PECL).  We’ve built our conversational AI specifically for Medicare (150+ intents for just MA enrollments!), so our tool understands the nuances of what needs to be said and when.  For example, if our tool detects the correct SOA was stated, but a plan had been discussed, a corrective action task is still created. 

Many times there are multiple conversations that take place with a customer before the call in which the enrollment takes place.  Our tool can thread all of these calls together in order to give a comprehensive score for the entire sales experience.  Having been specifically designed for Medicare, Conversely AI is already equipped to help its clients achieve peace of mind that PECL elements are accurately being communicated to the enrollee. 

#3: Finding an Applicable Plan for the Enrollee

CMS has listened to hundreds of marketing & enrollment calls and found that 80% of the time agents and brokers failed to ask pertinent questions to help a beneficiary enroll in a plan that best meets their individual needs.

How Conversely AI Can Help:

We use AI to determine if a proper assessment is conducted ahead of enrollment.  Of particular importance is understanding if the enrollee:

  • has any chronic conditions
  • is on Medicaid
  • has any prescriptions they would like to be looked up
  • finds any other benefits (dental/vision/hearing etc.) to be of particular importance
  • wants to continue seeing their doctor(s)

In addition to understanding if the proper probing questions are being asked, our conversational AI can analyze the customer responses and inputs to determine if the plan being discussed and sold fits the customer’s situation and provide a score.

DOWNLOAD NOW: How to use AI to Nurture & Retain for Medicare Advantage

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