Compliance Intelligence: Helping health care insurers maneuver legal landscape, project positive brand image

Compliance Intelligence: Helping health care insurers maneuver legal landscape, project positive brand image


The Patient Protection and Affordable Care Act has opened a vast marketplace for today’s health care insurers as millions of Americans shop for coverage in compliance with the new health care reform law.

Yet at the same time, this business boon brings to the forefront an array of highly complex and challenging compliance issues. Agent onboarding, training, and ongoing oversight are critical areas of focus and scrutiny, particularly as less reputable companies enter the arena.

To succeed, companies must stay ahead of the game – not only by avoiding legal issues and ensuring compliance, but by maintaining a positive brand image and driving member satisfaction at each and every touch point.

The cost of non-compliance

Selling in the health insurance marketplace exposes a company to significant risks. Non-compliance with laws on the local, state or national level can carry hefty fines, or worse, it can shut a company down. Consider recent regulatory actions against health care insurers:

  • In April, the Kansas Insurance Department fined a prominent insurance agent $1,000 for publishing false and misleading information about the Affordable Care Act.
  • In California, regulators have shut down HealthcareOne, a telemarketed Arizona-based discount card program that advertised itself as “A Real Healthcare Plan Starting For As Little As About 25 Cents “.
  • The National Better Living Association, a Georgia company offering a fixed indemnity policy, misleadingly told a Montana consumer with a heart condition “that his preexisting condition was covered and, had to be, because [of] new federal health reform legislation,” according to an investigation by the Montana Department of Insurance. Regulators are now seeking fines and restitution from the company.

Even one poorly performing agent can translate into irreparable damage to a company, underscoring the critical need for careful selection, onboarding and training, as well as overseeing work in the field.

Putting “compliance intelligence” to use

To maneuver through the newly laid landscape of Health Care Reform, many insurers are using compliance intelligence to help:

  • Avoid legal issues and ensure compliance;
  • Identify key performance indicators that drive patient satisfaction;
  • Provide ongoing training tools to measure and manage more effectively; and
  • Maintain a positive brand image.

At Service Evaluation Concepts, we provide front-line business intelligence that measures the member experience for any Medicaid and/or Medicare plans, ensuring that all maintain enrollment protocol privileges of CMS and/or SDOH. To date, we have conducted 25,000 audits covering marketing/sales for compliance and customer service.

The SEC advantage

Service Evaluation Concepts uses proven research methodologies – from mystery shopping to operational audits, from competitive benchmarking to call center monitoring and recording – to generate compliance intelligence that is both accurate and actionable. Our goal is to help you:

  • Ensure CMS, MIPPA and State compliance to avoid legal issues and maintain a positive brand image;
  • Identify key performance indicators (KPIs) that drive member and patient and satisfaction;
  • Align organization-wide focus on creating superior service at every touch point in the member pathway;
  • Provide ongoing training tools to measure and manage more effectively; and
    Improve agent sales and relationship-building skills.

Each member of our panel of more than 250,000 brand agents, or undercover compliance agents, must successfully complete plan-specific training and certification before conducting an evaluation. SEC customizes evaluation collateral so that it incorporates both organizational needs, and CMS’ regulatory requirements. Additionally, SEC’s Business Intelligence Reporting & Dashboard Gallery provides access to real-time audit data, allowing you to monitor compliance with CMS’ suggested protocol and best practices to develop effective and relevant training.

To learn more, call us at 516.576.1188, ext. 3530, or email us at