Report Insurance Fraud

With the rise of fraud and scams surrounding the health insurance industry, Health Agents for America (HAFA) has created this reporting form and compiled this free guide for all agents and consumers regarding what actions to take when fraud, scams or deceptive marketing practices have impacted a member’s health insurance policy through the Health Insurance Marketplace or other state-based exchanges. In aligning with the core principles of HAFA, we strive to keep our industry an ethical, professional and trusted resource for consumers seeking health insurance services. It is important for agents and consumers alike to be vigilant regarding suspicious activity affecting their Marketplace application, and take proper action when necessary.

Health Agents for America, Inc. “HAFA” was formed in November 2012 to answer a need for Independent Health Agents to provide exclusive representation, in order to address matters such as commissions, the ACA and our inclusion in the Marketplace(s). If you appreciate our efforts and want to offer support or join our cause, please consider becoming a member HERE! You will have access to many more resources and important legislative updates affecting our industry now and in the future.

STEP 1: Confirm with the consumer they have not worked with a different agent. This includes submitting their information on any online form. Before submitting a fraud complaint, you should verify that the other agent did not get proper authorization from the consumer. Agents are required to document consent prior to working with a client or accessing their application, AND also document that the consumer has reviewed and confirmed their application information is accurate (45 C.F.R § 155.220(j)(2)(ii)(A)(1)-(2)). Read about the current rules and regulations in the 2022 Understanding Marketplace Compliance Rules & Regulations slides and the 2023 Understanding Key CMS Rules and Regulations to Maintain Marketplace Compliance slides.

STEP 2: Revoke Access in Writing. Once you have the AOR name/NPN of the other agent, you can find their license and/or contact information by using Licensee Look Up tools such as State Based Systems or Florida Licensee Search, for example. We recommend that the consumer sends a written request to the other party that formally revokes any further access to their application(s) on the Marketplace, and demands that all of their contact information be deleted from their systems.

STEP 3: Inform the Marketplace Call Center. CMS requests that agents/brokers conduct a 3-way call with the consumer and the Marketplace Call Center at 1-800-318-2596 to report the unauthorized changes.

STEP 4: File A Report. If the above steps reveal that another agent has worked on the consumer’s application without their consent, please complete the form provided below. Once this form is submitted, a copy of your responses will be automatically emailed to CMS, HealthSherpa and your State’s DOI. Please do not include any PII or PHI in your report. Use identifiers such as application numbers or NPNs instead.

The contents of this webpage are for informational purposes only and are not meant to be nor should be construed to be legal advice by HAFA as well as any of its employees, volunteers or members. If you require legal advice, please contact your legal counsel.

More Ways to Report Fraudulent Activity to the Proper Authorities

By filling out our form above, you have successfully filed reports with FFM Help Desk, HealthSherpa Fraud Prevention Unit, and your State DOI (with the exception of the following states: CA, MT, NJ, and UT.) For additional ways to report fraudulent activity, please see the instructions below:

A. Health Insurance Marketplace (For Consumer Reporting): Call 1-800-318-2596 and say “report fraud.” Share your details with the representative. Note the representative’s name and the time of your call.

B. NAIC Online Complaint Form: You can use the National Association of Insurance Commissioners’ (NAIC) Online Fraud Reporting System (located here) to connect with the local Department of Insurance to file a report. Please do not include any PII or PHI in your report. Use identifiers such as application numbers or NPNs instead.

C. Enrollment Platform Complaint: It is important to report the situation to the enrollment platform/EDE partners involved. Please contact their agent services directly.

D. Insurance Carrier: We recommend sending an email or calling the carrier(s) to file a complaint and inform them of the situation. Be aware that the Agent of Record that you may see on the application may not reflect who the Agent of Record is at the carrier level. Each carrier may have their own rules on who they determine the agent of record to be. Again, please do not include any PII or PHI in your report. Use identifiers such as application numbers or NPNs instead.

E. Department of Health and Human Services (HHS) Complaint: Report online at HHS Fraud Report

F. Federal Trade Commission (FTC): File a report at FTC Report Fraud. This can also include filing reports for deceptive marketing and/or lead generation practices. Learn more about identity theft from the Federal Trade Commission here.

G. Local Police: If you believe a crime has been committed, you can also file a report with your local police department.

Join Us in Our Cause!

A. Help Preserve and Enhance the Role of the Independent Agent: Join us on the front lines in DC or sign up to support the efforts of those who can fight in your stead. Our mission is to be the leading advocacy association representing the interests of licensed insurance professionals in Washington, DC, and every state capitol. It is also to protect our industry by influencing public policy and educating independent insurance agents to better serve consumers.

B. Keep our Industry Ethical, Professional and Trusted: HAFA believes in the importance of trust between clients and agents. We have a commitment to uphold ourselves and others to the ethical standards established by the laws and standards that govern our industry.

C. Gain Access to Endless Resources and Important Legislative Updates: Supporting agents is a top priority for HAFA, including helpful agent resources. This includes access to forms and important legislative updates that affect our industry now and in the future.