Building Trust Through Action: A Blueprint for Reinforcing Integrity in ACA Insurance Markets

Last week at the ACA Summit in Las Vegas, representatives from the Centers for Medicare & Medicaid Services (CMS), alongside industry professionals and myself, an ambassador for the National Association of Benefits and Insurance Professionals (NABIP), gathered to tackle the critical issues of healthcare and policy. The Summit served as a vital forum for discussing strategies to curb exploitation by nefarious actors within the health insurance marketplace.

A Panel on Compliance and Ethics

A highlight of the Summit was a panel discussion featuring Joshua Van Drei, CMS Deputy Director of Division of Compliance, Oversight, & Monitoring, and I. The discussion centered on the necessity of explicit, informed consent from consumers, distinguishing this critical practice from mere terms of service agreements. Joshua outlined CMS's strategy to compliance, emphasizing a robust commitment to swiftly addressing deliberate fraud, while differentiating from unintentional non-compliance.

Strategic Enhancements for Robust Oversight

During the Summit, we discussed the need for a centralized reporting mechanism. This would involve a unified platform for reporting suspicious activities related to National Producer Numbers (NPNs), facilitating the sharing of information among CMS, state Departments of Insurance (DOIs), insurance carriers, and Direct Enrollment (DE)/Enhanced Direct Enrollment (EDE) vendors. Such a system would enhance the speed and efficiency of identifying and addressing bad actors, creating a comprehensive network of vigilance. Ally trade group, Health Agents for America, announced their newest tool for reporting fraud that helped with this very problem: https://www.hafamerica.org/fraud-reporting/

The importance of collaborative monitoring efforts was also emphasized. Establishing a shared system for monitoring NPNs under investigation could lead to quicker identification and resolution of fraudulent activities, ensuring a unified front against unethical practices. We did learn that there are some current barriers to a shared system, but that more engagement between regulatory bodies is likely to come ahead of the 2025 Open Enrollment.

Technological Advancements to Support Oversight

Technological enhancements were a significant focus, particularly in enhancing the technology brokers use to verify consumer information. An advanced search and verification system would require precise identity confirmation, thus deterring fraudulent enrollments and enhancing the security of consumer data.

Additionally, implementing algorithms to detect patterns indicative of fraudulent activities, such as an unusually high number of enrollments without SSNs or the repetitive use of identical contact information, was proposed. This would enable proactive investigations and interventions, further safeguarding the integrity of the insurance marketplace. I specifically requested that CMS monitor both NPN’s that have higher than statistically average applications without SSN’s, or lower than average Federally Facilitated Marketplace (FFM) application id’s from existing households (excessive APP creation). Additionally, I spelled out how tracking consumer changes at the household level to identify if a family has multiple, repetitive applications and could signify bad practices. Special Focus: Protecting Consumer Rights – Consent is not a power of attorney

The Summit also featured roundtable discussions where concerns were raised about consent forms resembling limited power of attorney. Reassurances were made that only specific, legally enforceable actions could be derived from these forms.

Recommendations and Future Steps

Notable suggestions from the event included limiting 150% Federal Poverty Level Special Enrollment Periods (SEPs) to once per year, requiring SEP documentation, and creating an optional security feature that allows consumers or brokers to require a full social security number for future application accesses. These measures aim to balance security with accessibility while closing loopholes used by bad actors for fraudulent enrollments.

Conclusion

The insights gained from the ACA Summit underscore ongoing efforts and future plans to secure the healthcare enrollment process. As we move forward, the adoption of these strategic and technological measures will ensure that the health insurance system remains a reliable and trustworthy resource for consumers, upholding the highest standards of integrity and professionalism in the industry. As an ambassador for NABIP, I am excited to bring these insights back and contribute to our ongoing advocacy for fair and secure healthcare practices. #ACASummit #HealthcarePolicy #NABIP #Medicarians