Resolving Sales Allegations – Ep. 23

Episode 23 goes over an agent’s worst nightmare… sales allegations! Hopefully, you never have to deal with sales allegations, but if you do, don’t start sweating yet. Through this podcast, you will learn what to expect if you get a sales allegation. What exactly does it mean if you receive one? What’s the process? How do you make sure you don’t receive one in the future? How do you make the process go smoothly and quickly? Our Queen of Compliance, Gina Angelo, has all the answers! 

Also, we talk about the Presidential election that is just around the corner and what the polls are telling us when it comes to Medicare for All. How do voters feel about it? What does this mean for the future of our industry? We’ll go over the numbers and give you a starting point for your own research before you have to pick a candidate!

Podcast Episode 23 – Resolving Sales Allegations Transcription:

Disruptive Waves [01:00] :

Jessica: Happy New Year everyone!!! This is our first podcast in the new year and we are pumped for what is to come this year for Selling SMART. 2020 is going to be AMAZING! 

Sarah: Yes SO MUCH is going to happen this year I can feel it! And one of the big things that we all KNOW is going to happen is the Presidential election. 

Jessica: This is true, and as we all know, healthcare is a huge topic of discussion going into these primaries and debates. 

Sarah: Which is why we feel like it’s important to update you on some recent polls that have been conducted by Kaiser Health News and a few others. Obviously, polls change all the time. The article that we found on Kaiser Health News discussing these polls was published on December 3rd, so it’s fairly recent but we know people’s minds change all the time… so just wanna put that disclaimer out there.

Jessica: Yeah, also it may be good to go and check out the article. Kaiser Health News does a really great job of staying impartial and just reporting on the facts, but we know that whenever you’re hearing statistics and numbers, it’s always good to double-check your resources. We’ve gone ahead and made sure that they were legit and there wasn’t any kind of bias, but we’re human so we want to encourage you to use this information as a starting point to your own research to come to your own conclusion of these topics.

Sarah: Yes that is definitely a good idea! And also if any of you know the history of Kaiser I think it’s also good to let you know that we did some digging to see what their relationship with Kaiser Permanente and Kaiser Industries. Because when we first found the article, we were a little concerned that their relationship with those entities could make them biased. BUT! We found that in 1985 Kaiser Health News separated from Kaiser Permanente/Kaiser Industries and now their only tie is that one of the family members gets to serve on the board of Kaiser Health News.

Jessica: Right, so that’s also good to know. And if you want to go find the article yourself to do further digging it’s on the Kaiser Health News website and it’s called “Candidates Are Betting Big On Health. Is That What Voters Really Want?” and it was written by Julie Rovner.

Sarah: So now that we got all of that out of the way, let’s talk about what’s actually in this article.

Jessica: Yes! So obviously health care is a top issue for voters during this 2020 Democratic presidential primary race. Kaiser’s Family Foundation found in their latest tracking poll that 24% of Democrats and Democratic-leaning independents said that they want to hear candidates discuss health care. That number is twice the total for the next top issue which is climate change and four times the total for immigration which is the number three issue. 

Sarah: So it’s clear that health care is very important to voters, but the question that still remains is whether that interest is going to reward a candidate that backs up the “Medicare for All” type of plan or a relatively more modest plan like a public option where a person can voluntarily join a government health insurance plan.

Jessica: And based on conversations you’ve had and people you’ve discussed this topic with, you may have an answer in your mind of what you think voters want. However, the poll numbers didn’t conclude with a clear answer.

Sarah: Right, so on one hand, Democratic and Democratic-leaning respondents in the Kaiser Family Foundation poll said that when it comes to health care, the candidate they would trust the most is Bernie Sanders, who (as many of you know) has been pushing for a Medicare for All plan.

Jessica: Here’s whats a little confusing though. Those SAME people say that they prefer a public option, which is not what Bernie Sanders is pulling for. 

Sarah: Nope. Not at all. That’s what Joe Biden has been wanting. 

Jessica: Yeah, so I think it’s safe to say that’s NOT what many people would expect the polls to conclude. 

Sarah: So also, in a separate poll done by Quinnipiac University, 36% of respondents said that Medicare for All is a good idea while 52% say it’s a bad idea.

Jessica: And a NBC/Wall Street Journal poll from September found similar results with 67% of respondents saying they would support allowing people under the age of 65 to “buy their health coverage through the Medicare program,” while only 41% favored “adopting Medicare for All, a single-payer health care system in which private health insurance would be eliminated.” 

Sarah: Yeah so with that being said, people’s opinions may change between now and the primaries, but these are interesting numbers. 

Jessica: For sure! It will be very interesting to see what happens. Especially since this is the industry we work in and these are pretty major changes that they are talking about. So it’s very possible that this will have a huge effect on us and our every day lives.

Sarah: Right, so definitely do some more research, figure out what every candidate is proposing and be an educated voter!

All Aboard the Knowledge Train [09 :10] :

Jessica: So we are super happy to have our Queen of Compliance, Gina Angelo, on the podcast today! Gina, would you mind just giving us a brief overview of who you are and what exactly your position at SMA entails? 

Gina: So my actual title is SR Compliance Manager- though Queen of Compliance does have a really nice ring to it. Anyway, what I do actually has a number of sides to it when you think of compliance- it’s part sales, part marketing, part corporate, and part workforce. So for the sales side, I ensure I’m an outlet for compliant sales activity for our organization and all the thousands of our downstream agents and brokers. For marketing, I make sure ALL of our formats are being delivered in a way that’s compliant with all guidelines. From a corporate level, I have to see to it that the organization fulfills all obligations on a Federal, multi-state, and carrier relationship level. And in regard to the workforce- I create, deliver, and document all compliance training for all of our employees. I also create and enforce all of our Compliance Policies and Procedures.

Sarah: That’s awesome Gina! We’re happy to have someone like you keeping us all out of jail haha. So let’s just start with the basics in case we have some new agents listening. What exactly are sales allegations? 

Gina: A sales allegation is essentially an inquiry that is opened due to potential sales misrepresentation. Sometimes they can be called by a different name, such as a “grievance”, “investigation”, or “complaint”. They can really come from anywhere, such as from a bene or a member of their family, other sales agents, the Department of Insurance, or directly from CMS. And that’s just a few examples. One thing I will say as someone who’s previously worked in both sales and service directly with a national carrier is that many allegations are prompted based on a call from the beneficiary and are automatic. So if any type of dissatisfaction is noted, in order to make a certain action possible for the bene to resolve their issue, it prompts the inquiry based on what the service rep is told as the order of events. So often the allegations come back as unfounded/unsubstantiated.

Jessica: So obviously a big part of your job is dealing with these sales allegations and I know that is a very scary topic for agents. First of all, you’re kinda getting in trouble so no one likes that, but then I also think it’s scary because agents aren’t entirely sure what the process looks like. Would you be able to take us through that whole process?

Gina: So first I’m going to point right back to what I just said as to WHY the allegations often happen. Anyway, when the case is first opened the carrier’s compliance oversight team will perform an investigation. They usually send out a questionnaire- now sometimes this will be straight to the agent, to both the agent and also to me, or just to me so that I alert the agent of the matter and ask for their response. Now, you have to remember that these are TIME SENSITIVE- so you will have to provide your response and all supporting information within a short period of time, sometimes in as little as 24 hours. Some of the additional info you’ll need will be things like the bene application, the Scope of Appointment, any notes, drug lists or provider searches, or recorded calls. 

Sarah: What would be your advice to an agent if they get a sales allegation?

Gina: REMAIN CALM! Also, please don’t be argumentative- just cooperate. The more you resist and argue, the worse things will be for you, I promise. It reflects very badly on your part. If you feel there has been a misunderstanding, then you can state that in the additional notes or comments section of the response form, but definitely fill in ALL of the other portions of the questionnaire and absolutely DO NOT use an arrogant or hostile tone. Some results of these investigations are additional remediation, suspension, and even termination. Tread carefully.

Jessica: And what are some ways that they can make the process easier for you and run super smoothly so that it’s resolved as quickly and efficiently as possible?

Gina: All those things I just said. Retain your notes (securely of course) and just COOPERATE.

Sarah: Are there certain questions that you feel like agents have a lot when it comes to resolving sales allegations? And if so, what are they and what are the answers?

Gina: They like to ask me “why” they’re getting an allegation. Well, since it actually came from another source, I do not have the answer. It is generally an automated process, often spurred by a call to a carrier’s customer service department. If you wish to dig deeper, I can get you in contact with that carrier’s compliance representative who sent me the inquiry, HOWEVER you are still bound by the timeframe requirements. You cannot postpone the inevitable.

Jessica: What steps should an agent take after a sales allegation? 

Gina: Once the response is submitted to the carrier and received by them, the investigation will continue until a conclusion is reached. The time this will take can vary greatly. As soon as the outcome is given back I WILL LET YOU KNOW. There is no reason to email me multiple times a day to ask about it- I promise!!! Once they evaluate it, all allegations generally fall into 3 primary outcomes: founded/substantiated, unfounded/unsubstantiated, and inconclusive.

Jessica: So most of the time are they true then? 

Gina:  Most often, generally outside of AEP, they are unfounded. Immediately after AEP, I do see a bit of an increase with founded and substantiated cases at least percentage-wise of what I receive.

Sarah: What can agents do once the sales allegation has been completely resolved to make sure they don’t have another sales allegation against them in the future? And are there certain resources that they can turn to for guidance? 

Gina: It’s extremely difficult to ensure you never receive another allegation, as there are so many different actions that initiate them on so many different levels. However, after one happens you can work diligently to change the way you approach certain situations and topics, and perhaps adjust the way you do your sales presentations. Also- I am actively working to add more resources on our Storefront related to compliant sales activity- so be sure to keep an eye out for those. Each time a new one is released we try to let everyone know via email and/or social media. Also, you can always send an email to or reach out to your sales contact with us.

Sarah: So a lot of what you have been talking about is related to you actually helping agents resolve these sales allegations. That really relates to agents who are with us at Senior Market Advisors, but what about agents who aren’t with an FMO? Do they go directly through the carrier or what does that look like?

Gina: So if they are already contracted with a carrier, whether it’s through a different FMO or direct with the carrier, they should have respective compliance contacts. However, if they find that they are not getting the compliance help that they need… maybe it’s time to make a switch? 

Sarah: That’s one this SMA helps with, you’ve got Gina Angelo right here to help you out with resolving all of those sales allegations.

Gina: Always here to help!

Jessica: Well this has been awesome, Gina! Thank you so much for sitting down with us and talking about probably one of the most “not fun” things about your job and an agent’s job haha but it’s important so we really appreciate you giving us your advice and insight! 

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SEP & Low Income Subsidy (LIS) – Ep. 2

Episode 2 is focused around the change from OEP to SEP and how to use the Low Income Subsidy Medicare Program to help you generate leads. With that in mind, in Episode 2, we begin by discussing the importance of SEP. As you probably already know by now, most of your business is done during AEP. But just because AEP is over and OEP is nearing close, doesn’t mean you can’t still help beneficiaries get the coverage they deserve!

Since most Medicare-eligible individuals don’t qualify for a Special Enrollment Period, it’s important for you to get creative with your lead generation techniques! One group of individuals who are eligible to enroll in plans outside of Annual Enrollment are the Dual Eligible population. Dual-eligible individuals also qualify for Low-Income Subsidies!

This brings us to our next topic… The Low Income Subsidy Medicare Program, also known as Medicare Extra Help. LIS helps beneficiaries save on their prescription drug costs. In this episode, we break down what LIS is, how to qualify beneficiaries for LIS and how to plan an event to generate LIS leads.

Finally, we end this week’s episode with feel-good stories from the hosts, Sarah and Jessica, so you can get to know them a bit better! Want to be featured on the podcast? Look for  “Share Your Story” under the Contact Us tab and send us your motivational stories!

Podcast #2: SEP & Low Income Subsidy (LIS) Transcript

Sarah: Welcome to Episode 2 of Selling SMART with Sarah Smith….

Jessica: And Jessica Vara!

Sarah: In today’s episode, we are going to talk about the Special Enrollment Period AKA SEP! With SEP approaching quickly, the amount of beneficiaries you will be able to help will decrease, meaning you’ll need to get more strategic with your lead generation! 

Jessica: Which brings us to our next topic… The Low Income Subsidy Program! We will be talking about what LIS is, why you should care, and how you can host an event focused around LIS! And of course we will end on a positive note! So lets go ahead and jump right in!!

Disruptive Waves:

Sarah: As you probably know by now, OEP is about to end and we are quickly moving into SEP. As a Medicare insurance agent, most of your business is done during AEP. But just because AEP is over and OEP is nearing close, doesn’t mean you can’t still help beneficiaries get the coverage they deserve! There are plenty of folks out there who are eligible for a Special Enrollment Period! Your job is to find those individuals!

Jessica: The Special Enrollment Period (also known as SEP) allows individuals who qualify to make changes to their Medicare plan outside of the Annual Enrollment Period. People who qualify for a Special Enrollment Period have special circumstances such as having low-income, moving to a new service area or losing current coverage.

Sarah: Since most Medicare-eligible individuals don’t qualify for a Special Enrollment Period, it’s important for you to get creative with your lead generation techniques! One group of individuals who are eligible to enroll in plans outside of Annual Enrollment are the Dual Eligible population, meaning they qualify for both Medicare AND Medicaid. While not every individual who qualifies for LIS is Dual-Eligible, but individual who is Dual-Eligible also qualifies for LIS! This brings us to our next topic… Low-Income Subsidies!

All Aboard the Knowledge Train:

Sarah: First off, what IS LIS?

Jessica: LIS stands for low income subsidy. The Low Income Subsidy program, also known as Medicare Extra Help, allows low-income Medicare-eligible consumers to save on their prescription costs.

Sarah: Some of the benefits included in the Low Income Subsidy Program include:

Jessica: Most people who are eligible for LIS don’t even know it. These people tend to be people who are struggling to afford basic expenses and really need help paying for their healthcare costs. This is where you, the agent, can help them apply for that extra help.  

Sarah: So, when is a beneficiary eligible for LIS? A beneficiary is eligible for LIS at 150% of the Federal Poverty Level. We don’t have updated resource and asset limits from CMS just yet, they should come out very soon, so you will still need to use the 2018 guidelines until the U.S. government determines the levels for 2019

According to Social Security, in 2018, beneficiaries  are eligible for Extra Help if they have Medicare Part A and meet the following requirements:

Individual Extra Help beneficiaries must have an income of no more than $18,210 per year, and resources valued at no more than $14,100 per year. Married Extra Help beneficiaries must have an income of no more than $24,690 per year and resources valued at no more than $28,150 per year. 

Income includes wages, social security income, annuities, and family support. Resources include real estate, stocks and bonds, mutual funds, and IRAs, or Individual Retirement Accounts. 

Jessica: So you know people who are eligible for LIS need your help, but how do you find them? A good way to find LIS leads is to host an event.

NOTE: You must register your event as an “informal sales event” with CMS. You won’t be able to collect lead information and permission to contact without classifying the event that way.

Sarah: Plan events at locations where low-income seniors either live or frequent often such as:

  • Low-income housing
  • Churches
  • Bingo tournaments, 
  • Flea markets, 
  • Food banks and veteran’s groups
  • And Clinics, doctor’s offices, dentists, and pharmacies

Jessica: Remember to bring a laptop for digital applications, branded materials, business cards, permission to contact forms, LIS information flyers, and a notebook to help you keep track of your new contacts.

You can sit with seniors and help them apply for LIS on the spot! You can apply online at Once you submit their application for LIS, Social Security will review it and send them a notification in the mail letting them know if they are eligible or not. 

Always collect a permission to contact form from the beneficiary and let them know you will be in touch to discuss next steps. prior to enrolling your Scope of Appointment form when you reach back out and they qualify.

Sarah: Make sure to follow up with your new clients to see if they qualified for the Low Income Subsidy Program. If your new client is accepted, see if they’d like to set an appointment to discuss their next steps. Don’t forget to get a Scope of Appointment to have on file prior to your appointment date. They will be eligible to enroll in a Medicare Part D plan at that time and you can help them find the right plan option for them.

If your new client is denied, let them know that you can help find a Medicare plan during the next AEP. Follow up with the facility as well! Thank them for their assistance and see if they can refer you to another facility for your next event.

Jessica: With LIS, you’re helping benes save money in a way that they may have not known about before. 

Sarah: What are you waiting for? Contact your local senior facilities and event coordinators now, so you can help seniors in need AND grow your business.