Humana is changing their process for investigating allegations against agents in order to more effectively promote compliant agent behavior when selling Humana plans. This is more on a risk-based model and leverage the issues more efficiently.
Depending on the nature of the allegation, your agents may receive:
- A notification of the allegation. Agents must acknowledge receipt by the date specified in the notice. (simply replying back will do, they have also received approval for agencies or agency compliance departments to acknowledge receipt on the agents behalf, with the understanding notification and appropriate training will be completed.)
- Training or other corrective actions designed to assist agents with understanding the compliance rules to prevent future allegations. (Again, the training or coaching must be completed, acknowledgement can also be completed by agency representatives)
- A request for an agent statement. Agents must provide the requested information by the due date listed in the request. (this is more like the original process, call recordings (if applicable) may also be requested.)
The allegations will have specific requests and directions, read them carefully and let me know if you have any questions.
Below is an example, I’ve highlighted the directions I reference.
Agent Notification of Allegation
This notification is to inform you that the below allegation was made by Daffy Duck concerning their enrollment on 10/07/2018.
Humana takes allegations made by Medicare beneficiaries very seriously. This is the first allegation Humana has received within the last 12 months regarding your solicitation of Humana products. This letter serves as a notification and a reminder that Humana expects all agents who distribute Humana MA/MAPD/PDP products to provide a complete and compliant sales presentation, following all CMS rules, regulations, and Humana policies.
Please, review the allegation outlined below as well as the Medicare Communications and Marketing Guidelines (MCMG) accessible at CMS.gov. Please note that Humana also has a wide range of training materials and job aids, available through Vantage at www.humana.com, to assist you in maintaining compliance with CMS, DOI, rules and regulations and Humana policies concerning the distribution of MA/MAPD/PDP products. Humana suggests you review the materials specific to your allegation to prevent future allegations.
They require that you please acknowledge receipt of this notification via email to AgentNotification@humana.com, so that they may close the case in their systems. Upon receipt, Humana will consider this incident closed and take no further action. As a reminder, an agent is not to contact the member in response to this notification.
If your response email contains the member name or any other member information, it must be sent secure. You can also respond without identifying the member and simply providing the allegation ID.
Thank you for your commitment to compliance. Humana appreciates your partnership.
|Allegation ID:||40000||Market Office: Kentucky|
|Sub-Channel:||SA Field Agencies|
|Beneficiary Name:||Daffy Duck|
|Beneficiary City:||Duck Hill|
NOTIFICATIONS TO AGENTS
|Although Humana is not issuing a finding regarding this allegation, please ensure you follow the Medicare Communications and Marketing Guidelines (MCMG), all other applicable laws/regulations and Humana’s policies when presenting Humana plans and enrolling beneficiaries.|
|You can access the MCMG at CMS.gov or the following link: Medicare Marketing and Communication Guidelines|
|Please acknowledge receipt and review of this notification by return email (sent secure) on or before the Due Date|
Due Date: 05/23/2019
This is neither legal nor accounting advice. If you have questions, please consult a lawyer or accountant. The information included in this post was provided by the entity referenced herein.