The Justice Department’s (DOJ) recent resolution with AssuredPartners and its former subsidiary, AP of South Florida (APSF), marks a notable False Claims Act (FCA) case arising from alleged fraud in the Affordable Care Act (ACA) marketplace. APSF agreed to plead guilty to major fraud against the United States and pay $27.6 million in restitution, while AssuredPartners will pay $107 million to resolve civil FCA allegations tied to fraudulent ACA enrollments.
According to the DOJ, APSF and its executives used “street marketers” to target vulnerable consumers at homeless shelters, bus stops, and drug treatment clinics, sometimes offering cash or gift cards to induce enrollment or obtain personal information. Employees allegedly submitted applications falsely stating that consumers would earn just enough income to qualify for the highest subsidies, manipulated Medicaid denials to trigger Special Enrollment Periods, and sent false responses to CMS verification requests. The government alleged that APSF’s purpose was to generate commissions, bonuses, and other insurer payments from federally subsidized ACA enrollments. The scheme allegedly caused $141.5 million in unwarranted subsidies.
From an FCA perspective, the theory is straightforward: if a company uses false statements to obtain federal healthcare dollars, it can face substantial liability. What makes this settlement especially significant, however, is the longstanding threshold issue of whether ACA premium assistance is the kind of government money the FCA reaches at all. ACA subsidies are structured as tax credits, and the FCA generally excludes claims, records, or statements made under the Internal Revenue Code. But the ACA also directs the Treasury to make advance premium tax credit payments directly to insurers, and DOJ’s settlement makes clear that it views fraudulent enrollment submissions that trigger those payments as actionable false claims. That is a major reason this case is important. It also fits squarely within DOJ’s broader enforcement priorities: in FY 2025, DOJ reported more than $6.8 billion in FCA recoveries, with over $5.7 billion tied to healthcare matters. DOJ consistently managed care as a major focus.
Whistleblowers were instrumental exposing APSF’s misdeeds. DOJ’s civil settlement resolved allegations originally brought in a qui tam lawsuit, and the whistleblower who brought it will receive $24.3 million. That is not incidental. In complex federal healthcare programs, fraud often looks routine from the outside; insiders are usually the only people who can identify the scripts, incentives, altered eligibility data, and ignored compliance warnings that make the scheme work. DOJ’s own FY 2025 statistics underscore the point: qui tam suits drove more than $5.3 billion in recoveries, and whistleblowers filed a record 1,297 cases that year.
For employees in insurance, enrollment, benefits, brokerage, managed care, or government-funded health programs, this case sends a clear signal: fraud involving ACA subsidies can create serious False Claims Act exposure. It also shows that whistleblowers play a critical role in exposing schemes that would otherwise remain hidden.
For whistleblowers considering whether to come forward, this case also reflects why experience matters. Whistleblower Partners has advocated for healthcare whistleblowers for decades and has particular depth in risk adjustment fraud and other FCA matters involving complex federal health programs. The firm’s results include representing a whistleblower in the $556 million Kaiser Permanente settlement, the largest FCA settlement under Medicare Part C, and in a settlement with Independent Health valued at up to $100 million.
If you have information about fraudulent ACA enrollments, subsidy manipulation, or other health care fraud involving federal funds, contact our whistleblower attorneys for a confidential review.
