Due to past instances of beneficiaries receiving misleading or inaccurate information, the Centers for Medicare & Medicaid Services (CMS) has intensified its oversight of Medicare marketing practices by increasing the use of “secret shopping.”
CMS now uses secret shoppers who call numbers from TV ads, newspaper ads, mailings, and online searches to better understand the beneficiary experience. Agents should anticipate this heightened scrutiny to remain in effect for the 2025 Annual Enrollment Period (AEP). By prioritizing compliance in every sale, you’ll not only meet CMS standards but also provide a positive experience for clients and any CMS secret shoppers who may be evaluating your interactions.
Record Marketing, Sales, & Enrollment Calls with Connect4Insurance
If you worked with Medicare Advantage products last enrollment season, you’re likely aware that CMS mandates full recordings of all marketing, sales, and enrollment calls with Medicare beneficiaries.
Though managing call recordings may seem time-consuming, Connect4Insurance recording features in Connecture and Sunfire make it straightforward. The Connect4Insurance platforms enable you to easily record and securely store both outbound marketing calls and inbound calls received through a unique, system-generated phone number. This not only helps reassure clients about the security of their information—an essential priority—but also ensures you’re fully prepared should a CMS secret shopper assess your calls.
Secure Permission to Contact
Understanding permission to contact (PTC) is essential, as it’s the foundation for connecting with prospective clients. PTC safeguards consumers from unsolicited outreach by agents selling Medicare products, and secret shoppers are attentive to any misleading tactics. Always keep in mind that the beneficiary must initiate contact.
If you use business reply cards (BRCs) to engage with prospects, note that they now expire after 12 months. Tracking the start and expiration dates within your CRM is a smart way to stay compliant and organized.
Obtain Scopes of Appointment 48 Hours in Advance
Before any one-on-one meeting with a client—whether in person or by phone—you must secure a Scope of Appointment (SOA) at least 48 hours prior to the appointment to remain compliant. Exceptions to this rule apply only if a beneficiary is within four days of a valid enrollment period ending or for walk-in visits that are not pre-scheduled.
Follow All CMS Guidelines
Staying compliant with all CMS rules eliminates the need to worry about secret shoppers. Beyond handling SOAs and BRCs correctly, it’s essential to stay informed about updates in each year’s Final Rule.
For 2025, CMS has introduced changes to compensation structures, updated requirements for network-based plans, mid-year enrollment notifications, and more.
As agents are classified as third-party marketing organizations (TPMOs), you must also adhere to TPMO-specific compliance regulations. This includes new rules focused on beneficiary data protection, requiring TPMOs to obtain written consent before sharing any personal information.
Let Prospects Take the Lead
Giving prospects control over the communication process is an effective way to boost their confidence and satisfaction. Using direct mailers to reach potential clients allows consumers to initiate contact, ensuring compliance and positively impacting any secret shopper evaluations.
Agents partnering with Essential Care can also use a Personal URL (PURL) to guide clients to a personal website. This site enables clients to access your contact information, generate their own quotes, and explore options that cover their preferred providers, doctors, and medications. Empowering prospects to research coverage options independently showcases your commitment to transparency and trustworthiness.
Sign up with Essential Care to access your personalized agent and client site!
What Secret Shoppers Are Looking For
When answering client questions, take your time and respond as accurately as possible. If you’re unsure of an answer, it’s better to admit that than to risk giving incorrect information.
If you’re looking for compliance guidelines, we’ve outlined some common secret shopper scorecard questions below to help you stay prepared:
General Questions
- Did the agent explain enrollment periods?
- Was the term “free” used in relation to plan premiums or benefits?
- Were distributed materials labeled with a CMS approval code?
- Did materials display the current year’s information?
All Products
- Did the agent outline which products would be discussed at the start of the presentation?
- Was the difference between Medicare Advantage and Medicare Supplement plans explained?
- Were enrollment eligibility requirements covered?
- Was the provider network for the plan discussed?
- Did the agent review plan benefits and costs, including cost-sharing?
Other Questions
- Did the agent claim to be an employee of CMS or AARP?
- Did the agent imply that any plans were endorsed by Medicare, CMS, or AARP?
- Were any incentives offered to encourage enrollment?
- Was it clear there was no obligation to enroll?
- Were any non-health-related products presented?
Note: This is a sample of possible secret shopper evaluation questions and may not cover every aspect.
If you suspect someone might be a secret shopper, continue to treat them with the same professionalism you would any client.
Following CMS guidelines may feel detailed, but it’s crucial to ensure clients feel informed and in control at each step. As long as you prioritize accurate information and compliance, you’ll be set up for success.
Not affiliated with or endorsed by Medicare or any government agency.
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