CMS Secret Shopper Test Call Guide

Overview of CMS and Its Role

The Centers for Medicare & Medicaid Services (CMS) is a vital federal agency within the U.S. Department of Health and Human Services. It oversees healthcare policies and administers key programs such as Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

To ensure eligible individuals receive accurate and accessible healthcare information, CMS conducts an annual Accuracy and Accessibility Study. This study evaluates the quality of information provided to Medicare beneficiaries through insurance program call centers.

What is CMS Testing?

CMS Testing assesses the effectiveness of communication within Medicare Advantage and Medicare Prescription Drug Benefit Plans. It evaluates the following:

Accuracy of information provided by call center representatives.
Availability of language interpreters for limited-English proficient (LEP) callers.
Efficiency of service, including hold times and ease of access.

Purpose of the CMS Annual Study

The test calls verify whether Medicare beneficiaries receive complete and accurate information from insurance plan representatives. The study results impact a plan’s star rating (1 to 5), which influences consumer choices and determines an insurance plan’s standing with CMS.

How CMS Test Calls Are Conducted

CMS employs secret shoppers, LEP individuals posing as beneficiaries, or family members to conduct test calls. These calls occur annually from February to early June.

Test Call Process:

Call Initiation: The secret shopper calls the insurance provider’s customer service. A live representative must be available within 10 minutes, including hold time.
Interpreter Access: After connecting to an interpreter, the caller asks an introductory question (e.g., “Are you the right person to answer questions about Medicare Part C/Part D?”). The first survey question should be asked within 8 minutes.
Survey Questions: The caller asks three survey questions, each requiring a response within 7 minutes. These questions are based on CMS publications and specific insurance plan details.

A CMS secret shopper would typically ask about Part C and Part D of Medicare, as these are the parts most commonly associated with private insurance plans and prescription drug coverage, which are the primary focus of CMS secret shopper evaluations.

Key points to remember:

Part A and B:

These are the “original Medicare” parts, usually handled directly by the government, so secret shoppers would less frequently focus on these aspects.
Part C (Medicare Advantage):

This is a private insurance plan that can cover all the benefits of Part A and Part B, and is often the subject of secret shopper inquiries.
Part D (Prescription Drug Coverage):

This is the part that covers prescription drugs, another common area of focus for CMS secret shoppers.

Evaluation Criteria

CMS assesses:

Interpreter Access – How efficiently the call center connects LEP callers to language interpreters.
Information Accuracy – Whether the interpreter accurately conveys information to the beneficiary.

Best Practices for Interpreters

Interpreters play a crucial role in ensuring call success. Follow these best practices:

1. Minimize Interventions

Keep Medicare glossaries readily available.
Limit interventions unless confirming insurance plans or prescription medication names.

2. Be Prepared for Common Medications

Maintain a checklist of frequently mentioned medications.
Seek clarification only when necessary to ensure accuracy.

3. Use Professional Intervention Scripts

In cases of unclear speech, interpreters should use structured interventions:

Requesting a Repetition:

“Excuse me, this is the interpreter, can you please repeat [term]?”
“Excuse me, this is the interpreter, I just asked for a repetition of [term].”

Requesting a Confirmation:

“Excuse me, this is the interpreter, I will confirm the term/spelling before I interpret.”
“Excuse me, this is the interpreter, I confirmed the term/spelling.”

4. Manage Anxiety

Take deep breaths before answering a call.
Maintain a clear, moderate pace to ensure clarity and accuracy.

Additional Resources for CMS, Medicare, and Medicaid

Interpreters should familiarize themselves with the following resources:

Official CMS Websites:

CMS.gov – Comprehensive information on Medicare and Medicaid regulations.
Medicare.gov – Details on Medicare benefits and plan options.
Medicaid.gov – State-specific Medicaid program details.
HealthCare.gov – Information on insurance enrollment and subsidies.

Multilingual Medicare Glossaries:

English: Medicare Glossary, Medicare and You Guide.
Spanish: Glosario de términos médicos y de cobertura médica.
Chinese: Medicare Glossary in Chinese, Medicare and You
Vietnamese: Medicare and You.

Preparing for CMS Call Testing Season

As CMS test season approaches, interpreters and call centers should ensure they are well-prepared. Higher star ratings help insurance providers maintain Medicare billing privileges and enhance their reputation as reliable healthcare partners.

By following these guidelines, interpreters can deliver accurate and efficient language support, contributing to a successful CMS evaluation.

Disclaimer: The views and opinions expressed in these blog entries are solely those of the author and do not necessarily reflect the official policy or position of the company. Any content provided by the author is of their opinion and is not intended to malign any religion, ethnic group, club, organization, company, individual, or anyone or anything.

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