AEP Prep: Harnessing AI for Compliance Risk Mitigation

The Medicare Annual Enrollment Period (AEP) is just around the corner. 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 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.

The new rule requires MAOS to adopt comprehensive best practices including:

• Strengthening oversight into telephonic enrollments to identify inappropriate and misleading agent and broker behaviors that are not compliant with CMS.
  
• Reviewing marketing and enrollment calls between beneficiaries and agents to ensure adherence to the updated pre-enrollment checklist (PECL).

• Ensure agents are finding an applicable plan for an enrollee by asking pertinent questions to help a beneficiary enroll in a plan that best meets their individual needs.

Preparing your operational processes to comply with these new rules across thousands of calls and sales in your organization before AEP begins may be a challenge—made even more difficult when laying on the challenges of a tight labor market, high turnover, and heightened CMS scrutiny.

Enter AI for AEP compliance risk mitigation.

With AI technology, calls can not only be transcribed, but can automatically identify performance gaps, identify training opportunities, and improve productivity with sophisticated automation at scale.  

Below are 3 ways in which AI can help your sales agency overcome potential CMS compliance issues at scale for the 2024 AEP season.

#1: Identify Inappropriate & Misleading Behaviors

CMS is advising that MAOs advise an oversight plan to identify behaviors that are not compliant with CMS. In general, CMS is disappointed in how many instances they feel a customer was misled into a plan when reviewing telephonic enrollments.

MA organizations and Part D sponsors need to be proactive in finding and addressing conversations in which agents and brokers are not following compliant processes.

With AI, you can have confidence this AEP season 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. 

With an AI tool designed for AEP enrollment, your company can devise 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 CMS 2024 rule to the PECL.  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) regarding the Summary of Benefits.  It also reinforces there is a certain order in the Summary of Benefits that needs to be read.  

AI classification models can automatically capture moments in which the agent discusses the elements of the pre-enrollment checklist (PECL).  Conversely AI built its conversational AI specifically for Medicare (150+ intents for just MA enrollments!), so its tool understands the nuances of what needs to be said and when.  For example, if the 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.  With a Medicare sales specific AI tool, all of these calls can be thread 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.

Use AI to determine if a proper assessment is conducted ahead of an AEP 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, 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.