The United States Files False Claims Act Complaint Against Three National Health Insurance Companies and Three Brokers Alleging Unlawful Kickbacks and Discrimination Against Disabled Americans
The United States filed a complaint today under the False Claims Act (FCA) against three of the nation’s largest health insurance companies — Aetna Inc. and affiliates, Elevance Health Inc. (formerly known as Anthem), and Humana Inc. — and three large insurance broker organizations — eHealth, Inc. and an affiliate, GoHealth, Inc., and SelectQuote Inc. The United States alleges that from 2016 through at least 2021, the defendant insurers paid hundreds of millions of dollars in illegal kickbacks to the defendant brokers in exchange for enrollments into the insurers’ Medicare Advantage plans.
Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may choose to enroll in health care plans (MA plans) offered by private insurance companies, such as defendants Aetna, Anthem, and Humana. Many Medicare beneficiaries rely on insurance brokers to help them choose an MA plan that best meets their individual needs. Rather than acting as unbiased stewards, the defendant brokers allegedly directed Medicare beneficiaries to the plans offered by insurers that paid brokers the most in kickbacks, regardless of the suitability of the MA plans for the beneficiaries. According to the complaint, the broker organizations incentivized their employees and agents to sell plans based on the insurers’ kickbacks, set up teams of insurance agents who could sell only those plans, and at times refused to sell MA plans of insurers who did not pay sufficient kickbacks.
The United States further alleges that Aetna and Humana each conspired with the broker defendants to discriminate against Medicare beneficiaries with disabilities whom they perceived to be less profitable. Aetna and Humana allegedly did so by threatening to withhold kickbacks to pressure brokers to enroll fewer disabled Medicare beneficiaries in their plans. The United States alleges that, in response to these financial incentives from Aetna and Humana, the defendant brokers or their agents rejected referrals of disabled beneficiaries and strategically directed disabled beneficiaries away from Aetna and Humana plans.
“Health care companies that attempt to profit from kickbacks will be held accountable,” said Deputy Assistant Attorney General Michael Granston of the Justice Department’s Civil Division. “We are committed to rooting out illegal practices by Medicare Advantage insurers and insurance brokers that undermine the interests of federal health care programs and the patients they serve.”
“It is concerning, to say the least, that Medicare beneficiaries were allegedly steered towards plans that were not necessarily in their best interest – but rather in the best interest of the health insurance companies,” said U.S. Attorney Leah B. Foley for the District of Massachusetts. “The alleged efforts to drive beneficiaries away specifically because their disabilities might make them less profitable to health insurance companies are even more unconscionable. Profit and greed over beneficiary interest is something we will continue to investigate and prosecute aggressively. This office will continue to take decisive action to protect the rights of Medicare beneficiaries and vulnerable Americans.”
The lawsuit was originally filed under the qui tam or whistleblower provisions of the FCA. Under the FCA, private parties can file an action on behalf of the United States and receive a portion of the recovery. The FCA permits the United States to intervene in and take over the action, as it has done here. If a defendant is found liable for violating the FCA, the United States may recover three times the amount of its losses plus applicable penalties.
The Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the District of Massachusetts are handling the matter, with valuable assistance from the Department of Health and Human Services (HHS) Office of Inspector General and the FBI. The case is captioned United States ex rel. Shea v. eHealth, et al., No. 21-cv-11777.
Trial Attorneys David G. Miller, Anna H. Jugo, Diana E. Curtis, and Sara B. Hanson of the Justice Department’s Civil Division and Assistant U.S. Attorneys Charles Weinograd and Julien Mundele for the District of Massachusetts are handling the matter.
The investigation and prosecution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the FCA. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to HHS at 800-HHS-TIPS (800-447-8477).
Filed under: General Problems
I have a good insurance guy and he like many, tries to steer MA beneficiary’d into a specific insurer and specific medical group. When I made my decisions clear, I did not select the insurer he was pushing or the med group he wanted, he immediately backed down, telling me my choices are good, hmm. First time he came out was for 2018 and all my meds were stopped cold turkey in 2016 so for all of 2017 I refused to see any doctor, my trust was now gone. My brain was in no position to do what I had always done on my own, select the insurer and med group. Poor guy had to come out three times, he said he never had anyone go line by line benefit then comparing each with the other plans. Every Medicare beneficiary needs to do that. Ask the agent for input however they make the final decision, not the insurance broker. The one I selected back for 2018 I have stayed with. I love my primary doctor although a few months ago she sold out to become a private equity doctor. I just hope they don’t cause her to burn out within the five years which is the time frame MD’s who sell out, eventually burn out and leave medicine. I also like my pain management group, although I only received my meds at one third my previous high doses were, I fully realize I am lucky to get what I do get, far too many get nothing.so I am comfortable with all my choices for now anyway. There were insurers who offered a monthly tab for OTC items or money back. They also have very large hospital and SNF copays, things most people just don’t think about. Like with day 21 days going forward in a SNF, , their daily copay is like $170, mine is only $30 a day. So if I wind up being in a SNF for 31 days, my copay is only $300, the other is well, close to $2000 so who has the better deal. As seniors we never know how a complication can knock us on our toosh for several months.