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GAO: Federal PPACA exchanges are open to fake people

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Investigators at the U.S. Government Accountability Office (GAO) created 12 fake health insurance test applicants and, for now, at least, have gotten qualified health plan (QHP) coverage for 11 through the public exchanges run by the U.S. Department of Health and Human Services (HHS).

All of the fake insureds are getting the Patient Protection and Affordable Care Act (PPACA) advance premium tax credit subsidy, which is supposed to go to QHP holders with incomes from 100 percent to 400 percent of the federal poverty level. Nine are getting the cost-sharing reduction subsidy, which is supposed to go to QHP holders with incomes from 100 percent to 250 percent of the federal poverty level, according to Seto Bagdoyan, a GAO acting director.

Bagdoyan described the GAO’s investigation in a written report for Rep. Charles Boustany, R-La., chairman of the House Ways and Means oversight subcommittee, and other subcommittee members. The subcommittee is holding a hearing today on exchange application verification procedures.

The GAO investigators did not try to compare QHP identity and eligibility verification efforts with application verification efforts at other government health programs, such as Medicare or Medicaid, or with application vetting efforts at traditional private health insurers.

See also: Republicans question Sebelius exchange system certification

The GAO investigators backed up the 12 fake system testing applications with counterfeit documents created using “publicly available information” and “publicly available hardware, software and materials.” The HHS-run exchanges rejected one of the 12 fake test applicants outright, because that fake individual provided no Social Security number. The HHS exchanges have fully approved one fake applicant, but they asked for more documentation for the other 10 approved fake applicants, and they are still reviewing the documents, Bagdoyan said.

The GAO also tried to see whether HHS exchange helpers would encourage applicants to lie about income to help them qualify for subsidies. The GAO created six fake applicants for that project.

The GAO investigators had trouble getting the fake applicants enough in-person assistance to complete that test.  

  • One Navigator told an undercover investigator that the investigator would have to make an appointment in advance, by phone. When the investigator was unable to reach the Navigator by phone, the investigator tried to visit the Navigator in person. The Navigator refused to see the investigator.
  • A second Navigator said it only helps people with applications in process on-line, and it could not find the on-line application, because the HHS enrollment system was down.
  • One of three in-person assisters is a health care facility. It said it only helps people who have bills from its facility.
  • A second in-person assister said it only helps people who expect to get Medicaid.
  • For another fake applicant, an investigator got no help from one in-person assister’s location. But the investigator visited two other locations and eventually got correct advice about income from an in-person assister.

For the cases involving fake people who sought in-person assistance, investigators called the call center. Call center reps eventually did give the investigators correct income eligibility information during the telephone calls, Bagdoyan said.

If the HHS exchanges could tell who had paid premiums, that would probably help with analyzing application verification efforts, but HHS has no system for identifying applicants who have and have not paid their premiums in place, and it has no timeline for completing and deploying such a system, Bagdoyan said.

See also: What if you lie to a PPACA exchange?