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