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Identifying High Risk Clients
Identifying High Risk Clients

Ensure you obtain sufficient consumer consent before enrolling clients.

Written by Joseph Gefroh
Updated over a week ago

HealthSherpa is rolling out functionality to help Agents identify clients deemed a "high risk". Clients that are "high risk" are likely to have enrollments submitted by other Agents within the current plan year.

When searching for a consumer using our Marketplace search and claim functionality, we will use an algorithm to determine whether the client is likely to have been submitted by another Agent, and will display a banner informing you if a client is deemed high risk.

Remember that CMS regulations and your individual market agreement require that you must personally verify consent with the consumer prior to any application submission or change.

Why is HealthSherpa highlighting this?

When Consumers have their marketplace applications submitted or changed without their explicit consent, it causes significant real-world harm. We have heard of instances where:

  • Consumers had to cancel their planned medical procedures when an application submission they did not authorize changed their plan, leading to a loss of coverage.

  • Consumers lost their legitimate subsidy eligibility, requiring back-payment of thousands of dollars in taxes.

Such events are extremely harmful to the people we serve.

When does this occur?

There are several legitimate reasons why a consumer might have application records with multiple agents; for example, if they are a dependent aging out of coverage, or have moved to a new state. However, one of the primary reasons a client may be identified as "high risk" is if the Consumer's information was obtained by the Agent/Agency from a third-party Lead Vendor.

Manufactured consent. Many Lead Vendors obtain their information from online forms, web scraping, or data harvesting, and manufacture "consent" through practices such as solicitations on social media or advertisements offering monetary rewards for providing consent. CMS guidance notes that these forms of consent are generally NOT considered sufficient for the purposes of enrolling in health coverage. Consumers are often unaware that they are even signing up for health coverage in these situations, leading to fraudulent enrollment activity.

Non-exclusive leads. Certain lead vendors may also re-sell the same client's information to multiple purchasers, further exasperating the issue as many different Agents attempt to submit the same consumer.

We recommend Agents be very diligent about the source of their leads, and ensure they have personally obtained full consumer consent prior to submission. Agents that believe their consumer's information may have ended up on a lead list are encouraged to speak with their consumer directly to identify how this might have occurred and help them mitigate any potential consequences.

Obtaining consumer consent for leads or clients obtained through online forms

In cases where consumers initiate a relationship by providing information through an online form via a website, social media, or marketing survey response, you must follow up with the consumer to personally confirm consent.

This consent can take the form of an in-person conversation, phone call, text message, or email. However this conversation occurs, agents are required to document the interaction. HealthSherpa offers active consent tools to help agents comply with requirements to document consent and ensure the consumer has reviewed and verified the accuracy of their application information.

Does the banner appearing always indicate that a consumer has been fraudulently enrolled?

No. There are certain cases (e.g. a dependent aging out, moving states, etc) where it is appropriate that a consumer may appear to be working with multiple agents. However, these cases are rare, and we would recommend checking with your consumer to ensure this isn’t what’s causing them to be flagged.

How should we process a change for a client if this banner appears?

You should reach out to the client to confirm whether you are the preferred agent. As a reminder, if you purchased a lead, even if it came with consent documentation, you are required to personally confirm consent with the client before taking action on their application.

If we’re the agent and this banner appears, how do we revoke the other agent’s access?

You should reach out to the client to confirm whether you are the preferred agent. As a reminder, if you purchased a lead, even if it came with consent documentation, you are required to personally confirm consent with the client before taking action on their application.

In some cases, the banner may show because a client has duplicate applications. The correct way to resolve this is to confirm with the client whether any duplicate applications are expected (e.g. due to dependent aging out, a move, or another legitimate reason) and ensure any unexpected duplicate applications are canceled/terminated. We recommend doing this by calling the call center at 1-800-318-2596. The Marketplace Support team may be able to retroactively terminate any duplicate coverage and minimize repercussions to the consumer. If the duplicate applications are all legitimate, no action is needed.

Can we block other agents from accessing/ making changes to this application?

If other agents have been accessing this application fraudulently, you should follow HealthSherpa, CMS, and State DOI complaint processes to report them. Note that even if banned from HealthSherpa, an agent may still be able to resubmit an application on or a different EDE partner, due to the current structure of EDE Person Search requirements. The best way to ensure fraudulent actors are stopped is for CMS to revoke their access to the FFM.

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