Montana has clawed back more than $23 million in fraudulent claims after PacificSource flagged more than 200 suspicious ACA enrollments tied to as much as $54.7 million in unjustified claims.
A state investigation identified a scheme in which out-of-state individuals targeted Native Americans in Montana, enrolled them in marketplace plans, transported them across state lines and then billed for substance abuse treatments that either did not occur, were medically unnecessary or were billed at inflated prices, according to a Jan. 20 news release from Montana State Auditor and Commissioner of Insurance James Brown.
“When scammers bill $10,000 a day in fake enrollments, premiums rise, provider networks shrink, and families pay more for worse care,” Mr. Brown said.
Native Americans can sign up for marketplace plans year-round under a special enrollment provision, which the perpetrators exploited to generate immediate, high-dollar claims.
The state’s investigation traced the fraudulent activity to California-based treatment facilities. Investigators found false residency claims, fabricated addresses and unsupported income information used to obtain coverage, followed by aggressive billing patterns designed to extract maximum payouts.
Of the 207 suspected fraudulent enrollments under review, CMS has approved the rescission of 80 policies so far, with dozens more pending. The commissioner’s office said additional investigations are ongoing and are likely to lead to further recoveries. The case has also been referred for criminal investigation at both the state and federal levels.
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