How to Report Insurance Fraud When Your ACA Health Insurance Plan is Switched


Have you been a victim of unauthorized enrollment into a health insurance plan under the Affordable Care Act (ACA)? Dealing with insurance fraud can be overwhelming, but it's crucial to take action to protect your rights as a consumer.

Insurance fraud is a serious issue that can have far-reaching consequences for consumers, healthcare providers, and the entire insurance industry. One prevalent form of fraud involves unauthorized enrollments in Affordable Care Act (ACA) health insurance plans, often facilitated by bad agents engaging in deceptive advertising and unauthorized plan switching.

At NavaQuote, we are committed to protecting the integrity of the healthcare system and protecting our client, in this guide we will walk you through the steps to report insurance fraud.

How to Report Insurance Fraud:

If you suspect that you or someone you know has been the victim of an unauthorized ACA enrollment or any form of insurance fraud, it's essential to report it promptly.

Step 1: Contact the Marketplace Call Center:

The Marketplace call center is a valuable resource for reporting unauthorized ACA enrollments. You can reach them at 1-800-318-2596 (TTY: 1-855-889-4325). Explain your situation in detail, and they will guide you through the necessary steps to address the issue. Be sure to ask the representative for the listed Agent of Record (AOR) name and National Producer Number (NPN).

Step 2: Formerly Revoke Consent

With the Agent of Record (AOR) name and National Producer Number (NPN) of the agent involved. You can then locate their license and contact details using Licensee Lookup tools like State Based Systems or the Florida Licensee Search. It's advisable that you send a formal written request to the agent's email and phone number, revoking any further access to their Marketplace application(s), and demanding the deletion of their contact information from the agent's systems.

Step 3: File a Complaint with Your State Insurance Department

Each state has an insurance department responsible for regulating the insurance industry and investigating fraud cases. You can use the National Association of Insurance Commissioners’ (NAIC) Online Fraud Reporting System to connect with your local Department of Insurance and file a report and formal complaint regarding the unauthorized enrollment or plan switching.

Step 4: Report to Insurance Company:

It is recommended to send an email or make a call to the insurance company involved, filing a complaint and informing them about the situation. Keep in mind that the Agent of Record displayed on the application may not match the Agent of Record recognized by the insurance company. Each insurance company may have its own rules for determining the agent of record.

Step 5: Report to the Department of Health and Human Services (HHS):

Submit a report online about your situation to the HHS Fraud Report.

Providing Necessary Information

When reporting insurance fraud, be prepared to provide the following information:

  • Your personal details (name, address, contact information)
  • Details of the unauthorized enrollment (plan name, enrollment date, etc.)
  • Any communication or documentation related to the fraud
  • Information about the suspected perpetrator (if known)

Understanding Unauthorized Enrollment

What is Unauthorized Enrollment?

Unauthorized enrollment refers to the illegal act of enrolling individuals in health insurance plans without their knowledge or consent. This can happen when someone, such as an agent or a third party, misuses your personal information to sign you up for a plan, often with the intention of receiving commissions or kickbacks.

Common Scenarios of Unauthorized Enrollment

  • An insurance agent or broker enrolls you in a plan without your consent, potentially using your personal information obtained through deceptive means.
  • Deceptive advertisements promising money every month for gas, groceries and rent. These are illigitmate ads and used to trick you into providing your personal information to enroll you in a plan, often as part of a larger insurance fraud scheme.

Consequences of Unauthorized Enrollment

Unauthorized enrollment can have severe consequences, including:

  • Financial burden: You may be responsible for repaying the Internal Revenue Service (IRS) any premium tax credits that you received but did not qualify for.
  • Coverage gaps: If you already have insurance, the unauthorized enrollment could terminate your existing coverage.

Protecting Yourself as a Consumer

Reviewing Your Insurance Documents

Regularly review any insurance documents, statements, or notices you receive, even if you don't recall enrolling in a plan. Look for unfamiliar plan names, coverage details, or premium amounts.

Monitoring Your Marketplace Account

If you have an account on the ACA Marketplace, check it periodically for any unauthorized activities or changes to your enrollment status.

Recognizing Suspicious Activities

Be wary of unsolicited calls, emails, or texts from individuals claiming to represent insurance companies or the Marketplace. Legitimate agents and representatives will not pressure you into enrolling or sharing personal information without your consent.

Working with Insurance Agents

Verifying Agent Credentials

Before working with an insurance agent, verify their license status with your state's insurance department or the Marketplace. Legitimate agents should be transparent about their affiliations and willing to provide documentation.

Seeking Assistance from Legitimate Agents

If you need help navigating the Marketplace or understanding your insurance options, consider seeking assistance from a legitimate, licensed broker from NavaQuote, or find assistance through the Marketplace.

Avoiding Unsolicited Agent Contacts

Be cautious of unsolicited contacts from insurance agents, especially those who pressure you into enrolling or sharing personal information. Legitimate agents will not use deceptive tactics or high-pressure sales techniques.

Understanding Medicare Implications

If you are eligible for Medicare, it's important to understand the differences between Marketplace plans and Medicare coverage, as well as the potential implications of unauthorized enrollment.

Differentiating Medicare from Marketplace Plans

Medicare is a federal health insurance program primarily for individuals aged 65 and older or those with certain disabilities. Marketplace plans, on the other hand, are offered through the ACA for individuals who do not qualify for Medicare or other government-sponsored programs.

Reporting Fraud Involving Medicare

If the unauthorized enrollment involves Medicare, report the fraud to Medicare and the Senior Medicare Patrol (SMP) program in your state.

Coordinating Medicare and Marketplace Coverage

If you have both Medicare and a Marketplace plan, ensure that your coverage is properly coordinated to avoid gaps or duplications. Consult with a licensed agent or representative for guidance.

Filing a Complaint

If your initial reports of insurance fraud are not addressed satisfactorily, you may need to escalate the matter by filing a formal complaint. If you don't already have an insurance agent or broker, you can contact NavaQuote to see if we can be of assistance in this process.

Gathering Evidence

Document all communication, transactions, and any evidence related to the unauthorized enrollment or fraud. This may include emails, call recordings, receipts, or any other relevant information.

Submitting a Formal Complaint

Submit a formal complaint to the appropriate state or federal agencies, such as your state's insurance department, attorney general's office, or the U.S. Department of Health and Human Services (HHS).

Following Up on Your Complaint

Keep track of your complaint and follow up with the authorities if you do not receive a response or update within a reasonable timeframe.

Prevention and Awareness

While reporting insurance fraud is crucial, prevention and awareness are equally important to combat these illegal practices.

Staying Informed About Insurance Scams

Stay up-to-date with the latest scams and fraud tactics related to health insurance by following reputable sources, such as consumer protection agencies, insurance industry publications, and news outlets. 

Advocating for Stronger Regulations

Engage with policymakers and advocacy groups to push for stronger regulations and enforcement measures to protect consumers from insurance fraud and unauthorized enrollment practices.

Reporting insurance fraud and unauthorized enrollment is not only a matter of protecting your personal interests but also contributing to the overall integrity of the healthcare system. By taking action and raising awareness, you can help create a more transparent and secure environment for all consumers.

If you suspect unauthorized enrollment or any form of insurance fraud, don't hesitate to report it. By taking action you can make a difference in combating these illegal practices and protecting the rights of consumers like yourself. Stay informed, be proactive, and never hesitate to seek assistance from NavaQuote. Together, we can build a more transparent and trustworthy healthcare system for all.


What is Unauthorized Enrollment? 

Unauthorized enrollment refers to the act of bad acting agents enrolling you in a health insurance plan without your knowledge or consent. This can occur through various deceptive methods, leading to potential financial issues for the victim.

What are some common scenarios of Unauthorized Enrollment? 

Common scenarios include individuals using your personal information to enroll in a plan without your consent, unauthorized changes made to your existing plan, or fraudulent enrollment by insurance agents or brokers seeking to profit.

What are the consequences of Unauthorized Enrollment? 

It can lead to financial losses, disruption of healthcare services, and complications in accessing the healthcare services you need.

How can I protect myself as a consumer? 

You can protect yourself by regularly reviewing your insurance documents, monitoring your marketplace account for any suspicious activities, and promptly reporting any unauthorized enrollment or fraud to the appropriate authorities.

How do I report insurance fraud?

You can report insurance fraud by contacting the marketplace where you obtained your insurance, reaching out to state authorities responsible for insurance regulation, and providing detailed information about the fraudulent activity.

What should I do if I suspect insurance fraud involving Medicare? 

If you suspect insurance fraud involving Medicare, you should report it to Medicare immediately. Differentiating between Medicare and marketplace plans is crucial, as the procedures for reporting fraud may vary.