Skip to main content

Handling a suspected unauthorized enrollment or fraud

Learn what agents can do when a consumer’s application may have been claimed, changed, or submitted without consent.

Siga las instrucciones aquí para traducir esta página a otro idioma usando Chrome.

If an agent suspects a consumer's application has been claimed or modified without consent, taking prompt action helps protect the consumer’s coverage and supports appropriate servicing by the authorized agent.

Agents will follow the below steps when handling a suspected unauthorized enrollment or fraud.

Step 1: Confirm the situation with the consumer

Confirm whether the consumer has worked with a different agent or broker.

Determine whether the consumer may have:

  • Worked with another agent or broker

  • Submitted their information through an online form

  • Submitted their information through another enrollment website

  • Authorized anyone else to search for, update, or submit their Marketplace application

Step 2: Verify consent documentation

The Centers for Medicare & Medicaid Services (CMS) requires agents to document that they have consent from Affordable Care Act (ACA) consumers when providing assistance. To support agents in meeting CMS consent requirements, consent tools are built into the HealthSherpa account.

Agents should confirm consent is documented before taking further action.

Step 3: Reach out to the other agent

If the consumer confirms they did not work with another agent, reach out to the other agent to attempt resolution.

When contacting the unauthorized agent, it may help to explain that consent has been documented to support the authorized agent’s role.

Unauthorized activity can include:

  • Conducting a search for consumer applications using approved Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) websites

  • Enrolling consumers without their explicit consent

  • Making unauthorized changes to consumer applications without their explicit consent

  • Inappropriately accessing CMS systems

Step 4: Report unauthorized activity

Unauthorized enrollment submissions or application changes should be reported to the appropriate organizations.

Suggested organizations include:

The Marketplace

The term Marketplace, also called an exchange, can refer to either the Federally Facilitated Marketplace (FFM) or a State-based Marketplace (SBM). The type of Marketplace a consumer uses depends on the state where they live.

Unauthorized activity should be reported to the appropriate Marketplace help desk. Agents assisting consumers in states using the FFM can contact the FFM Producer Assister Help Desk by email at FFMProducer-AssisterHelpDesk@cms.hhs.gov.

When reporting to the Marketplace:

  • Include the Marketplace application ID

  • Include relevant National Producer Numbers (NPNs)

  • Do not include Personally Identifiable Information (PII) or Protected Health Information (PHI)

The Marketplace application ID can be found on the consumer’s eligibility letter and is displayed within the consumer’s Details page in the HealthSherpa account.

National Association of Insurance Commissioners (NAIC)

Agents can report suspected fraud using the National Association of Insurance Commissioners (NAIC) Online Fraud Reporting System. This connects the agent with the applicable state Department of Insurance (DOI) to file a formal report.

When reporting to the NAIC:

  • Do not include PII or PHI

  • Use identifiers such as application numbers or NPNs

Carrier

Contact the carrier to ask how they can assist or advise on the suspected unauthorized activity.

The Agent of Record (AOR) reflected in the HealthSherpa account may not match the AOR at the carrier level, as each carrier applies its own rules when determining AOR.

HealthSherpa

To report suspected fraud directly to HealthSherpa, contact the HealthSherpa Fraud Prevention Unit (FPU). The FPU team can be reached by email at fraud_prevention@healthsherpa.com or by phone at (855) 977-0525.

HealthSherpa reviews reports in the order they are received. Do not send consumer PII or PHI through an unsecured method.

Agents should provide accurate, relevant information and follow all privacy and confidentiality guidelines when reporting suspected unauthorized activity.

Step 5: Encourage consumer action

If the agent and consumer suspect unauthorized activity by a third-party, encourage the consumer to report the suspected fraud directly.

Encourage the consumer to report suspected fraud to:

  • Their carrier

  • Their state DOI

CMS resources

For more information from CMS, review these resources:

Additional resources

For help using HealthSherpa or for other assistance, contact Agent Support. Agent Support is available by phone at (888) 684-1373, by email at Agent_Support@HealthSherpa.com, or by chat directly from your account.

Did this answer your question?