Medicare Grievances & How Insurance Agents Can (Try To) Prevent Them

Many are familiar with today’s derogatory expression of “being a Karen,” which put simply, entails making complaints and demanding desired results.

While receiving fries instead of onion rings at a fast-food restaurant might not require a complaint to the government, issues involving the purchase and use of Medicare or other health insurance coverage is a different story.

It’s true you can’t make everyone happy, but your job as an insurance agent is to sell quality coverage and do everything in your power to eliminate a cause for clients’ dissatisfaction with their sales experience and health coverage. You don’t want to have a Medicare grievance filed against you.

Let’s examine the basics of these grievances so you’re prepared to prevent them from occurring.

What Is a Medicare Grievance?

When a client has concerns about the quality of their care or other services received from a Medicare provider, they can file a grievance (also referred to as a complaint). These issues can be in relation to:

• A doctor, hospital, or provider
• The health or drug plan
• Quality of care
• Dialysis or kidney transplant care
• Durable medical equipment

Clients may come to you for grievance support and assistance.

While these issues may not have anything to do with you directly, as your clients’ main point of contact concerning their health care coverage, they may come to you for help and support. How complaints are filed depends on the problem at hand, which is why it’s important to have, at the very least, a basic understanding of grievances and how to handle them. Should something arise, you can assist your clients throughout the process. Medicare.gov is a great resource to use when clients are looking for proper direction.

Statistics for Medicare Complaints

Data collected by the National Association of Insurance Commissioners (NAIC) reveals the number of closed complaints by coverage type for 2023 and 2024 so far. Check out some of the Medicare plan-related numbers.

^*Report reflects data reported from the state insurance departments to the NAIC as of October 21, 2024.

Is a Medicare Appeal a Grievance?

Medicare appeals do deal with beneficiaries’ issues, however appeals regard disagreements with a payment or coverage decision made by Medicare or your clients’ Medicare plans. Examples of reasons for appeals include a plan denying:

• A health care service, supply, item, or drug a beneficiary thinks Medicare should cover
• A bill for a health care service, supply, item, or drug a beneficiary already received
• A request to change the amount to be paid for a beneficiary’s health care service, supply, item, or drug

A beneficiary may also appeal:

• If their coverage stops providing or paying for all or part of a health care service, supply, item, or drug they think they still need
• An at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines

Can Grievances Be Filed Against Insurance Agents?

Grievances don’t exclude insurance agents. There’s a reason for annual certification training and compliance rules! Some complaint allegations made against agents can include:

• Contacting issues, like cherry picking or failing to collect a Permission to Contact
• Illicit activities, such as signing a form for the client or paying for referrals
• Deceitful interaction with clients, including misrepresenting oneself or sales materials
• Inappropriate or incorrect operational behavior, like poor hygiene or failing to submit an application
• Issues with plan and product knowledge, like presenting inaccurate plan coverage information
• Negligence, including failure to enroll their client into a plan that adequately meets their needs

Consequences of Grievances Against Agents

What happens if a grievance is filed against an agent and proven depends on the state and insurance carrier involved. Each state’s insurance bureau has their own system for filing complaints, so the processing times and outcomes could differ. Similarly, insurance carriers also have their own protocol for grievances filed against agents. Depending on the allegation and final determination, some of the consequences agents could face from the carrier can include:

• Applicable remediation
• Mandatory trainings
• Evaluations and shadowing
• A formal record of the complaint
• Termination of the contract

It’s also very likely that the carrier will reach out for a response from the agent and any related documentation on the client, such as a Scope of Appointment (SOA).

Preventing Medicare Grievances

There is no way to fully prevent grievances, but you shouldn’t have to worry about them if you’re the honest, helpful, compliant agent we believe you are! Sometimes things happen out of our control, but you can follow certain best practices in an effort to do everything you can to prevent complaints about you.

Collect Scopes of Appointment (SOA)

We’ve mentioned the importance of SOAs many times here on the Ritter blog. They’re an essential compliance element that protects you and gives your client control of the conversation. Should a complaint be made stating you didn’t review something properly — or at all — with a client, an accurate SOA can be extremely useful documentation.

Make SOA collection easier by using Integrity’s PlanEnroll Client Sync. This feature allows your clients to create a consumer PlanEnroll profile where they can seamlessly and securely complete an SOA. Get started by completing the sign up with MedicareCENTER.

Follow Guidelines Set By CMS

As you’re surely aware, the Centers for Medicare & Medicaid Services’ (CMS) Final Rule for Contract Year 2023, implemented strict rules for third-party marketing organizations (TPMOs). These included incorporating a disclaimer on various marketing materials, disclosing certain actions within the sales process to beneficiaries, recording all calls with clients, enforcing required consent to share client data, and more. Make sure you are following all Medicare compliance guidelines from CMS to a T, including the Final Rule guidelines for Contract Year 2025.

If you plan on holding a Medicare educational or sales event before or during the Annual Enrollment Period (AEP) it is imperative that you’re aware of what you can and cannot do. You also have to be cognizant of what you say during sales appointments. Sometimes you may say something innocently if you’re caught up in conversation or getting excited about the prospect of a sale, but innocent in nature or not, saying the wrong thing can lead to a complaint.

Ritter can provide tools and solutions to make staying compliant easy!

We understand that there are many rules from CMS you need to follow. As a field marketing organization (FMO), Ritter must adhere to being compliant too! New guidelines are continuously being implemented and keeping everything straight is a job in and of itself. This is where a partnership with Ritter can be extremely helpful. We can help keep you up to date on the latest happenings within Medicare compliance and even provide tools and solutions to make staying compliant easy!

Use Reliable Sales Tools & Data

One reason for a complaint could be misquoted premiums. This could occur from using sales resources with out-of-date data. For this reason, it’s important to use plan quoting tools you can trust, like MedicareCENTER, PlanEnroll, and Market Advisor^TM.

Ritter’s partner, Integrity’s, MedicareCENTER and PlanEnroll platforms make the Medicare enrollment process simple. You or your clients, respectively, can simply enter a zip code to compare top-rated plans in their area.

Note: Agents should use MedicareCENTER to quote, compare, and enroll clients into plans, while consumers should use PlanEnroll to quote, compare, and enroll directly into plans.

Market Advisor^TM is powered by another esteemed Integrity partner, CSG Actuarial, and enables quoting and comparison of Med Supps and ancillary products and online Medicare Supplement enrollments!

You can gain access to these quoting tools and Integrity’s full technology Suite of Solutions by registering with Ritter first and then completing the quick and easy sign up for MedicareCENTER.

Additional capabilities of the MQE include:

• Run tailored quotes using client’s age, zip code, county, gender, and marital status
• Show the plan’s rating, type, and any costs associated with it and plan enrollment statistics
• Filter results based on plan type and carrier

Access and use of the MQE and all of the other tools in the Platform are of no cost to you! All that’s required is the quick completion of a registration on RitterIM.com. Once complete, you have unlimited access to all of the tools and resources, which can help you provide accurate information to your clients and avoid complaints!

Don’t Just Sell to Make a Sale

Keep in mind, the quality of sales is better than quantity. A great agent knows when it’s more important to admit that they may not have the best product to meet a client’s needs in their portfolio. Is it a bummer? Of course! But it’s a chance to prove what kind of agent you are and a learning opportunity for your next sale and AEP!

The quality of sales is better than quantity.

This will also go a long way in preventing appeals against the Medicare plans you’re offering. If a plan is truly the right fit for your client, there’s less of a chance the services or prescriptions they need won’t be covered.

Someday, you may find yourself in a situation where a client reaches out to you wanting to file a complaint or appeal. If this happens, be sure to listen to their issue and concerns and offer to support them through the process. We certainly hope you’ll never be in the position where a grievance has been filed against you. However, if you follow compliance guidelines and put your clients first, the chance of that happening decreases!

It’s also a good idea to partner with an FMO like Ritter to support you. Registering on RitterIM.com is free and easy. Let’s succeed and stay grievance-free together!