OIG Files: Open (Enrollment) Season on Fraud

September 8, 2022

Open enrollment will be upon us in the coming month.  With it will come a slew of fraud complaints as it relates to managed care enrollment.  Brokers work to enroll eligible members into plans that are supposed to be the best suited for the member.  That, however, is not always the case.  Brokers are paid commissions based on enrolling a member in the plan for which they are working.  The biggest area of complaint will come from individuals who allege that they were moved into a particular plan without their consent.  CMS has some very specific guidance, and specifically prohibits the broker from soliciting potential plan members directly. 

One thing of interest is that although CMS often is the recipient of the complaints about members being moved into plans they did not ask to be moved into, those complaints are filtered down to the internal investigative units of the plan in question.  These plans must field complaints filtered down from CMS, as well as complaints made directly to the plan by the complaining member.  Thousands of complaints are made, with the largest volume coming soon after the new year and the open enrollment ending.  There is often great confusion from the member as to the benefits offered, the benefits that are actually provided and the collateral benefits (of usually the lack thereof) that come from being switched.

In a unique attempt to assist and facilitate steering members to the right plan, the State of New Jersey opened a grant program to facilitate paying community organizations to be “navigators,” to assist in properly plan selection.  Instead of putting the broker in the driver seat, this program will allow the unbiased assistance to be the driving force

While fraud during open season will always be an issue, since there is a financial inducement for the broker, this novel approach may actually be a way to get members into plans that are best suited for their individual health needs, and not just lining the pockets of some unscrupulous broker. 

When I was an OIG agent, I worked on a case with a broker who created a sham not for profit for the purpose of getting into senior and low-income buildings.  He would taut all of the work of the not for profit, but really was seeking sales opportunities, which, at one point, included genetic testing.  The fraud will always be there, but there are absolutely ways that we can all work to reduce the opportunities.

By Eric Rubenstein

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