Each year Premier Marketing tracks Compliance Violation and Member Complaint data so we can better educate you on how to avoid compliance issues. Each of us has a responsibility to do business compliantly. Hopefully this will help you in your efforts.

Over the course of 2019, the top reasons for Compliance Violations and Member Complaints for Premier agents were:

1. Cost Information (19% of all member complaints were directly related to Cost) – Down from 21% last year
2. Agent Service/Behavior Issues (19%) – Up from 15% last year
3. Provider/Rx Network (15%)
4. Unqualified Sales (15%) – Up from 12% last year
5. Enrollment without Permission (14%) – Down from 17% last year
6. Benefit Coverage Info (8%) – Down from 10% last year

Cost Information

• Copays/Coinsurance and Rx Costs continue to be the overwhelming reason members file complaints due to
  inaccurate Cost Information
• Plan Premiums, Deductibles, along with
  Dental/Vision costs are also make the list

Agent Service/Behavior Issues

• This is a broad category
• Types of allegations included here are:
• Deceitful/Fraudulent Activity;
• Client thought Plan was a Med Supp;
• Agent selected Wrong Plan on App;
• Agent won’t return calls;
• Non-Compliance Scope of Appointment
• Agent who presented plan isn’t the AOR
• Non-Compliant Marketing Material

Provider/Rx Network

• Roughly 80% of this type of allegation stems from a Provider being Out-of-Network
• Verify Providers!!
• Most of these can in some way be attributed to COST as well – Out-of-Network equals higher cost to the client

Unqualified Sales

• This continues to be an area of concern as the percentage of Unqualified Sales compared to Total Complaints continues to rise
• Somewhat alarming since it should be the easiest area to avoid
• Most unqualified sales are due to Certification issues
• Take the time to certify for all products in the Carrier’s portfolio!!
• Make sure you are appointed in each state you plan to sell in!

Enrollment Without Permission

• Still continues to be a major reason for Member Complaints but the overall percentage did go down from last year – so nice work!!
• Most end up being “Unfounded” since the client did in fact sign the app, but they still count as a complaint nonetheless
• Go above and beyond to ensure the plan is the absolute best fit for the client!

Benefit Coverage Info

• Overall percentage compared to total complaints was down in 2019 compared to 2018!
• Misinformation regarding Dental and Vision benefits are still the most popular cause for complaints in this category
• Rx coverage is also an area of concern

Takeaways

• We estimate over 50% of all complaints or allegations we see are related to COST in some way or another
• Get the client the best plan for their needs and explain all COSTS involved
• Make sure you’re RTS prior to presenting/selling a plan
• Clearly explain all pertinent plan benefits – especially Dental, Vision, and Rx coverages

Please pass this information on to your downline agents
(if you have any). Contact us with any questions or for more information regarding compliance. We are here to support YOU!

compliance@premiersmi.com