MA Complaint from 1-800-Medicare

[allhealthandlife]

I have been selling Medicare products since 1992 and recently heavily in to MA as captive with UHC in Florida. Anybody selling there MA products in Florida knows they have some issues when it comes getting the right information from broker support or anybody for that matter about providers etc. This complaint alleges that this members doctor wasn't in network and that the member was confused about the proposed effective date of coverage. The doctor was in network but because of provider network issues the member was told they weren't and they were issued a card with a randomly selected doctor. The member was confused about effective because her enrollment took over 45 days to get approved as did about 35 of my other enrollments in the month of Febuary because UHC was processing all my MA applications as PDP applications and they were getting kicked back from Medicare.

So all this to say I didn't do anything wrong but when a MA member calls Medicare to complain and accuse an agent of misrepresentation Medicare doesn't verify before sending complaint to carrier and the carrier's compliance dept doesn't verify facts before issuing an STI to agent so it's guilty until proven innocent. In fact I called the compliance lady at UHC to specify what doctor they were refering to that wasn't in network and she said " oh we don't know that Medicare doesn't tell us "

So heres the deal if you didn't already know.

Medicare put the carriers in charge of policing themselves so a complaint comes into Medicare and the carrier has to take action against agent without first filtering out nuisence or malicious claims. But the carrier has no real incentive to improve quality of service ( i.e provider network updates) that lead to the complaint in the first place because it's cheaper to replace agents. The carriers have done the math for them the profit margins are better by constantly recruiting independent agents than hiring and training customer service.Big business at it's finest.

What really pissed me off about this BS complaint is that it says if I don't respond to the 21 ( mostly unrelated to complaint ) questions listed in complaint within 4 days my commissions will be suspended , contract terminated and I will be reported to CMS,State insurance dept and law enforcement. Very threatening

I have done about 1500 MA enrollments in the last 3 1/2 years for these people and I think I have had enough. This has become the hardest 200.00 to earn in the insurance game and I don't even feel good about myself earning it anymore.

 

[insurance0707]

Reply to the 21 questions and attach a letter telling your side of the story. That the doctor was in network, that the insurance company, not you, assigned the wrong doctor on her card. Let them know about the confusion on the issue date was due to them taking 45 days, rejecting your apps, etc. Turn it back on them and don't let them make you feel bad when you did your job and turned it in correctly. You might want to send a letter to the client explaining the situation. Although with all of the ridiculous rules I don't know if they'd allow that. Did you call the client and explain the situation?

 

[Cenla Agent]

My understanding is that if any kind of complaint is filed you are forbidden from having any contact with the client. It's possible that that's a carrier rule and not CMS, but I rather doubt that CMS wants agents contacting (which would tend to be viewed as "harassing" from their standpoint) members who have made complaints one way or another.

The more I see these kinds of threads (coupled with the commission hold back) the more I think I'd be better off never selling MA again. I'm considering just getting a broker contract and referring MA prospects in the future. It's been over a year since I've sold one and I have to say that all things considered I think that's just as well.

 

[allhealthandlife]

Reply to the 21 questions and attach a letter telling your side of the story. That the doctor was in network, that the insurance company, not you, assigned the wrong doctor on her card. Let them know about the confusion on the issue date was due to them taking 45 days, rejecting your apps, etc. Turn it back on them and don't let them make you feel bad when you did your job and turned it in correctly. You might want to send a letter to the client explaining the situation. Although with all of the ridiculous rules I don't know if they'd allow that. Did you call the client and explain the situation?

We are forbidden to contact client. I found out through broker support that Medicare gave her a SEP to change plans due to agent misrepresentation. So to add insult to injury I do a bunch of work , get charged back and a complaint filed against me because Medicare or the carrier didn't verify this claim was valid first.

I must be stupid to be willing to go through this for $ 200.00. I mean I have a college degree and 18 years of experience in Medicare health insurance.

 

[Norwayguy]

We are forbidden to contact client. I found out through broker support that Medicare gave her a SEP to change plans due to agent misrepresentation. So to add insult to injury I do a bunch of work , get charged back and a complaint filed against me because Medicare or the carrier didn't verify this claim was valid first.

I must be stupid to be willing to go through this for $ 200.00. I mean I have a college degree and 18 years of experience in Medicare health insurance.

I can understand you pain...And you are right the CMS rigamarole is ridiculous...however these types of problems persist throughout the industry...I got a call a couple months ago late on a friday afternoon from the chief compliance officer of my B/D now the call went into voicemail do to being in an appointment so I had to wonder all weekend. Seems they had recieved a written complaint that I had not be responding to my clients requests to make changes to her variable annuity.

Long story short once I recieved the letter from Compliance it was quite apparent that she had been calling the insurance company and not me...The Insurance carrier never forwarded anything to me...however once again you are right the agent is always responsible not the carrier..

Don't let me tell you how I almost lost a school districts 403(b) program...Client was on the phone with customer service...Granted the customer was a little hard on the customer service person but they then proceeded to respond to the client in writing and I don't know if they were playing around or not forgot to change the salutation back to the clients name from Dear Jack A$$....Client promptly runs to the School District office and I promptly get a call from complaince about a customer complaint.....once again there is written proof that this is coming directly from the CARRIER and not me.

I have only been in the business for 10 years but I've spoken with old time career agents with NYL, Met etc and they say years ago you could call the home office ask a question and take the answer to the bank...now they and I will call the home office ask the same question of 3 or more people and get 3 or more different answers. Its crazy and I don't know what the answer is.

 

[Senior Benefit]

I am sorry to say that we have received numerous reports from brokers that when they had Medicare on speakerphone with the consumer in the room to try to help them work out issues with either Medicare Advantage Plans or Part D Plans, the CMS representative seems to almost always ask the consumer if they wish to file a complaint. What is really disturbing is when the consumer finds out that CMS has not updated their system (so in essence CMS is actually at fault), the consumer is not allowed to file a complaint against CMS.

As for UHC, we saw in the early stages of MA plans their STI form being sent out when someone called into customer service because their physician told them that they were no longer in Medicare. I believe those forms had about 12 questions or so, and did give a very short time to respond. From what I remember they were pretty good about hearing out the agent's side and seeing that the complaint was really due to the consumer allowing someone else to influence them. Not saying it goes that well for everyone, but it sounds like you have a good case.

Also...NEVER contact a consumer after a CMS complaint has been issued.

 

[insurance0707]

I'm trying to help a client right now that enrolled into a PDP plan effective 2-1-09. He was supposed to be automatically disenrolled from the MAPD plan the same date, 2-1-09. He was enrolled right on Medicare's website. He has the PDP card and has been using it. Medicare has never disenrolled him from the MAPD plan. They keep saying they never received the info from the PDP plan. They told me that when a complaint is filed they have 30 days to fix the problem. A complaint was filed in the beginning of March and again April 3. We did a 3 way call today......still not fixed. The complaint seems basically useless. Meanwhile my client's medicare claims keep getting rejected. Zodora at Medicare said we can file another complaint if you'd like.

I don't know what else to do for this client. This is the most frusterating, ridiculous thing I've ever seen! We call weekly on this claim, either the PDP company or Medicare, no one is helping

 

[Joe Moore]

I'm trying to help a client right now that enrolled into a PDP plan effective 2-1-09. He was supposed to be automatically disenrolled from the MAPD plan the same date, 2-1-09. He was enrolled right on Medicare's website. He has the PDP card and has been using it. Medicare has never disenrolled him from the MAPD plan. They keep saying they never received the info from the PDP plan. They told me that when a complaint is filed they have 30 days to fix the problem. A complaint was filed in the beginning of March and again April 3. We did a 3 way call today......still not fixed. The complaint seems basically useless. Meanwhile my client's medicare claims keep getting rejected. Zodora at Medicare said we can file another complaint if you'd like.

I don't know what else to do for this client. This is the most frusterating, ridiculous thing I've ever seen! We call weekly on this claim, either the PDP company or Medicare, no one is helping

We had a similar situation that had been lingering since 11/15/08. Clients wanted to move from a $81/mo plan to a $-0-/mo plan. New application was taken on husband and wife. Husband's got changed fine, wife's never got changed.

My son has dealt with it probably 10 times since 1/1/09, and was told it was fixed every time. Client called plan and they 3-way called with Medicare 3/27/09, Medicare and plan says it was fixed. Client attempts to buy medicine 5/4/09, card won't work, calls Medicare and plan and is told sorry but she was disenrolled from everything. Client shows up at our office 5/5/09 (from about 50 miles away), I get involved and am told by Medicare there is nothing they can do, she is out until next year. I told her to file a complaint with Medicare.

I got back on the phone and told the 1-800-Medicare doufas that either this gets fixed this week or we are going to our Congressman with the problem. It got fixed the same day, and the lady was able to get her medicine 5/6/09.

I had a very similar situation last year, a problem could not get fixed even after about 10-12 attempts. I got the Congressional office involved, and the client actually got a call from the Congressman himself. The problem was fixed the next day.

I got a call from CMS in Atlanta asking me to please not get Congress involved, that they could fix their problems without Congressional involvement. I explained that we had tried many times and nobody had a clue how to fix the problem.

This time we never had to go to the Congressman, a threat of it was enough to finally get something done. Use this threat next time, and I bet something will happen very fast.

 

[kennethbroyles]

Thanks for the info......

 

[Senior Benefit]

I would agree with Joe in regards to having the client state that if it does not get fixed immediately then they will file a complaint with their local Congressman. One thing I will say is that we actually had our Congressman, his two assistants, and two Medicare (Supervisory position) representatives out of DC in our office almost 3 years ago to address the issues that were taking place in the MA and PDP market. The Medicare representatives at first denied everything until we overloaded with case after case. They then promised the Congressman they would start getting things fixed. When we kept having issues, the Congressman's office called the Medicare supervisors....guess what....they never returned his call. I hate to say it, but I think that it really depends on the person you get on the other end of the line at Medicare when your client calls. CMS reps have a standard line of telling the consumer that they can't do anything and that they need to contact the carrier. This is not true. We have had multiple cases where the broker has simply had their client state that they know for a fact that Medicare can enroll them into a plan while they are on the phone. This is for Medicare Advantage or PDP. In fact they can also disenroll someone out of one plan and put them into another plan right over the phone. Please note that this has taken place either in the AEP or SEP (for PDP plans). Medicare Advantage can be a bit easier since the person also has the provision to move out of a MA plan back into traditional Medicare if they had a Med Supp inforce when they took out the MA plan.

If the CMS representative won't do it, then tell them you need to speak to a supervisor. The supervisor is the one who will understand what it feels like to catch a bit of hell for having a Congressman call up their boss and lay into him/her.

Good luck.