UPDATED MARCH 18
The U.S. District Court for the Western District of Virginia has unsealed a whistleblower complaint against Sentara Health that accused the Hampton Roads health care system of improperly inflating local insurance rates in 2018 and 2019.
On Feb. 14, the court revealed the plaintiffs are Sara Stovall, Ian Dixon and Karl Quist — a trio of Charlottesville residents who were galvanized into action after Sentara’s Optima Health insurance division (now part of Sentara Health Plans) significantly raised rates for 2018 and 2019 health insurance coverage under the federal Affordable Care Act. At the time, Sentara was the only insurer offering health coverage on the ACA exchange in the Charlottesville region.
The previously sealed complaint, filed in 2020, says that Stovall, Dixon and Quist are trying to recover more than $200 million in damages and civil penalties on behalf of the U.S. government from Sentara Healthcare, Optima Health Plan and Seattle-based independent actuarial and consulting firm Milliman, which certified Optima’s insurance rates.
Stovall, Dixon and Quist have accused Sentara, Optima and Milliman of imposing “knowingly fraudulent surcharges,” falsifying calculations and engaging in intentional cost shifting to generate “massive illicit profits.”
The complaint accuses Sentara of violating the federal False Claims Act, which prohibits knowingly falsifying records or statements to the U.S. government. Those found in violation are liable for treble damages.
In September 2017, when Sentara announced it would expand the availability of its Optima Health plans in Virginia, the health system said that 70% of existing customers statewide would see their premiums go up just $4 a month on average, thanks to federal subsidies. However, the remaining 30% would see a more significant average increase of 81.8%.
In fall 2017, when Optima was selling insurance plans on the exchange for the coming year, Quist and Stovall found alternative insurance plans outside of Optima, and Dixon signed up for a 2018 Optima small group plan, although he said in an interview with Virginia Business last year that he was forced to hire an employee he didn’t need to qualify for the plan. The three plaintiffs aired their concerns in a November 2017 interview with The New York Times, and they met with state and federal officials and filed complaints with the state Bureau of Insurance and the American Academy of Actuaries.
In 2021, the U.S. Department of Justice launched a civil federal False Claims Act investigation into how Sentara set its 2018 and 2019 premiums. The investigation was made public in November 2023, when the Justice Department filed a petition in U.S. District Court in Charlottesville, alleging Sentara withheld relevant documents from government investigators. Sentara has fought back against what it categorizes in court filings as government overreach and a “misunderstanding of the ACA’s framework.”
In court filings and public statements, the health care system denies all allegations and has portrayed itself as a good corporate citizen that stepped up during a politically volatile time to prevent vulnerable Virginians from losing health insurance coverage.
A Dec. 20, 2024, notice by the federal government to the U.S. District Court for the Western District of Virginia revealed that the federal government intends to intervene on the allegations made by Stovall, Dixon and Quist that Sentara, Optima and Milliman violated the False Claims Act by making materially false statements and omissions in Optima’s rate filings for the 2018 and 2019 plan years. However, the government declined to intervene in allegations against Milliman based solely on its marketing and use of its health cost guidelines.
The notice says the federal government intends to file a complaint within 90 days of the order to unseal the whistleblower complaint and reserves the right to name additional defendants. The federal government on Dec. 20 also requested that the trio’s complaint and the notice be unsealed.
Plaintiffs ‘completely thrilled’
“At a very basic level, we are, of course, completely thrilled that the Department of Justice, after years of investigation, is so confident in our allegations that they are taking on the case and prosecuting it themselves,” Stovall said. “We knew we were right. We’ve known that we were right, and this, of course, is the ultimate approval of that.”
She and the other plaintiffs remain undecided on how they will proceed with the allegations of the case that the federal government has not decided to intervene in, she said, adding that the three are discussing the matter.
Stovall said she’s curious to see what is revealed when the federal government files its official complaint, saying it would be the result of years of investigation.
“We’ve been trusting them, we’ve been excited,” she said. “We know they’ve learned things, but we don’t know what, so we’ll be learning along with everybody else what’s inside of that complaint, what exactly they found in their investigation.”
Sentara ‘fully compliant with the law‘
Sentara Health spokesperson Mike Kafka says that in 2017, there were “historic market disruptions” and 350,000 people in Virginia were at risk of losing Affordable Care Act coverage. At the request of federal and state officials, Sentara worked with regulators to help fill a potential gap in coverage in a short period of time, he said.
“We quickly formulated rates based on sound actuarial principles, the best data available, and with the support from one of the nation’s preeminent actuarial firms,” he said. “Our rates complied with all relevant state and federal laws and rules and were repeatedly approved by regulators.”
Kafka says under the law, insurance companies like Sentara Health Plans (formerly Optima Health) do not keep excess profit premiums, which must be rebated back to customers.
“Sentara was fully compliant with the law and issued over $98 million in rebates to Virginia policyholders for the 2018 plan alone, in accordance with ACA regulations,” Kafka said. “The allegations of wrongdoing are without merit.”
For last year alone, Kafka said Sentara’s participation in the ACA market drove substantial losses without government support or assistance. But Sentara stayed in the market, he added, because “providing health coverage to those who need it is central to our mission.” The complaint, he argued, could have “a chilling effect” and drive insurers like Sentara out of the ACA market entirely.
“The facts are on our side, and we will carefully review any complaint that is filed and make clear that we complied with all applicable laws and regulations while we worked to fulfill our not-for-profit mission,” Kafka said.
CORRECTION: An earlier version of this story incorrectly stated that the plaintiffs in the whistleblower complaint against Sentara Health did not disclose their status as the complaint whistleblowers during 2017 and 2018 in a New York Times interview and in dealings with state officials and others. The whistleblower complaint was not filed until 2020, well after those interactions took place.