Health Insurance Compliance Automation 101

An overview of compliance automation for individual health, group benefits, and senior insurance agencies

One thing we can count on in the health insurance industry is that change is always around the corner. 

In recent years, there has been an increase in compliance-related regulations for individual health, group benefits, and senior insurance organizations. Some of the top ones to recount include:

• Broker Compensation Disclosure — for group benefits
• CMS call recording requirements
• ACA Consent to Contact 
• Updated regulations for Medicare Scope of Appointment — most recently, the addition of the 48-hour rule

With more changes and new regulations looming on the horizon, it’s essential that health agencies, GAs, and IMO/FMOs partner with industry-specific technology that prioritizes compliance automation. 

Understanding Compliance for Health Insurance

First things first, what exactly is compliance? 

“Compliance is the state of being in accordance with established guidelines or specifications or the process of becoming so. The definition of compliance can also encompass efforts to ensure that organizations are abiding by both industry regulations and government legislation.”
— TechTarget

When it comes to health insurance, many of the regulations for compliance are in place for:

• Transparency: For insurance consumers, health insurance can be confusing. The Centers for Medicare and Medicaid (CMS) has committed itself to increasing transparency in the health insurance industry and wants to provide more understanding about the role brokers and agencies play. An example of a transparency-focused recent ruling is the Consolidated Appropriations Act (CAA) of 2021, also known as the Brokers Compensation Disclosure.
• Consumer protection: Another big area of focus for compliance regulators is advocating for more protection of insurance consumers and policyholders. This type of compliance also includes ensuring that carriers provide optimal and beneficial products to consumers. The recent discussions about the Contract Year 2025 Policy & Technical Changes to the Medicare Advantage Plan Program would be a recent example.
• Agent or insurance agency/upline protection: The other half of the equation is protection for those who sell health insurance products — health, benefits, and senior insurance agencies and uplines. There is the standard protection and insurance all insurance organizations and agents can purchase, like E&O insurance. However, regulators are focused on launching additional compliance regulations that add more protection. To a certain degree, the call recording requirements in the CMS Final Rule 2023 can be an example. Having comprehensive records of conversations and interactions provides agents, agencies, and uplines additional protection should the need arise. 

Why maintaining compliance is crucial for health insurance agencies

Although compliance can be a nuisance when new regulations come into force with little to no explanation, it’s essential to maintain compliance for a number of reasons. The first one is it’s just the right way to do business, and your company could face repercussions if you don’t. 

The other primary reason is that it’s an added level of protection for your business. Although some compliance regulations are created for the sole purpose of protecting agencies and uplines, extra protection never hurts. 

In the last year, reports have surfaced about fraud in policies where the agent of record is updated without consent or knowledge from the policyholder. Sometimes, the policyholder isn’t even aware they’re being enrolled in a policy. 

This issue directly affects health insurance agencies and uplines that sell policies because it cuts their commissions and creates unease for consumers. Compliance regulations requiring insurance organizations to track and manage consent documentation, customer and prospect interactions, and more can help insurance organizations build trust with their policyholders and increase retention rates.

How industry-specific technology can help health insurance agencies stay compliant

Yes, compliance regulations can be a headache and often mean more paperwork and things to do, but this is where industry-specific technology can assist. Using technology created for your organization's industry niche, like individual and group health insurance, can make all the difference. 

Often, when technology is built for a specific industry, it considers the top needs and concerns that industry faces — like compliance. Industry-specific technology could have integrated compliance-focused tools, like compliance automation, that are pre-built and make compliance simple.. 

Health Insurance Compliance Automation Tools in AgencyBloc’s Plus Suite

AgencyBloc’s AMS+ solution is an insurance-specific CRM built for health and benefits agencies and uplines. It has the tools your teams need to succeed, including automated compliance management tools. Our Plus Suite of industry-specific solutions are focused on the individual health, group benefits, and senior insurance space, and we are committed to staying current with ever-evolving compliance changes. 

Every AMS+ package comes with integrated compliance tools that include:

• Scope of Appointment (SOA): Easily obtain signed CMS-friendly Scope of Appointment forms from Medicare beneficiaries to simplify compliance. Send the documents via email or text message. Then, once the form is completed and returned, the signed copy will automatically attach to the contact’s record for easy access.
• ACA Consent to Contact: Similar to the SOA forms above, AMS+ has built-in ACA Consent to Contact compliance automation. Easily send and obtain consent from all contacts, then attach those records to the contact’s profile for seamless compliance.
• CMS Call Recording Requirements: AMS+ has an integrated voice over internet protocol (VoIP), also known as a digital/virtual phone system, that automatically records all incoming and outgoing calls and attaches the recordings to the contact’s profile. This automated process allows your team to easily capture and store recordings, taking the worry out of compliance.

To add automation, quickly trigger SOA or ACA Consent to Contact documents to send — AMS+ will do the rest. Likewise, AMS+ will automatically create a list of contacts who haven’t signed their SOA documents that your team can quickly send. 

Source | AMS+

AgencyBloc has an insurance-specific management platform called the Plus Suite, which is designed to support individual health, group benefits, and senior insurance agencies, GAs, IMO/FMOs, call centers, and carriers. With AMS+, Commissions+, and Quote+, your organization can accelerate growth, create efficiencies, and, most importantly, stay compliant.

Posted by Allison Babberl on Tuesday, March 12, 2024 in Electronic Compliance Management

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