Centene Corporation, the largest carrier on the Health Insurance Marketplace and the largest Medicaid Managed Care Organization in the United States, is committing a massive healthcare fraud through sales of its health insurance product called Ambetter. Centene sells Ambetter insurance plans that have very few, if any, participating doctors or hospitals in their networks. Worse, Centene falsifies its lists of in-network providers, representing to potential customers that their doctor is in-network or that the plan provides options. Only when a participant attempts to use their doctor or hospital do they discover that they do not participate in Centene’s insurance plan.
For example, Cynthia Harvey lives in the Spokane, WA area. In December 2016, she purchased an Ambetter plan from Centene on the Washington Health Insurance Marketplace. In 2017, she had to make a trip to the emergency room. She was later billed $1,544 for that visit. It was only after she received treatment that she discovered not only that the doctor who treated her was out-of-network, but also that Centene had no emergency room physicians in-network in the entire Spokane area.
Likewise, Steven A. Milman, who lives in Texas, also signed up for Centene’s Ambetter plan, paying over $1,200 per month for himself and his wife. He selected the plan after looking at the list of available in-network providers and finding that a particular clinic was in Ambetter’s network. He soon found out that none of the doctors at that clinic was in-network. Further, after many efforts to get assigned to a primary care physician, he discovered that his assigned doctor was an obstetrician/gynecologist, who, of course, does not treat men.
Last month, Washington’s Insurance Commission briefly ordered a unit of Centene to stop selling 2018 plans in Washington. The commission found that the company failed to cover enough doctors and other care providers as required under the Affordable Care Act.
On January 11, 2018, Terrell Marshall Law Group and three other law firms filed a lawsuit against Centene, taking issue with its false statements. Like the Insurance Commissioner, the lawsuit claims that Centene’s actions violate the Affordable Care Act and consumer protection laws in Washington and Texas.
To read the complaint, click here.
To read about the case in The New York Times, click here.
To read the press release, click here.