The U.S. Department of Justice is seeing numerous fraud trends in the Affordable Care Act market targeting vulnerable populations. At Doctors Conference On Monday in Las Vegas, an official explained how the DOJ is tackling this fraud.
One example of fraud involves preying on people who are homeless, unemployed, struggling with mental health issues or dealing with substance use disorders, according to Ricardo Carcas, assistant special agent in charge of the Bureau of Investigations. These people are often covered by Medicaid and are targeted by what Carcas calls “street vendors.”
These marketers falsify information to obtain denial of Medicaid coverage, then use that denial to open a special enrollment period and falsify income in order to move people into subsidized ACA marketplace plans with the fraudsters as agents of record. When they are official agents, they have “control over that person for about a year,” Carcas said.
“Throughout this year of being the agent of record, they are now changing these individuals’ health plans on a daily, weekly and monthly basis, generating commissions each time they enroll in a new plan,” he said. “This is obviously a huge problem because all of this is being done without consent. These individuals have no idea that their policies are being changed on a daily, weekly and monthly basis.”
This leads to disrupted and often uncovered care due to insurance changes. This in turn affects access to medications for mental health, opioid addiction and HIV, because these people are now “bearing a cost that they cannot afford,” Carcas said.
There are other examples of fraud as well, including those using AI to deceptively market ACA plans, he added.
To combat fraud, the administration launched the Crushing Fraud, Waste and Abuse initiative, which aims to prevent fraud in Medicare, Medicaid, the Children’s Health Insurance Program and the health insurance marketplace. Carcas noted that fraud in the ACA marketplace is only part of the problem, as traditional Medicare is also a major priority for the administration.
He noted that the administration has been very “aggressive” in targeting bad actors, giving the example of some people who were just convicted and sentenced to 30 years in prison for fraudulent activity.
“There is a price to pay if you commit these crimes,” he said. “Obviously, we do our due diligence, and we’re very methodical with our cases, and we build those cases so that when we go to trial, we want to make sure that we have a very high conviction rate. Right now, we’re trying to get to 100 percent.”
Carcas added that people can report fraud, waste and abuse on the Office of Inspector General websiteand there is also a section for whistleblowers.
“There are only a limited number of us,” he said. “There are a lot more bad actors out there. This is a problem we’re not going to be able to mitigate on our own. … We have to help each other in this area.”
Photo: Feodora Chiosea, Getty Images
