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Government Security United States IT

Affordable Care Act Exchanges Fail To Detect Counterfeit Documentation (atr.org) 246

Tulsa_Time writes with this excerpt of an account from the (unapologetically partisan) Americans for Tax Reform about a report released by the Government Accountability Office in which "application and enrollment controls on the federal exchange and two state exchanges (California and Kentucky)" were investigated by supplying false information; in each case, the investigators were able to obtain and activate health insurance through the exchanges. A slice: Ten fictitious applicants were created to test whether verification steps including validating an applicant's Social Security number, verifying citizenship, and verifying household income were completed properly. In order to test these controls, GAO's test applications provided fraudulent documentation: "For each of the 10 undercover applications where we obtained qualified health-plan coverage, the respective marketplace directed that our applicants submit supplementary documentation we provided counterfeit follow-up documentation, such as fictitious Social Security cards with impossible Social Security numbers, for all 10 undercover applications."
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Affordable Care Act Exchanges Fail To Detect Counterfeit Documentation

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  • I'm sure submitting false information on those forms is illegal. So, make sure all the people responsible go to jail.

    • by ShanghaiBill ( 739463 ) on Friday October 23, 2015 @07:50PM (#50791193)

      I'm sure submitting false information on those forms is illegal.

      Why should it be illegal? If you want to buy insurance for someone that doesn't exist, that is fine with me.

      • by ScentCone ( 795499 ) on Friday October 23, 2015 @08:08PM (#50791295)

        Why should it be illegal? If you want to buy insurance for someone that doesn't exist, that is fine with me.

        How about if in the course of applying, the fake person also describes a lifestyle that qualifies them for completely subsidized care that other people get to go to work every day to buy for them? This is no different than any other of benefit fraud.

        • by jopsen ( 885607 ) <jopsen@gmail.com> on Friday October 23, 2015 @08:41PM (#50791447) Homepage

          How about if in the course of applying, the fake person also describes a lifestyle that qualifies them for completely subsidized care that other people get to go to work every day to buy for them? This is no different than any other of benefit fraud

          Well, it is different, an insurance is just paper (contract), when you obtain the contract to benefit a person that doesn't exist, you've acted in bad faith and obtained a contract that is invalid by nature.

          So your chances of successfully upholding the contract is slim. That said, yesm the fake people could probably get some care, before the private insurance company starts looking at the details... This is another problem with private insurance, if there is a problem with contract the insurance company will declare it invalid (but they won't do so before you file a claim, ie. only when do it when you the insurance).

          But yes, this is great :)
          Note. insurance contracts in the US are in my experience, super sketchy have through my employer and had to fight very hard to get any kind of actual paper... and I'm still not satisfied that I have sufficiently strong contract to sue my insurance provider should it come to that, and certainly not if my employer decided not to look out for my interest (which I don't have contract saying they will). So legally speaking I'm is a poor standing (despite working for tech company, and having an good PPO plan).

        • How about if in the course of applying, the fake person also describes a lifestyle that qualifies them for completely subsidized care

          Who cares? Now they have a FREE insurance policy that is worth $0 because it is in the name of someone that doesn't exist. Since no doctor is going to treat someone whose name and SSN doesn't match their insurance card, this would cost the taxpayers nothing.

          • Or it's in the name of someone who DOES exist, but because of a fake SSN and other information - you cannot verify the fact they earn above the subsidy levels, so they can get subsidized insurance.
          • It';s potentially very useful for illegal immigrants, for drug addicts faking a medical record to get pain opiates, for fake billing by medical staff or insurance companies, for getting treatment for conditions your limited medical insurance is unwilling to provide for statistical reasons, and to obtain and and resell expensive medications on the black market.

          • Re: (Score:2, Funny)

            by ScentCone ( 795499 )
            You're foggy on the whole fraud thing, aren't you? Fraudulent medical billing and the provision of services to people who aren't supposed to get them (because they're posing as someone else, or getting someone else's opiate prescription, etc) is rampant. In the billions of dollars. Fake IDs, stolen identities ... these are front and center in massive, ongoing, and routine fraud. Very popular in the illegal immigrant set, who also receive hundreds of millions in fraudulently claimed incomes tax refunds and c
      • by hawguy ( 1600213 ) on Friday October 23, 2015 @08:11PM (#50791321)

        I'm sure submitting false information on those forms is illegal.

        Why should it be illegal? If you want to buy insurance for someone that doesn't exist, that is fine with me.

        But are you ok with them submitting and getting paid for claims for that fictitious person? Buying insurance for a fictitious person should be as illegal as submitting claims for them, so if you find that someone has bought 1000 policies for fictitious people, you have a tool to stop them before they start submitting claims.

        • But are you ok with them submitting and getting paid for claims for that fictitious person?

          Claims have to be submitted through a medical office, which checks your ID. Besides, if you want to submit false claims, you can do that as easily for a real person as a fictitious person. The only difference is that the real person will have much less difficulty cashing the checks. Banks also check IDs.

          Sorry, but I just don't see the point in getting an insurance policy for a non-existent person.

          • by hawguy ( 1600213 )

            But are you ok with them submitting and getting paid for claims for that fictitious person?

            Claims have to be submitted through a medical office, which checks your ID. Besides, if you want to submit false claims, you can do that as easily for a real person as a fictitious person. The only difference is that the real person will have much less difficulty cashing the checks. Banks also check IDs.

            Sorry, but I just don't see the point in getting an insurance policy for a non-existent person.

            But can you see the point in not allowing it?

          • by khallow ( 566160 )

            Claims have to be submitted through a medical office, which checks your ID. Besides, if you want to submit false claims, you can do that as easily for a real person as a fictitious person. The only difference is that the real person will have much less difficulty cashing the checks. Banks also check IDs.

            Unless they don't do that say because you bribed them.

          • But are you ok with them submitting and getting paid for claims for that fictitious person?

            Claims have to be submitted through a medical office, which checks your ID. Besides, if you want to submit false claims, you can do that as easily for a real person as a fictitious person. The only difference is that the real person will have much less difficulty cashing the checks. Banks also check IDs.

            Sorry, but I just don't see the point in getting an insurance policy for a non-existent person.

            Offhand, if you're running this scheme for money then the doctor is in on it--one of the problems with traditional Medicare/Medicaid fraud is that the patient is an actual, real person who can be asked if you performed the procedures you billed for. As you might notice, this is a real thing and none of the problems you've mentioned should exist--the doctor is cashing the checks, the doctor is generating the false claims.

            Now, you can also use this so somebody with fake ID--something that exists, and I'm not

      • by khallow ( 566160 ) on Friday October 23, 2015 @09:43PM (#50791667)

        Why should it be illegal? If you want to buy insurance for someone that doesn't exist, that is fine with me.

        Consider this scenario:
        1) Create a pile of fake people.
        2) Conspirator at insurance company gets them insurance.
        3) Siphon money out of the company as commission bonuses.

        If instead, you control the insurance company, then you can rake in the subsidies. Fake low income people, subsidized by Uncle Sugar, who never need medical care would be great for the bottom line.

    • Arrest the GAO? (Score:5, Insightful)

      by cirby ( 2599 ) on Friday October 23, 2015 @07:55PM (#50791225)

      You want to arrest the GAO for fraud, for doing their actual job?

      That's who wrote the report. Americans for Tax Reform just reported on it.

    • by jedidiah ( 1196 ) on Friday October 23, 2015 @09:22PM (#50791573) Homepage

      Forget about illegal. The system couldn't even figure out that the details were completely invalid and fictitious. It's unable to do the slightest bit of basic sanity checking.

    • Wow. Die hard Obamabot. It's amazing you can breath, with your head shoved so far up his ass.

  • by rmdingler ( 1955220 ) on Friday October 23, 2015 @07:55PM (#50791223) Journal
    Judging by the frequency with which the courts around here have a "Tampering With Gov't Records" case before them, I would venture a guess this sort of lie for profit is universally problematic for assistance programs.

    This is the typical charge for obtaining gov't assistance under many different false pretenses, but typically under-reporting income.

    I, for one, would prefer to keep the trust but verify nature of the programs... the aim is not to catch fraudsters straight away, but to help folks when they need it. Sure, some will game the system, but likely not for an extended period before getting caught with the hand in the cookie jar.

    • Only Trust (Score:5, Insightful)

      by SuperKendall ( 25149 ) on Friday October 23, 2015 @08:25PM (#50791379)

      I, for one, would prefer to keep the trust but verify nature of the programs

      I would if there was any "verify". There was not.

      People claim the U.S. should emulate Europe, but it seems they go mysteriously silent when it comes to emulating the controls that Europe has to make healthier care voting work to prevent fraud. If a system has endemic fraud it will eventually fail.

    • by AHuxley ( 892839 )
      Yes the "trust but verify nature of the programs" should have been done.
      It could have all been fixed with a 100 point check like system https://en.wikipedia.org/wiki/... [wikipedia.org]
      Bring in any mix of a birth certificate, passport like paperwork to show citizenship, refugee docs, licence or permit, local government docs, utility bill, rent agreement.
      If a person has problems finding or updating the paperwork, help them get some of the above sorted out. The REAL ID Act https://en.wikipedia.org/wiki/... [wikipedia.org] will be the n
  • by Anonymous Coward

    If they are running the checks it means they are using them as a "manual override" against their internal data(which may be flawed). These checks exist to redistribute wealth via price discrimination according to a "means" test. If a person can claim to make less money than they actually do: the idea of selling a commodity below market price falls apart and attempts at rationing quickly become unsuccessful.

    If the auditors scammed them successfully, that is "smoke" to the fire of a process breakdown. Gasp! I

  • Easy answer (Score:5, Insightful)

    by rsilvergun ( 571051 ) on Friday October 23, 2015 @08:29PM (#50791397)
    Single payer. Book it done.
    • by spauldo ( 118058 )

      I agree.

      Too bad it'll never happen here.

    • Which is exactly the outcome ACA was designed for: a broken system leads to future single-payer, since people will accept that when anything looks brilliant in comparison to ACA.
  • by Tablizer ( 95088 ) on Friday October 23, 2015 @08:40PM (#50791443) Journal

    Quality/accuracy auditing takes money. There's usually a brake-even point where the savings from catching problems is less than the cost of auditing as more auditors are added. We'd need more info to know where the break-even point is.

    I suspect it may not be a real problem as long as they check credentials when an expensive procedure or treatment is done, such as surgery or an expensive medication.

    Before such, as long as the "fakes" pay their insurance fees, they are not a (significant) cost drain to the system.

    In short, fraud happening on the enrollment end may not be a practical problem.

  • Yes, shame on the ones that dared to provide help for fellow human beings.

    While we speak about lost money, how much did we pour into banks?

  • You don't need to do hardly any up front auditing and you collect premiums. Make a single claim or claims over a trivial amount and then you do get audited - likely after someone has made payments under these fake accounts. The insurance company then just keeps all the money and cancels the contract.

    Hell they do this now to honest people - they are experts at setting up a one sided contract and simply not paying for the i meat of reasons when the payout time comes.
  • by cpm99352 ( 939350 ) on Saturday October 24, 2015 @01:00AM (#50792209)
    I worked for seven years in the medical insurance business (so glad to have left the field!) and the ignorance seen in many high-rated posts here is astounding.

    1. GAO report, so no fraud
    2. Even if someone wanted to fraudulently create an applicant, I don't see the problem, as long as they don't submit a claim. What's wrong w/ additional premium? (I will ignore the geeky underwriters, as I understand their position, but haven't seen any relevant objections so far about messing up the statistics.)
    3. You cannot begin to appreciate the stupidity of pretty much everyone in the insurance business - so the inability to do very basic SSN validity checking comes as no surprise at all.

    I left the year ACA came into effect, so got to experience the fun as we tried to implement insurance plans that Congress had not defined. See, ACA went into effect 2014, but we (that is, insurance companies) didn't have black letter law or even Federally-defined policies established (on many different fronts) until way past Jan 2014. How can you determine policies if underwriters don't know what the rules are???

    Biut what continues to be under-reported is what a complete disaster/fail the back-office procedures are. Are we finally able to determine if someone is eligible? When I left, there was no way to tell if an applicant was qualfied for subsidies under the various arcane income rules.

    If I were dictator, I'd immediately force hospitals and pharmaceutical companies to fall under the anti trust [wikipedia.org] laws that everyone else has to follow. The high-deductible plans were created under the assumption that consumers would be motivited to shop around for the cheapest deal. But, it is impossible to get an actual quote for a procedure. If you require hospitals to produce a rate sheet that applies to all, and permitted people to import drugs from anywhere in the world, a massive amount of money could be saved.

    But this cuts into rx profits, and we can't have that.
  • When my wife attempted to sign up for coverage they repeatedly asked for the same documentation and when they received it, they said that they couldn't find her in the system, so it does weed out legitimate people, just apparently not people with fake documentation.

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