Court Dismisses False Claims Act Lawsuit Against Insurers Over ACA Premiums

The court has dismissed a False Claims Act lawsuit alleging that health care insurers improperly inflated insurance premiums in violation of the Affordable Care Act. This decision was based on the filed-rate doctrine, which prohibits courts from questioning rates that regulators have already approved. The case involved Sentara and Milliman, Inc., both of whom argued that the claims were barred by this doctrine.

The filed-rate doctrine, initially used to regulate carrier rates, has since been applied to the insurance sector by several courts. It prevents litigants from challenging regulator-approved rates through judicial forums, ensuring courts do not examine the reasonableness of these rates. The court's decision to apply this doctrine was crucial, given that a state agency regulated the rates under federal ACA mandates, and the relators’ claims were brought under federal law.

Complainants argued their lawsuit targeted Optima's eligibility to provide insurance, rather than the rates themselves. However, the court determined that the challenge ultimately concerned the rates, backed by allegations of fraudulent representations by the defendants. Relators claimed that the doctrine does not apply to governmental actions, citing various cases, but the court noted there is no prevailing authority supporting a government exception in rate challenges.