The U.S. Department of Justice is seeing numerous trends of fraud in the Affordable Care Act Marketplace targeting vulnerable populations. At the Medicarians Conference in Las Vegas on Monday, an official discussed how the DOJ is tackling this fraud.
One example of fraud is attacking individuals who are homeless, unemployed, dealing with mental health issues or battling substance use disorders, according to Ricardo Carcas, assistant special agent in charge of the Office of Investigations. These people are often covered by Medicaid, and they’re being targeted by what Carcas referred to as “street marketers.”
These marketers falsify information to get Medicaid coverage denied, then use that denial to open a Special Enrollment Period and falsify income to move people into subsidized ACA marketplace plans with the fraudsters as agents of record. When they’re an agent of record, they have “control over that individual for about a year period,” Carcas said.
“Throughout that year that they are the agent of record, they are now changing these individuals’ health plans on a daily, weekly and monthly basis, generating commissions every time that they enroll in a new plan,” he stated. “Obviously, it’s a huge issue, because all of this is done without consent. These individuals have no idea that their policies are being changed on a daily, weekly and monthly basis.”
This leads to care being disrupted and oftentimes not being covered due to changes in insurance. It then affects access to medications for mental health, opioid addiction and HIV, as these individuals are now “incurring a cost that they can’t afford,” Carcas said.
There are also other examples of fraud, including people using AI to deceptively market ACA plans, he added.
To combat fraud, the administration has the Crushing Fraud, Waste and Abuse initiative, which is aimed at preventing fraud in Medicare, Medicaid, the Children’s Health Insurance Program and the Health Insurance Marketplace. Carcas noted that fraud in the ACA Marketplace is just part of the problem, as traditional Medicare is a major focus for the administration as well.
He noted that the administration has been very “aggressive” in targeting the bad actors, giving the example of some individuals who were just convicted and sentenced to 30 years in jail for fraudulent activity.
“There is a price to pay if you are committing these crimes,” he said. “Obviously, we do our due diligence, and we’re very methodical with our cases, and we build these cases up so when we go to trial, we want to make sure that we have a very high success conviction rate. Right now, we’re trying to get to 100%.”
Carcas added that people can report fraud, waste and abuse on the Office of Inspector General website, and there is also a section for whistleblowers.
“There are only so many of us,” he said. “There’s a lot more of the bad actors. It’s an issue that we’re not going to be able to mitigate ourselves. … We gotta help each other out when it comes to this.”
Photo: Feodora Chiosea, Getty Images
