How MAPD Complaint was Handled

[Joe Moore]

One of our contracted agents had an interesting experience with a client complaint last year.

In 2006, this agent wrote a MAPD-PFFS plan with one of the major player companies. About a year later, client had a stroke and entered nursing home. Instead of looking at Summary of Benefits or calling our office, nursing home contacted insurance company home office to find what the nursing home benefit was.

Insurance Company Home Office informed nursing home that client had "999 days" of nursing home benefit. Nursing home called back and it was verified there was "999 days" of benefit. Where "999 days" came from, no one knows.

Nursing home gets paid for first 60 days at 80% (which is what policy should do) and then the money stops. After about 4-5 more months with no money, nursing home panics and gets to checking further. Home office of insurance company says they don't really want to hear their problems, UNLESS THE AGENT DID SOMETHING WRONG. All of a sudden the agent became the villain. He had portrayed the MA plan as a Medicare Supplement, per the nursing home and client. When the complaint was filed, this gets the State Insurance Department involved.

The client could not read or write. So, the nursing home typed him up a statement to put blame on the agent that the agent misrepresented the product to him. Thank goodness for the recorded telephone interview. My understanding is that the company really did not have to supply the agent with this, but some sympathetic soul at the company did. This cleared up the whole situation. The question of "do you realize this product is not a Medicare Supplement", clearly answered "yes"; and the question "do you realize coverage with this plan can have limitations", also answered "yes", put an end to this stupid discussion.

We found the DOIs have much control over the agents, but they have no control over what mistakes and mis-information coming out of home offices. I don't have a clue whether the nursing home ever got their money or not.

I am posting this to try to let agents know how easy it can be to find yourself in a bad situation. If not for the telephone interview, I do not know where this would have ended.

 

[retread]

One of our contracted agents had an interesting experience with a client complaint last year.

In 2006, this agent wrote a MAPD-PFFS plan with one of the major player companies. About a year later, client had a stroke and entered nursing home. Instead of looking at Summary of Benefits or calling our office, nursing home contacted insurance company home office to find what the nursing home benefit was.

Insurance Company Home Office informed nursing home that client had "999 days" of nursing home benefit. Nursing home called back and it was verified there was "999 days" of benefit. Where "999 days" came from, no one knows.

Nursing home gets paid for first 60 days at 80% (which is what policy should do) and then the money stops. After about 4-5 more months with no money, nursing home panics and gets to checking further. Home office of insurance company says they don't really want to hear their problems, UNLESS THE AGENT DID SOMETHING WRONG. All of a sudden the agent became the villain. He had portrayed the MA plan as a Medicare Supplement, per the nursing home and client. When the complaint was filed, this gets the State Insurance Department involved.

The client could not read or write. So, the nursing home typed him up a statement to put blame on the agent that the agent misrepresented the product to him. Thank goodness for the recorded telephone interview. My understanding is that the company really did not have to supply the agent with this, but some sympathetic soul at the company did. This cleared up the whole situation. The question of "do you realize this product is not a Medicare Supplement", clearly answered "yes"; and the question "do you realize coverage with this plan can have limitations", also answered "yes", put an end to this stupid discussion.

We found the DOIs have much control over the agents, but they have no control over what mistakes and mis-information coming out of home offices. I don't have a clue whether the nursing home ever got their money or not.

I am posting this to try to let agents know how easy it can be to find yourself in a bad situation. If not for the telephone interview, I do not know where this would have ended.

Interestingly, I got a phone call from a former client's sister the other day, saying that the nursing home where her brother is staying says he owes them $2000 and wanted to know how that could be since I was the one to sell him an MA plan.

Before getting too excited, I called the carrier to determine the status of any claims. They inform me that he was terminated 7/31/07 and was no longer covered. I called back the client's sister and asked how long he had been in the nursing home, and she replied "a year". At that point, I said (knowing a little about his financial circumstances at this point) that he should be covered by Medicaid since he dropped coverage over a year ago.

She accepted this, (which I am sure she already knew) and I provided her with a little more Medicaid info than she had known, and she thanked me and hung up. Never heard any more about this... I think she was fishing to see if there was any way to hook something by chance.

I had called this client and his sister several times over the past year and never got a response. There are always some clients who will stonewall you, then when disaster strikes, expect you to have done something impossible. This is why I document everything. Frank's YIO program is very good for this purpose.

 

[fostever]

I had a client who I spent 2 hours with using the company developed compliance flip chart, summary of benefits, formulary, and even side by side with her current plan that was an MAPD FFS. We went over finding the closest pcp and she finally said yes. Since she was locked in until 2009 and she changed her mind, with the help of a uninformed social worker, she called CMS and said I misrepresented. Thank goodness for the phone verification that backs me up.

 

[Slim]

I had MAPD client I
did lots of service work for filed a formal complaint my 1st month in the market.
. Complaint was about 4 or 5 sentences.

Very serious accusations.

My answer was 12 pages. Full of times, dates, conversations, subjects, names, etc.

I have not received any communication about it since. Hopefully I will not be bothered with it again.

The client called after I answered complaint, to help him with something on a problem he complained on and I helped him on multiple times. One Health pro who could have help him (outside insurance Co) did not want to take the time.

Their office called once after the complaint too. I told the client and the office staff to call Customer service. Luckily I was away from client's file when he & office called. I did answer best I could and was pleasant, but not overly friendly. Definitely did not go out on a limb and did not extend as much time with them as I could have .

Remember , the agent ALWAYS will be first to blame. Will ALWAYS be easiest to tag. I think. That may not be totally
unfair either. The Agent markets and has immediate financial
gain when the application is signed.

That means if you want to get ahead in the business,
make a lot of money and help a lot of people including yourself and your family, then you may need to record / document all of your interactions.

Memory is not good but ink lasts a lifetime.

The old adage "the one with the most notes wins" is not
trivial when it comes to protecting your reputation
and career.

 

[midwestbroker]

I had a complaint against me at the Missouri DOI from a MAPD client.

Long story short, I was in the clear. Missouri Medicaid had dropped him prior to us meeting and he did not understand why things were still not free (even after I showed him all the co-pays).

Never a fun situation. The Missouri DOI has no idea what is going on.

They did ask me in a letter explaining my appointment to explain how the low income subsidy worked with social security. I sent them a tri-fold brochure from Social Security and informed them to call the 800 number on the back. I knew it was a risk but after the prior letters (there were 4 total) I knew the person I was talking to did not have any idea how Medicare or Medicaid worked.

 

[The Rabbi]

According to Reader's Digest, most people lie on a regular basis. I can attest to having witnessed this phenomena.