DOJ sues the nation’s largest health insurers’ alleging ‘unlawful kickbacks’
The U.S. Department of Justice has filed a lawsuit against three of the nation’s largest Medicare Advantage insurers, CVS Health’s Aetna, Elevance Health and Humana, accusing them of paying illegal kickbacks to boost plan enrollments and expand their market share. The complaint, unsealed Thursday, alleges that from 2016 to 2021, the companies paid hundreds of millions of dollars to insurance brokers to steer Medicare beneficiaries toward their plans.
DOJ sues Aetna, Humana and Elevance for breaking federal law
“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.
Medicare Advantage is a federally funded program that allows beneficiaries to choose health plans through private insurers of their choice. Many use brokers to help them select a plan based on their individual health needs. The DOJ says the brokers involved in the scheme pushed plans based on the size of the kickback, not the quality or appropriateness of the coverage.
In statements to multiple news outlets, Aetna said, “We are still reviewing the complaint, but disagree with the allegations and intend to defend the case vigorously.”
A Humana spokesperson struck a similar tone, saying, “Humana strongly disagrees with the allegations in the complaint and we look forward to vigorously defending ourselves in the legal proceedings. As always, Humana’s highest priority remains ensuring our members are provided with outstanding healthcare coverage and access to care, while also continuing to support healthcare innovation, better health outcomes, and deeper patient engagement.”
Elevance responded to the DOJ’s lawsuit with confidence. “We are confident that our health plans have complied with and continue to comply with the Centers for Medicare & Medicaid Services (CMS), marketing and broker compensation regulations, rules and guidelines,” a spokesperson said.
What does the DOJ allege?
The DOJ said this arrangement violated the False Claims Act and prioritized profits over patient needs. Three broker firms, eHealth, its affiliate GoHealth and SelectQuote, were also named as defendants. According to the complaint, these brokers created internal teams that exclusively sold plans from insurers offering kickbacks. In some cases, the complaint said brokers refused to sell plans from companies that didn’t provide similar incentives.
Court documents give different examples of the false claims made to the government. Including, “In March 2016, under its contract H6609 and plan HumanaChoice, Humana submitted a claim with beneficiary data to CMS, including data related to Beneficiary 1. Humana received payment pursuant to this claim. In total, Medicare paid $6,278.22 to Humana for Beneficiary 1 in the year of Beneficiary 1’s enrollment.”
Federal prosecutors also allege individuals with disabilities or chronic health conditions were discouraged from enrolling, as they were seen as less profitable for the insurers.
“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,” said Leah B. Foley, U.S. Attorney for the District of Massachusetts, in a statement. “This office will continue to take decisive action to protect the rights of Medicare beneficiaries and vulnerable Americans.”
What happens next?
The case was originally filed under the False Claims Act’s whistleblower provisions, which allow private individuals to sue on behalf of the U.S. government and also share in any financial recovery. The Justice Department has since taken over the case. If found liable, the defendants could be required to pay triple the government’s losses, plus civil penalties.
Ella Rae Greene, Editor In Chief
