Coordinating Complaint Referrals
Central Office and Regional Office Roles
Background
• Signing Parties
– State Department of Insurance (DOI)
– CMS (CPC & Regional Offices)
• All states signed MOU August 2008
– Including the District of Columbia, US Virgin
Islands, and Puerto Rico
• Membership
– NAIC Senior Issues Task Force
– NAIC Anti-Fraud Task Force
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MOU Purpose
• Promote cooperation between CMS &
States
• Sharing of information
– Regulatory cooperation and information
sharing regarding conduct of companies
and persons engaged in MA and PDPs
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CMS-State Information Sharing
• Enforcement actions taken by CMS or
States against organizations or agents
• Complaints involving specific
agents/brokers
• Consumer complaints involving plans doing
business in their state
• Potential violations of federal laws or fraud,
waste, or abuse with the appropriate
federal law enforcement agency
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Compliance & Enforcement (C&E)
MEDIC Transition
• Since September 29, 2009 CMS utilized
C&E MEDIC, Safeguard Services (SGS), LLC
to assist with marketing issues
• Effective September 29, 2010 CMS will
discontinue this contract
• SGS will no longer be responsible for
conducting agent/broker investigations
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C&E MEDIC Transition (con’t)
• Egregious agent/broker issues will be
referred to the State DOIs
• Benefit Integrity MEDIC, Health Integrity
(HI) contractor will continue to fight fraud,
waste, and abuse complaints
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Role of National DOI Liaison
• To serve as the Central Office contact and
coordinate with the Regional Office in
facilitating the sharing of information
related to marketing misrepresentation
cases with State DOIs and internal/external
partners
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Role of Regional Office (RO) Department
of Insurance (DOI) Liaison
• Serve as the point of contact for local DOI
contacts
• Exchange information and resolutions for
specific agent/broker complaints
• Share information about complaints with
Medicare Advantage and Prescription Drug
Plan CMS account Managers for possible
compliance actions
• Answer policy questions related to CMS
marketing guidelines
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What will change?
• CMS will strive to make this a seamless
transition as possible
• Should only be a change to where the
referrals are sent
• Continue to send FWA complaints to BI
MEDIC
• Continue to send the same type of
complaints that were sent to C&E MEDIC
• CMS will work to provide resolutions of
issues as possible
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What to refer to RO
Types of complaint information:
• Adjudicated enforcement actions (i.e.,
cease and desist orders, disciplinary
actions, etc.)
• Use of aggressive marketing tactics by
specific agents
• Misleading advertising and phone calls
• Offering inducements to enroll
• Enrollment of beneficiaries without consent
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What to Include in a Referral
•
•
•
•
•
•
•
Beneficiary name
Medicare or Social Security number
Name of agent/broker
Name of MA of PDP plan
Date of incident
Location
As much specifics of the incident as
possible
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Next Steps
• Continue to track complaints using
SMARTFACTS
• Fax complaints to RO DOI Liaisons
– Complaint will be recorded in CMS HPMS CTM
• RO DOI Liaisons will ensure casework
action is taken and associated follow-up
activities
– Final disposition will be sent to SMPs to update
SMARTFACTS
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Outreach/Communication
• CMS will be issuing a memo late
September announcing the transition
• Conduct upcoming Webinar in October and
November to review transition activities
with SMPs
• Conduct monthly meetings with SMPs and
RO DOI Liaisons to review complaints and
address outstanding items
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CO/RO Contact Information
National Central Office DOI Liaison
Deanna Greene: [email protected]
Technical Advisor for the
Consortium for Medicare Health Plans Operations
Paul Collura: [email protected]
Regional Office DOI Liaisons by Regions
Attachment A
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