September 2025 OIG Work Plan Update: Medicare Advantage Enrollment Under Scrutiny

The HHS OIG has added to their work plan an analysis of Medicare Advantage Enrollment. According to OIG, the Medicare Advantage program is vulnerable to schemes designed to increase Medicare Advantage organization (MAO) profits by improperly influencing enrollment. They explained that known examples of such schemes include enrolling people into MA plans without their consent, structuring incentive payments to agents to minimize enrollment of people with disabilities, and paying kickbacks to providers in exchange for enrollments.

For example, in May 2025, the United States filed a complaint under the False Claims Act (FCA) against three of the nation’s largest health insurance companies — Aetna Inc. and affiliates, Elevance Health Inc. (formerly known as Anthem), and Humana Inc. — and three large insurance broker organizations — eHealth, Inc. and an affiliate, GoHealth, Inc., and SelectQuote Inc. The complaint alleges 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. (see the following for a copy of the complaint https://www.justice.gov/opa/media/1398796/dl)  

Another example in the news was published in August 2025 (see: https://www.justice.gov/opa/pr/troy-health-inc-enters-non-prosecution-agreement-and-admits-fraudulently-enrolling-medicare).  This case involved a North Carolina-based provider of Medicare Advantage, Medicare Part D, and Dual Eligible Special Needs Plans. The company entered into a non-prosecution agreement with the Department of Justice (DOJ) to resolve a criminal investigation into a health care fraud and identity theft scheme involving the use of artificial intelligence and automation software to illegally obtain Medicare beneficiary information and fraudulently enroll beneficiaries into its Medicare Advantage plans. 

DOJ officials said the company “told low-income Medicare beneficiaries that it would use new technologies, including its proprietary artificial intelligence platform, to improve patient health outcomes. Instead, the company misused patient data to enroll beneficiaries in its Medicare Advantage plan without their consent.” 

In regards to the OIG Work Plan item description, the OIG believes these schemes put taxpayer dollars and Medicare enrollees' well-being at risk. To date, enrollment manipulation schemes have been identified primarily through whistleblowers, with minimal visibility into schemes that go unreported.  

OIG wants to address this gap, by conducting a large-scale analysis of enrollment and disenrollment data to identify aberrant patterns that may signal improper MAO actions to influence enrollment. 

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