The United States has filed a complaint today under the False Claims Act (FCA) against three of the largest health insurance companies in the country – Aetna Inc. and Affiliés, Elect Health Inc. (formerly known as Anthem), and Humana Inc. – and three major organizations of insurance broker – Ehealth, Inc. and an affiliate, Gohealth, Inc. Insurers paid hundreds of millions of $ dollars in illegal bribes to defendant brokers in exchange for registrations at the Medicare Advantage of insurers.
As part of the Medicare Advantage (MA) program, also known as Medicare Part C, the beneficiaries of Medicare can choose to register for health care plans (MA plans) offered by private insurance companies, such as defendants Aetna, Anthem and Humana. Many beneficiaries of health insurance are counting on insurance brokers to help them choose a MA plan that best meets their individual needs. Rather than acting as impartial commissioners, defendant brokers would have directed the beneficiaries of Medicare to the plans offered by insurers who paid the most bribes, regardless of the relevance of MA plans for the beneficiaries. According to the complaint, the broker’s organizations prompted their employees and agents to sell plans according to the bribes of insurers, set up teams of insurance agents who could only sell these plans, and have sometimes refused to sell plans of my insurers who did not pay enough bribes.
The United States also alleys that Etna and Humana have each conspired with the broker’s defendants to discriminate the beneficiaries of a disabled medication which they perceived as less profitable. Aetna and Humana would do it by threatening to retain the bribes at the pressure brokers to register fewer beneficiaries of a disabled medication in their plans. The United States alleges that, in response to these financial incentives of Aetna and Humana, defendant brokers or their agents rejected the references of disabled beneficiaries and disabled beneficiaries strategically distant from the Aetna and Humana plans.
“The health care companies trying to take advantage of the bribes will be held responsible,” said deputy prosecutor Michael Granston of the civil division of the Ministry of Justice. “We are committed to eliminating illegal practices by insurers and insurance brokers from Medicare Advantage who undermine the interests of federal health care programs and the patients they serve.”
“It is worrying, at the very least, that the beneficiaries of Medicare would have been directed to plans which were not necessarily in their best interest – but rather in the best interest of health insurance companies,” said American lawyer Leah B. Foley for the Massachusetts district. “The alleged efforts to ward off beneficiaries specifically because their handicap could make them less profitable for health insurance companies is even more unacceptable. The profit and greed of the interest of the beneficiaries are something that we will continue to investigate and pursue aggressively.
The trial was initially filed under the tam or provisions of denunciation of the FCA. Under the FCA, private parties can take action on behalf of the United States and receive part of the recovery. The FCA allows the United States to intervene and resume action, as it has done here. If a defendant is deemed responsible for the FCA violation, the United States can recover the amount of its losses three times more the applicable penalties.
The Civil Division of the Ministry of Justice, the Directorate of Trade Disputes, the Fraud Section and the US Prosecutor’s Office for the Massachusetts District manages the case, with precious help from the Office of the Inspector General of the Ministry of Health and Social Services (HHS) and the FBI. The case is subtitled United States ex re. Shea c. EHEALTH, et al.N ° 21-CV-11777.
Lawyers of the David G. Miller trial, Anna H. Jugo, Diana E. Curtis and Sara B. Hanson of the Civil Division of the Ministry of Justice and the assistant lawyers of the United States Charles Weinograd and Julien Mundele for the Massachusetts district manage the question.
The investigation and prosecution of this case shows the government placed by the government on the fight against health care fraud. One of the most powerful tools of this effort is the FCA. Advice and complaints of all sources concerning potential fraud, waste, abuse and mismanagement, can be reported to HHS at 800-HHS-TIPS (800-447-8477).
The claims asserted in the complaint are only allegations. There was no determination of responsibility.
Note: Read the complaint here
