司法部起诉三家全国性健康保险公司与三家经纪机构：指其以数亿美元回扣换取联邦医保优势计划投保并歧视残障受益人
美国司法部2025年5月1日宣布，美国已向位于马萨诸塞州萨福克县波士顿（Boston）的联邦地区法院提起《虚假申报法》诉讼，起诉对象包括全美三家最大的健康保险公司与三家大型保险经纪机构。
被诉保险公司为 Aetna Inc. 及关联公司、Elevance Health Inc.（前称 Anthem）与 Humana Inc.；被诉经纪机构为 eHealth, Inc. 及一家关联公司、GoHealth, Inc. 与 SelectQuote Inc. 美国指控称，2016年至至少2021年间，上述保险公司向上述经纪机构支付了数亿美元非法回扣，换取经纪机构把受益人引导投保其联邦医保优势计划（Medicare Advantage）。
司法部称，联邦医保优势计划又称联邦医保 C 部分，受益人可选择投保 Aetna、Anthem 与 Humana 等私营保险公司提供的计划。许多受益人依靠保险经纪人帮自己挑选最合需要的计划；但诉状指，被诉经纪机构没有作不偏不倚的把关人，而是把受益人引向回扣给得最多的保险公司的计划，不论该计划是否适合受益人。诉状还指，经纪机构激励自家雇员与代理人按回扣高低卖计划、组建只能卖特定计划的代理人团队，有时甚至拒绝销售回扣不足的保险公司的计划。
美国还指控，Aetna 与 Humana 各自与经纪机构被告合谋，歧视它们认为盈利较少的残障联邦医保受益人：两家公司被指以扣住回扣相要挟，施压经纪机构少让残障受益人投保其计划。美国指，在这种金钱激励下，经纪机构或其代理人拒绝接受残障受益人的转介，并有策略地把残障受益人引离 Aetna 与 Humana 的计划。
司法部民事司副助理部长 Michael Granston 说：「试图靠回扣牟利的医疗保健公司将被追究责任。我们致力于根除联邦医保优势计划保险公司与保险经纪机构破坏联邦医疗保健计划与所服务患者利益的违法做法。」马萨诸塞州联邦检察官 Leah B. Foley 说，受益人被指被引向未必最合其利益、而是最合保险公司利益的计划，令人担忧；为残障可能让受益人较不盈利就把人引开的做法「更加令人发指」，其办公室将继续积极调查起诉这类行为、保护联邦医保受益人与弱势美国人的权利。
本案最初是依《虚假申报法》的举报人（qui tam）条款提起的诉讼；该法允许私人代美国提起诉讼并分享追回款，美国可介入并接手诉讼，本案美国已经介入。被告若被判违反该法，美国可追回三倍损失加适用罚款。本案由司法部民事司商业诉讼处欺诈科与马萨诸塞州联邦检察官办公室承办，卫生与公众服务部监察长办公室与联邦调查局协助，案名为 United States ex rel. Shea v. eHealth, et al.，案号 21-cv-11777。诉状中的主张仅为指控，尚未有责任认定。（来源：美国司法部）
Justice Department Sues Three National Health Insurers and Three Brokers Over Alleged Medicare Advantage Kickbacks and Discrimination Against Disabled Beneficiaries
The Justice Department announced on May 1, 2025, that the United States had filed a complaint under the False Claims Act in federal court in Boston, Suffolk County, Massachusetts, against three of the nation's largest health insurance companies and three large insurance broker organizations.
The defendant insurers are Aetna Inc. and affiliates, Elevance Health Inc. (formerly known as Anthem), and Humana Inc.; the defendant brokers are eHealth, Inc. and an affiliate, GoHealth, Inc., and SelectQuote Inc. The United States alleges that from 2016 through at least 2021, the defendant insurers paid hundreds of millions of dollars in illegal kickbacks to the defendant brokers in exchange for enrollments into the insurers' Medicare Advantage plans.
Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may choose to enroll in health care plans offered by private insurance companies such as Aetna, Anthem and Humana, the Justice Department said. Many beneficiaries rely on insurance brokers to help them choose a plan that best meets their needs. Rather than acting as unbiased stewards, the defendant brokers allegedly directed beneficiaries to the plans offered by insurers that paid brokers the most in kickbacks, regardless of the suitability of the plans. According to the complaint, the broker organizations incentivized their employees and agents to sell plans based on the insurers' kickbacks, set up teams of agents who could sell only those plans, and at times refused to sell plans of insurers that did not pay sufficient kickbacks.
The United States further alleges that Aetna and Humana each conspired with the broker defendants to discriminate against Medicare beneficiaries with disabilities whom they perceived to be less profitable. Aetna and Humana allegedly did so by threatening to withhold kickbacks to pressure brokers to enroll fewer disabled beneficiaries in their plans. In response, the brokers or their agents allegedly rejected referrals of disabled beneficiaries and strategically directed disabled beneficiaries away from Aetna and Humana plans.
"Health care companies that attempt to profit from kickbacks will be held accountable," said Deputy Assistant Attorney General Michael Granston of the Justice Department's Civil Division. "We are committed to rooting out illegal practices by Medicare Advantage insurers and insurance brokers that undermine the interests of federal health care programs and the patients they serve." U.S. Attorney Leah B. Foley for the District of Massachusetts said it was concerning that beneficiaries were allegedly steered toward plans not necessarily in their best interest but in the insurers', and called the alleged efforts to drive beneficiaries away because their disabilities might make them less profitable "even more unconscionable," adding that her office would continue to investigate and prosecute such conduct aggressively and protect Medicare beneficiaries and vulnerable Americans.
The lawsuit was originally filed under the qui tam, or whistleblower, provisions of the False Claims Act, under which private parties can file an action on behalf of the United States and receive a portion of any recovery, and the United States may intervene and take over the action, as it has done here. If a defendant is found liable, the United States may recover three times its losses plus applicable penalties. The Justice Department's Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney's Office for the District of Massachusetts are handling the matter, with assistance from the Department of Health and Human Services Office of Inspector General and the FBI. The case is captioned United States ex rel. Shea v. eHealth, et al., No. 21-cv-11777. The claims asserted in the complaint are allegations only; there has been no determination of liability. (Source: U.S. Department of Justice)
来源：美国司法部
发布：GSM·美国（发布链接）
图片来源：图：位于马萨诸塞州波士顿（Boston）的 John Joseph Moakley 美国联邦法院大楼（资料图），本案诉状即向该院所在的马萨诸塞联邦地区法院提起。Beyond My Ken 摄，CC BY-SA 4.0，经 Wikimedia Commons。 / Photo: The John Joseph Moakley United States Courthouse in Boston, Massachusetts (file photo), home of the U.S. District Court for the District of Massachusetts, where the complaint was filed. Beyond My Ken, CC BY-SA 4.0, via Wikimedia Commons.
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