GoHealth’s Statement on Recent Allegations in the United States False Claims Act Complaint
- Strong track record in serving special needs beneficiaries (35% of enrollees vs. 17% industry average)
- Established programs like Low Income Subsidy team and PlanFit demonstrate commitment to beneficiary needs
- Company maintains focus on core mission while defending against allegations
- Subject to a United States False Claims Act lawsuit regarding 2016-2021 events
- Allegations of receiving kickbacks and placing beneficiaries in suboptimal plans
- Legal defense could divert resources and management attention
Insights
GoHealth faces serious False Claims Act lawsuit from the government alleging Medicare Advantage kickbacks and improper enrollments, creating significant legal and financial risks.
The U.S. Government's False Claims Act complaint against GoHealth represents a significant legal challenge that could have substantial consequences. Unlike whistleblower-initiated cases, this direct government action suggests extensive prior investigation into alleged improprieties occurring between 2016-2021.
The allegations appear to focus on two key areas: (1) potential kickbacks from Medicare Advantage carriers and (2) placing beneficiaries into suboptimal plans based on compensation rather than beneficiary needs. Such False Claims Act cases typically carry treble damages plus per-violation penalties that can accumulate rapidly given the volume-based nature of Medicare enrollment businesses.
GoHealth's defense strategy appears two-pronged: asserting technical compliance with Medicare Advantage broker compensation laws while providing evidence of their service to vulnerable populations. Their statistic that 35% of enrollees were special needs beneficiaries (versus 17% industry average) appears designed to counter allegations of beneficiary harm.
Companies facing similar government actions typically experience extended legal proceedings with considerable defense costs regardless of outcome. Notably absent from the press release is any mention of financial reserves established for this matter, which investors should monitor in upcoming financial disclosures. While GoHealth promises a "vigorous defense," the company faces potentially significant financial exposure and compliance oversight even if allegations are ultimately unproven.
This government complaint targets fundamental aspects of GoHealth's Medicare Advantage broker operations, questioning both compensation arrangements and enrollment practices. The timing is significant - covering 2016-2021 - a period when CMS increasingly scrutinized third-party marketing organizations in Medicare Advantage.
The allegations touch on particularly sensitive regulatory areas: kickback arrangements between brokers and carriers, and the improper steering of beneficiaries into plans that may have generated higher commissions rather than meeting beneficiary needs. These allegations strike at the heart of the fiduciary responsibility expected when enrolling vulnerable populations in healthcare plans.
GoHealth's defensive positioning is strategically notable. By highlighting that special needs populations represented 35% of their enrollees versus 17% industry average, they're attempting to demonstrate commitment to underserved populations. Their emphasis on specialized compliance programs - the Low Income Subsidy team and PlanFit program - suggests they're positioning themselves as compliance-focused rather than commission-driven.
This case exists within a broader regulatory landscape where CMS has implemented increasingly stringent marketing oversight of Medicare Advantage enrollment channels. Regardless of outcome, this action signals continued regulatory pressure on commission structures and marketing practices throughout the Medicare Advantage broker ecosystem. The industry implications extend beyond GoHealth, potentially requiring operational adjustments for all Medicare Advantage marketing organizations as regulators continue focusing on enrollment quality over quantity.
GoHealth firmly denies allegations; affirms leadership in regulatory compliance and prioritization of beneficiaries’ needs
CHICAGO, May 07, 2025 (GLOBE NEWSWIRE) -- GoHealth, Inc. (GoHealth) (NASDAQ: GOCO), a leading health insurance marketplace and Medicare-focused digital health company, firmly denies the allegations made by the Government in a lawsuit in which the company has been named as a defendant related to events that allegedly occurred between 2016 and 2021. We are disappointed that the Government is pursuing claims against a company that has at all times worked to advance the interests of the Medicare Advantage program and the Medicare beneficiaries it serves.
GoHealth maintains that it complied with the laws that were specifically designed by Congress and HHS to address payments by Medicare Advantage carriers to the brokers that sell their plans. GoHealth denies that it received kickbacks, and similarly, it denies that it placed beneficiaries in suboptimal plans due to compensation from carriers or that it engaged in any form of discrimination.
GoHealth has a history of being a leader in enrolling special needs beneficiaries. Over the last five years, the special needs population represented
GoHealth strives to lead the way in our industry to ensure Medicare beneficiaries are well served. We share our Government’s goal of ensuring the Medicare industry provides the best possible healthcare for eligible American citizens.
GoHealth intends to vigorously defend itself and we will not be distracted from our purpose and mission to provide our customers with peace of mind in their healthcare decisions so they can focus on living their lives.
Forward Looking Statements
This press release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended (the “Securities Act”), and Section 21E of the Securities Exchange Act of 1934, as amended (the “Exchange Act”). These forward-looking statements are made in reliance upon the safe harbor provision of the Private Securities Litigation Reform Act of 1995. All statements other than statements of historical facts contained in this earnings presentation may be forward-looking statements. Statements regarding our future results of operations and financial position, business strategy and plans and objectives of management for future operations and strategies are forward-looking statements.
In some cases, you can identify forward-looking statements by terms such as “may,” “will,” “should,” “aims,” “expects,” “plans,” “anticipates,” “could,” “intends,” “targets,” “projects,” “contemplates,” “believes,” “estimates,” “predicts,” “potential,” “likely,” “future” or “continue” or the negative of these terms or other similar expressions. The forward-looking statements in this press release are only predictions, projections and other statements about future events that are based on current expectations and assumptions. Accordingly, we caution you that any such forward-looking statements are not guarantees of future performance and are subject to risks, assumptions and uncertainties that are difficult to predict. Although we believe that the expectations reflected in these forward-looking statements are reasonable as of the date made, actual results may prove to be materially different from the results expressed or implied by the forward-looking statements. These forward-looking statements speak only as of the date of this press release and are subject to a number of important factors that could cause actual results to differ materially from those in the forward-looking statements, including the factors described in the sections titled “Summary Risk Factors,” “Risk Factors” and “Management’s Discussion and Analysis of Financial Condition and Results of Operations” in our Annual Report on Form 10-K for the fiscal year ended December 31, 2024 (“2024 Annual Report on Form 10-K”), our forthcoming Quarterly Report on Form 10-Q for the fiscal quarter ended March 31, 2025 (“Q1 2025 Quarterly Report on Form 10-Q”) and in our other filings with the Securities and Exchange Commission.
You should read this press release completely and with the understanding that our actual future results may be materially different from what we expect. We qualify all of our forward-looking statements by these cautionary statements. Except as required by applicable law, we do not plan to publicly update or revise any forward-looking statements contained herein, whether as a result of any new information, future events, changed circumstances or otherwise.
About GoHealth, Inc.
GoHealth is a leading health insurance marketplace and Medicare-focused digital health company whose purpose is to compassionately ensure consumers’ peace of mind when making healthcare decisions so they can focus on living life. For many of these consumers, enrolling in a health insurance plan is confusing and difficult, and seemingly small differences between health plans may lead to significant out-of-pocket costs or lack of access to critical providers and medicines. GoHealth’s proprietary technology platform leverages modern machine-learning algorithms, powered by over two decades of insurance purchasing behavior, to reimagine the process of matching a health plan to a consumer’s specific needs. Its unbiased, technology-driven marketplace coupled with highly skilled licensed agents has facilitated the enrollment of millions of consumers in Medicare plans since GoHealth’s inception. For more information, visit https://www.gohealth.com.
Investor Relations
John Shave
jshave@gohealth.com
Media Relations
Pressinquiries@gohealth.com
FAQ
What allegations is GOCO facing in the False Claims Act lawsuit?
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