Federal prosecutors from the Department of Justice have accused three of the nation’s largest health insurance companies of paying hundreds of millions of dollars in illegal kickbacks to three large insurance broker organizations in exchange for enrollments into the insurers’ Medicare Advantage plans from 2016 through at least 2021.
The United States filed a complaint on May 1 under the False Claims Act (FCA) against Aetna Inc. and affiliates, Elevance Health Inc. (formerly known as Anthem), and Humana Inc. — as well as insurance broker organizations eHealth, Inc. and an affiliate, GoHealth, Inc., and SelectQuote Inc.
Under the Medicare Advantage (MA) Program, 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.
“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.”
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 complaint 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.
“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 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.
The investigation and prosecution illustrates the government’s emphasis on combating healthcare fraud, according to a press release announcing the complaint. 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).
The complaint points out that the claims asserted are allegations only. There has been no determination of liability.
• Read the complaint here
