What to Do If a Client Reports You as an ACA Agent

Getting reported by a client can feel like a punch to the gut. Maybe you thought things were going fine—or maybe you knew something was off. Either way, if a client files a complaint against you through the Marketplace, a carrier, or CMS directly, it’s serious business.

The good news? It’s not always the end of the world, especially if you handle it the right way.

Here’s what to know and how to handle it.

Why Clients Report Agents

There are lots of reasons a client might file a complaint. Some are legitimate, and some are just misunderstandings. And it’s important to know that complaints can be filed not only with CMS or a carrier—but also with your state’s Department of Insurance (DOI). If a client feels wronged, they may go straight to the DOI, which can carry serious regulatory consequences if not addressed.

Also, many clients become upset when their plans are canceled—even if the cancellation was due to their own actions, such as failing to pay premiums or not submitting required documents. Unfortunately, agents often become the target of that frustration.

This is why it’s critical that agents stay on top of their book of business. If documents are outstanding, help the client get them submitted. If a premium is due, make sure the client understands how and when to pay it.

Managing a large book can be a challenge, and that’s where PolicySync really shines. It helps you track which policies are at risk—whether due to cancellation, expiration, or outstanding issues—so you can prioritize follow-ups and avoid unnecessary complaints.

Common reasons include:. Some are legitimate, and some are just misunderstandings. Common reasons include:

• They didn’t understand they were being enrolled in a plan

• They claim they never gave you permission to enroll them

• Their subsidy or plan changed unexpectedly

• They believe you misrepresented something on the application

• They didn’t know they had a new agent or their Agent of Record was changed

In today’s CMS environment—especially with the focus on consent, 3-way calls, and Marketplace recordkeeping—clients have multiple ways to raise red flags. Even if you did everything by the book, a complaint can still land on your desk.

Step 1: Don’t Panic, But Take It Seriously

Take a deep breath. Getting reported doesn’t automatically mean you’re in the wrong, or that your license is in danger. But it does mean it’s time to get organized and respond quickly and professionally.

Document everything:

• When and how the client was contacted

• What was said or agreed upon

• Consent forms, 3-way call logs, or recorded calls (if applicable)

• Screenshots or timestamps from HealthSherpa or your CRM

The more clean documentation you have, the easier it is to clear things up.

Step 2: Respond to the Carrier and CMS

If a carrier notifies you that a client has reported you, respond professionally and thoroughly. Many times, they’ll ask for a written explanation or supporting documentation.

If CMS or the Marketplace is involved, they may investigate further or request a call with you and the client. The key here is:

• Be transparent and respectful.

• Don’t get defensive.

• Stick to the facts and provide whatever is requested promptly.

If you’re at fault, own it. If you made an honest mistake, explain it and what you’ll do to prevent it moving forward.

Step 3: Reach Out to the Client (If Appropriate)

Sometimes it makes sense to reach out to the client directly—especially if you think this was a misunderstanding or miscommunication.

• Be empathetic and open.

• Ask what confused them or what didn’t sit right.

• Offer to explain or walk through the enrollment process again.

You’d be surprised how often a simple, kind follow-up can resolve tension. Even if they don’t stay with you, you’ll show that you care and that you’re willing to make things right.

Step 4: Learn and Adjust

Every report is a chance to tighten up your process. Ask yourself:

• Did I rush the enrollment without properly explaining the plan?

• Did I forget to mention something about the subsidy or premiums?

• Was the 3-way call or consent process done properly?

If you’re using a CRM, like GoHighLevel, go back and review your client activity and history. Having a visual record of enrollments, policy switches, and client communications can help prevent future misunderstandings. Adding in additional automations pre-enrollment and post-enrollment could mean the difference between getting reported and not.

What Are the Consequences of Being Reported?

While not every report leads to serious action, it's important to understand that there can be real consequences if CMS or a state Department of Insurance finds wrongdoing—or repeated issues—on your part.

Some consequences we’ve seen include:

• Temporary suspension of FFM certification, which can restrict your ability to sell ACA plans. These suspensions can last anywhere from 3 months to 2 years depending on the severity and frequency of the issue.

• Loss of carrier appointments if the report involves a specific insurer.

• Permanent revocation of your FFM license in cases where an agent has multiple complaints or is found to have engaged in fraudulent or deceptive practices.

This isn’t an exhaustive list, but these are real outcomes that we’ve witnessed across the industry. That’s why proper documentation, compliance, and client communication are so essential.

No one wants to get reported. But in a high-volume, high-pressure environment like ACA enrollments, it happens (especially recently). What matters most is how you handle it.

Stay professional, document everything, and use each experience to improve. And remember—you’re not the only agent this has happened to. Learn from it, grow, and keep doing right by your clients.

Want to better track your book and spot red flags early? Tools like PolicySync help you monitor policy changes, AOR losses, and activity history so you can stay one step ahead.

Check it out at www.policy-sync.com.