Ambetter Health: Advancing Program Integrity Through Strong Fraud, Waste and Abuse (FWA) Prevention
Tens of millions of Americans depend on the Health Insurance Marketplace for their care. As one of the nation's largest Marketplace issuers, serving millions of members, including those in many of the country's hardest-to-reach counties, Ambetter Health has both the scale and the responsibility to lead the way on program integrity.
Every dollar lost to fraud, waste or abuse in the Marketplace is a dollar unavailable for member care. Effective oversight strengthens accountability across brokers and issuers, supports responsible stewardship of taxpayer dollars, and helps ensure that healthcare spending reaches the people it is intended to serve.
Ambetter Health has built a comprehensive approach to preventing, detecting and addressing fraud, waste and abuse across the Marketplace — an integrated model refined over more than a decade. It reflects the same core principles behind Centene's broader FWA reform agenda: prevention, early detection, rapid intervention and close partnership with regulators to safeguard members and taxpayer dollars.
Marketplace Fraud Prevention: Agent of Record Lock, NPN Accountability and Broker Controls
Ambetter Health has implemented a series of proactive, structural controls, many adopted ahead of federal requirements, designed to deter misconduct and eliminate the financial incentives that attract bad actors. Below are two examples of industry leading safeguards implemented by Ambetter Health.
- In 2024, Ambetter Health's Agent of Record (AOR) lock prevented unauthorized mid-year agent takeovers by securing the original broker for the plan year, removing the incentive and the operational ability for another broker to switch a member's plan without consent. Ambetter Health adopted this safeguard and subsequently worked with CMS to implement a similar control for the entire Marketplace.
- In 2025, Ambetter Health implemented a control requiring the broker who enrolled a specific member to be listed as the agent of record. This control eliminated a common practice referred to as “NPN override,” which historically could make it challenging to ensure precise broker oversight and accountability.
When non-compliant activity is identified, Ambetter Health pursues commission clawbacks and payment suspension, creating meaningful financial consequences. All brokers must complete training, certification and formal attestations that establish clear expectations and a documented basis for enforcement.
Many of these front-end controls were later reflected in federal system changes on HealthCare.gov — underscoring the strength of Ambetter Health's preventive approach.
Marketplace Fraud Detection: Broker Monitoring, Data Analytics and Complaint Investigations
Ambetter Health has invested in centralized oversight capabilities that combine data analytics with human investigative expertise to identify emerging risks before they become systemic.
A dedicated Broker Oversight Team continuously monitors broker behavior, complaint trends, enrollment anomalies and alignment with CMS enforcement lists. Ambetter Health's Member Intent Reconciliation (MIR) Team conducts end-to-end investigations across federal, regulatory and customer complaint channels, ensuring no allegation goes unresolved regardless of its source.
Ambetter Health's monitoring infrastructure provides an early-warning system for emerging fraud schemes by tracking complaint-to-enrollment ratios, enrollment spikes, duplicate and irregular activity patterns, and alignment with CMS sanction lists.
Broker Enforcement and Program Integrity Results: Terminations, Clawbacks and Corrective Actions
When misconduct is identified, Ambetter Health acts decisively and transparently. A structured, tiered enforcement framework ensures responses are proportionate, documented and escalated appropriately. A standing Broker Oversight Committee convenes monthly to review trends and adjudicate cases, with quarterly reviews of the top agencies providing additional structural accountability.
Ambetter Health maintains full regulatory transparency, reporting all "for cause" broker terminations to CMS and state Departments of Insurance. When warranted, Ambetter Health takes decisive action, including broker terminations, commission clawbacks and corrective measures that protect members and reinforce program integrity.
This model has produced measurable results: thousands of investigations conducted across complaint channels, significant financial recoveries through commission clawbacks, and hundreds of broker terminations and corrective actions taken.
These results are consistent with the enterprise-wide impact Centene has delivered, including the identification of more than 1,000 fraudulent DME suppliers, the prevention of over $57 million in likely fraudulent claims, and the interruption of a behavioral health fraud scheme costing a state Medicaid program more than $10 million per month. Across programs, Centene's efforts to stamp out FWA have saved taxpayers hundreds of millions of dollars.
Industry Leadership: Regulatory Collaboration and Fraud, Waste and Abuse Policy Reforms
Ambetter Health and Centene do not view program integrity as a compliance obligation. It is a shared responsibility across regulators, health plans, providers, and other stakeholders. Centene actively collaborates with the Centers for Medicare & Medicaid Services (CMS), the Center for Consumer Information and Insurance Oversight (CCIIO), America's Health Insurance Plans (AHIP), and state regulators. Centene also publicly advocated for seven common-sense reforms designed to strengthen fraud prevention efforts, including proactive payment suspensions, standardized reporting requirements, and mandatory bidirectional data-sharing among MCOs, state agencies and law enforcement. Ambetter Health's approach reflects scale, sophistication and accountability. It is grounded in the conviction that protecting members and safeguarding public resources are not competing priorities, but one and the same.
Learn more about Centene's enterprise-wide approach to combating fraud, waste, and abuse, including the seven reform proposals presented to CMS.