news-quote”>“The worst part of this alleged Ambetter scheme is that it intentionally targets and manipulates the most vulnerable people amongst us,” said Justin Boley, Partner at Wexler Boley & Elgersma LLP.”
August 08, 2022
Centene Corporation—currently the largest provider of health-insurance plans sold on the online exchanges established by the Affordable Care Act (ACA)—and its affiliates have been allegedly selling fraudulent health-insurance policies to millions of predominantly low-income consumers under the “Ambetter” brand name, according to a RICO lawsuit filed on Friday in the United States District Court for the Northern District of Illinois, Havrilla, et al. v. Centene Corp., et al., Case No. 1:22-cv-04126.
Centene and its affiliate companies market their signature Ambetter policies across 26 states. According to the suit, those consumers have been allegedly overcharged by hundreds of millions of dollars each year because the plans don’t deliver the benefits promised to consumers and fail to satisfy the minimum requirements imposed by the Affordable Care Act. Specifically, the suit alleges that Centene and its affiliates have misrepresented the benefits of Ambetter plans by, among other things, providing lists of in‑network providers that defendants know to be false. When the consumers who purchase the plans attempt to find a medical provider, the suit alleges, they quickly learn that very few—sometimes none—of the providers on the Ambetter in‑network list actually accept Ambetter insurance.
The class action lawsuit may affect over 10 million customers who have purchased Ambetter plans. In addition to consumers, the lawsuit highlights the overcharges Ambetter has inflicted on taxpayers and government entities. Ambetter Silver‑tier plans sold by Centene qualify for cost‑sharing through federal subsidies, meaning that the government pays for part of the monthly premiums and the insured individual receives lower out-of-pocket costs. Approximately 90% of the Ambetter plans sold through the exchanges are Silver‑tier plans, and the lawsuit alleges that, by knowingly selling the misrepresented Ambetter plans, Centene and its affiliates have defrauded the federal government of hundreds of millions of dollars every year.
“The worst part of this alleged Ambetter scheme is that it intentionally targets and manipulates the most vulnerable people amongst us,” said Justin Boley, Partner at Wexler Boley & Elgersma LLP. “These are victims that need care and are working with government-subsidized programs designed to ensure they receive at least a bare minimum of coverage. That’s not what they’re getting.”
The lawsuit alleges that Centene and its affiliate companies have used mailings and wire communications to carry out their alleged scheme by sending Ambetter plan documents and invoices to current or potential plan members, electronically filing Ambetter plan documents with the online health insurance exchanges of 26 states, and receiving fraudulently procured premium payments electronically from plan members. According to the complaint, these actions constitute millions of violations of the mail-and wire-fraud statutes by Centene and its affiliates, constituting a pattern of racketeering activity under federal RICO laws.
Plaintiffs seek to recover the overcharges that persons who purchased Ambetter plans incurred as a result of the defendants’ deceptive practices, as well as an injunction ordering Centene and its affiliate companies to stop the alleged unlawful conduct.
About Wexler Boley & Elgersma LLP
Wexler Boley & Elgersma is a high-stakes litigation law firm with a commitment to excellence and the achievement of meaningful relief for those we serve. Based in Chicago, WBE has extensive experience in antitrust, business & commercial, and complex class action litigation in both state and federal court. More information is available at http://www.wbe-llp.com or 312-346-2222.
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