ATLANTA — Tyesha Foreman said going to the doctor has been difficult each time because she doesn't know if her health insurance will cover her when she settles down.
“It's stressful and scary and it's embarrassing to look back and think, 'Why? Why are you covered and then giving us a card that says you're not covered again?' ? said the foreman. Channel 2 consumer researcher Justin Gray.
A Douglas County mother said for the past few months, when she goes to pay her health insurance premiums, she gets her premiums back. The family had to pay for the MRI scan out of pocket, and even thought the emergency surgery might not be covered.
“You go to the doctor as soon as you get insurance, and a few weeks later you get your premium back, but you don't have insurance,” Foreman said.
In January, Foreman received a $1,700 tax bill in the mail for an overpayment of federal health insurance subsidies.
It was for an additional health insurance policy, something Foreman said he had no idea about.
She said an insurance broker she had never met gave her a policy she didn't ask for.
“For three months, I was on the phone, trying to get the marketplace to understand that I wasn't doing these applications. I didn't know who this agent was.” Foreman said.
An Ohio family noticed a problem when they went to the pharmacy to pick up Randy Delaney's diabetes insulin.
“You can imagine my shock when I was told it was $1,096,” said his wife, Laurie.
After months of frustrating phone calls, the Delaneys discovered that their medical plan had also been changed multiple times without their consent. They are now worried that they will be hit with a huge tax bill in January.
A proposed class action lawsuit alleges that some families who rely on the Affordable Care Act marketplace are victims of a multimillion-dollar health care fraud scheme.
“I think this is the biggest health insurance fraud case in history,” said Atlanta attorney Jason Doss, who filed the lawsuit on behalf of families across the country.
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He says unscrupulous insurance agents are abusing provisions added during the coronavirus pandemic that allow low-income Americans to switch coverage at any time on the market, not just voluntary enrollment. said.
“The question is, what happens if the bad guys own the registration platform? They have the keys to the castle,” Doss said.
Insurance agents are paid a monthly fee of approximately $20 per ACA policy. You can make money by changing your customers' insurance.
Callie Nabrides, an insurance agent in Georgia, said she has had many of her clients transferred to other agencies without their knowledge or approval.
“All they need is their first name, last name, date of birth and state,” Nabrides said.
Nabrides estimates that at some point he lost 40% of his customers to fraudulent agents.
Each switch represents a potential gap in coverage.
“They think they're covered until they go to the pharmacy to pick up their medication, and the pharmacist tells them your health insurance has been canceled,” Nabrides said.
The complaint alleges that one of the ways the agents obtain information is through social media ads promising bank cards with “free money.”
Foreman's husband clicked on one of those ads and ended up speaking with a representative from a company called TrueCoverage, who later changed the family's health insurance plan.
“They just asked his name and where he lived. He had no idea this was happening,” Foreman said.
The federal government's own numbers illustrate the enormity of its scale.
In the first eight months of this year, approximately 275,000 people complained that they were changed from or enrolled in a plan without their consent.
“It's like someone is there, messing up your life every day,” Rory Delaney says.
This system was designed to give private companies access to federal market databases.
But the Centers for Medicare and Medicaid Services blocked the companies, Benefit Align and TrueCoverage, from the market in August due to “unusual activity.”
A True Coverage whistleblower who once worked there as an insurance agent agreed to speak with Gray if his identity was concealed.
“I don't like the word guilt, but I felt ashamed. I was embarrassed,” he said.
In an affidavit as part of the lawsuit, another whistleblower alleges that an internal email from TrueCoverage's senior director of quality assurance instructed the agency to be “vague” about cash cards during phone calls. revealed.
The email said it was “not specific” about the cash “despite what is advertised.”
“The people who did the best were the ones who blatantly lied and told people they were going to get the cash,” the whistleblower continued.
However, there is no free money. Federal subsidies for insurance actually go to insurance companies, not consumers.
What's worse, if your income doesn't qualify for these health plans, you'll have to pay back the subsidy at tax time.
“What you receive at the end of the year is a fine from the IRS,” Nabrides said.
CMS has taken steps in recent months to address this issue.
CMS said in a statement: Channel 2 Action News: “From June 2024 to October 2024, CMS will suspend the marketplace agreements of 850 agents and brokers due to reasonable suspicion of fraud or misconduct related to fraudulent enrollments or fraudulent plan switching.” I did.”
According to CMS, new security measures include blocking changes unless an agent or broker is already associated with a consumer's account, and requiring a new agent or broker to switch plans before allowing a new agent to switch plans. This includes requiring three-way phone calls.
Within the past two weeks, Foreman finally received an amended tax return that she can use to get a refund for the taxes she paid.
“We're grateful that this solves that problem, but there are a lot more people for whom this isn't happening,” Foreman said.
True Coverage told Gray in a statement: “While we cannot comment on ongoing litigation, we strongly believe the allegations are baseless and without merit.”
In a motion to dismiss the lawsuit, TrueCoverage and the other companies named in the lawsuit even argue that consumers with gaps in coverage have not suffered “tangible loss.”
“These injuries” are essentially those without health insurance and “are not tangible or tied to any economic metrics,” attorneys representing True Coverage said in a filing. Ta.
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