DOJ Files Major Medicare Fraud Lawsuit Against National Health Insurers

by Caroline Soper and Madison A. Gregg

Kickback Allegations Against Major Insurers and Brokers

On May 1, 2025, the United States filed a False Claims Act (“FCA”), 31 U.S.C. § 3729 et seq., lawsuit against Aetna, Elevance Health (formerly known as Anthem), and Humana – three of the largest insurance companies in the country – as well as eHealth, GoHealth, and SelectQuote – three of the largest insurance broker organizations in the country.

The Medicare fraud lawsuit alleges that from 2016 through 2021, the insurance companies (Aetna, Elevance, and Humana) paid hundreds of millions of dollars in kickbacks to the insurance brokers (eHealth, GoHealth, and SelectQuote), in exchange for the brokers enrolling beneficiaries in the insurers’ Medicare Advantage plans.  The Government explained that this misconduct violated the Anti-Kickback Statute (“AKS”), 41 U.S.C. § 1320a-7b(b), and led to the submission of false claims in violation of the FCA.

Medicare Advantage and Broker Influence

If an individual is eligible for Medicare Part C, which is also known as Medicare Advantage, they can choose to enroll in Medicare Advantage plans that are offered through private insurance companies.  Many enrollees choose to go through an insurance broker, such as the three named in the complaint, to find a plan that suits them best.

Legal Framework: FCA and AKS Violations

The FCA penalizes any person who “(A) knowingly presents, or causes to be presented, a false or fraudulent claims for payment or approval; (B) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (C) conspires to commit a violation of subparagraph (A) [or] (B).”  31 U.S.C. § 3729(a)(1).

In order to submit claims to the Government for payment, Medicare Advantage insurers are required to comply with the AKS, which bars the solicitation, receipt, offer, or payment of “illegal remunerations” (kickbacks).  41 U.S.C. § 1320a-7b(b).  Therefore, when an insurer violates the AKS by paying kickbacks (and when a broker violates the AKS by accepting kickbacks), it is a per se violation of the FCA.
Broker Behavior and Sales Tactics

The complaint alleged that instead of offering Medicare Advantage beneficiaries unbiased advice and information to allow them to find a plan which suits them best, the brokers directed enrollees to the plans of whichever company was paying the most in kickbacks.

The complaint further alleges that employees of the insurance brokers were incentivized to sell the plans of the companies which paid the most in kickbacks; that the brokers set up teams of insurance agents whose role was to only sell certain plans that were paying the broker kickbacks; and that the brokers would even refuse to sell the insurance plans of other companies which failed to pay them kickbacks.

According to the complaint, a broker executive told Aetna representatives directly that their plan was unattractive to enrollees and that they needed to offer the brokers “more money” to “help drive sales.”

Discrimination Against Disabled Beneficiaries

The United States also claims that the named insurance companies and brokers conspired to prevent people with disabilities from signing up for plans with the named insurance companies.  Allegedly, Aetna and Humana “threaten[ed] to withhold kickbacks to pressure brokers to enroll fewer disabled Medicare beneficiaries in their plans.”  This means that disabled beneficiaries were funneled away from Aetna and Humana – despite the fact that “Medicare Advantage is a guaranteed issue program for all Medicare-eligible beneficiaries,” which means “federal law bars insurers from favoring enrollment of healthier beneficiaries and discriminating against beneficiaries with disabilities who might be less profitable.”

FAQ About Medicare Fraud Lawsuits