With over 79 million individuals enrolled in Medicaid and CHIP, ensuring accurate eligibility verification is essential. However, outdated manual processes often lead to delays, improper payments, and fraud—costing taxpayers billions annually. The Government Accountability Office (GAO) reported that improper Medicaid payments totaled over $100 billion in 2023, largely due to identity verification failures and eligibility errors.
To address these challenges, CITIZ3N’s VERIFY platform automates eligibility verification, reduces fraud, waste, and abuse (FWA), and empowers agencies with data-driven insights. Let’s break down how VERIFY simplifies the entire Medicaid verification process from application submission to approval.
The VERIFY Process: A Step-by-Step Breakdown
Step 1: Application Submission
When an individual applies for Medicaid, they submit personal details such as name, address, income, employment, and assets. Traditionally, this information requires manual verification, which is slow, labor-intensive, and prone to errors.
Step 2: Automated Identity Verification with the Identity Module
The IDENTITY module instantly cross-checks applicant data with trusted government and third-party sources to verify:
- Identity and residency (Preventing duplicate or fraudulent applications)
- Income and employment (Without requiring employer paperwork)
- Immigration and incarceration status (Ensuring compliance with eligibility rules)
By automating identity verification, agencies can approve legitimate applications faster while flagging inconsistencies in real time.
Step 3: Real-Time Asset Verification with the Asset Module
Many Medicaid programs require asset verification to determine eligibility. The ASSET module automates this by:
- Checking bank account balances, interest, and transaction history
- Identifying real estate, vehicles, and other valuable assets
- Ensuring accurate financial disclosure by cross-referencing local, regional, and national databases
This ensures applicants meet financial eligibility criteria without requiring excessive paperwork or lengthy manual reviews.
Step 4: Fraud, Waste, and Abuse Detection with the DETECT FWA Module
Medicaid fraud schemes—including phantom billing, eligibility fraud, and provider misrepresentation—cost billions annually. The DETECT FWA module uses AI-driven analytics and color-coded risk scoring to:
- Cross-reference applicant data with fraud databases
- Identify high-risk applications for further review
- Flag duplicate or suspicious claims in Medicaid, SNAP, and TANF programs
This proactive approach reduces fraudulent payments and ensures resources go to those who truly need them.
Step 5: Data-Driven Decision Making with DATAHUB and CITIZ3N.AI
Once an applicant’s information has been verified, agencies need real-time insights to make informed decisions. The DATAHUB module centralizes all verification data into customizable dashboards, allowing agencies to:
- Analyze trends in applicant demographics, eligibility approvals, and fraud patterns
- Generate instant reports for compliance and audits
Visualize data with charts, heatmaps, and predictive analytics
Additionally, CITIZ3N.AI leverages large language model (LLM) technology to provide agencies with:
- Summarized insights from industry-specific data
- Automated policy recommendations based on emerging trends
Custom reporting tailored to agency needs
Why Medicaid Agencies Trust VERIFY
- Speeds up eligibility determinations – Automating verification reduces processing time.
- Reduces fraudulent claims – AI-powered risk detection prevents billions in improper payments.
- Improves accuracy – Eliminates human error, ensuring 100% compliance with federal regulations.
- Enhances efficiency – Agencies can process more applications with fewer resources.
The Future of Medicaid Eligibility Verification
As Medicaid programs face increasing regulatory scrutiny and fraud challenges, VERIFY provides a modern, scalable solution to ensure accuracy, efficiency, and integrity.
By implementing CITIZ3N’s VERIFY platform, agencies can reduce costs, protect public funds, and streamline enrollment—ensuring Medicaid benefits reach those who truly need them.
