The Centers for Medicare & Medicaid Services (CMS) secret shopper program is an essential compliance check for Medicare Advantage and Part D plans. Health plans must ensure their call centers meet CMS’ rigorous standards for timeliness, accuracy, and accessibility, as CMS can call at any time of day to validate performance. Preparation is key to avoiding compliance issues and ensuring a seamless experience for beneficiaries.
What to Expect from CMS Monitoring
Two Types of CMS Calls
Prospective Calls (February–June)
CMS evaluates:
Accuracy and availability of foreign language translation services.
TTY call accessibility.
This monitoring occurs annually from early February through early June. Plans should focus on validating the accuracy of phone numbers, hours of operation, translation and TTY availability and consistently answer beneficiary questions promptly during these calls.
Current Member Calls (Quarterly):
CMS measures timeliness metrics, including:
Call response time.
Average hold time.
Call blocked rate.
Monitoring occurs for four consecutive weeks each quarter, with specific dates communicated via HPMS memos.
How Health Plans Can Prepare
To meet CMS requirements and excel in secret shopper evaluations, health plans should take proactive steps to optimize call center operations:
Validate Systems and Processes:
Verify the accuracy of phone numbers, hours of operation, and call routing.
Ensure that tools and documents are updated with 2025 benefits and accurate information.
Enhance Staff Training:
Train representatives on handling translation requests via conference calls rather than transferring the caller to a translation line.
Reinforce knowledge about 2025 plan benefits to ensure representatives can answer questions confidently and accurately.
Conduct Test Calls:
Simulate both prospective and current member calls to identify gaps in performance.
Validate compliance with CMS metrics such as response time, availability, and accessibility.
How We Can Help
We partner with health plans to prepare for CMS secret shopper evaluations by:
Process Reviews: Helping plans understand CMS requirements and identifying areas for improvement.
Evaluate or Provide Training: Designing and delivering targeted training for call center representatives.
Test Call Simulations: Conducting mock calls to validate compliance and readiness for CMS monitoring.
Year-round Monitoring: Our staff will monitor your results throughout 2025 so there are no surprises.
Why It Matters
Compliance with CMS standards is critical to maintaining high Star Ratings and ensuring beneficiary satisfaction. By proactively addressing potential issues, health plans can avoid costly errors and deliver a seamless experience to their members.
Let us help you navigate the complexities of CMS monitoring and ensure your call centers are ready for every secret shopper call.
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