Fraud, waste, and abuse (FWA) doesn’t begin with a billion-dollar indictment; it starts at the front door—when a rogue broker flips a plan for commission, when income is “estimated” to force a zero-premium outcome, when criminal networks launder dollars through shell entities disguised as health care. If we want different outcomes, we need different controls at day zero. That’s the promise of CITIZ3N Verify.
The evidence is clear—and recent.
- Rogue broker activity, at scale. CMS logged 90,863 complaints of unauthorized plan switches and 183,553 complaints of unauthorized enrollments in Jan–Aug 2024, and then later tightened systems to block any agent from changing a policy unless they’re already associated with that consumer (three-way call required). CMS reports a ~30% drop in casework after the July 19 changes, and 850 agents/brokers were suspended for suspected fraud/abuse Jun–Oct 2024.
- Exploitation of vulnerable people. Investigations documented commission-seeking agents enrolling people experiencing homelessness into zero-premium ACA plans—without informed consent—by manipulating addresses and income to create eligibility.
- Eligibility gaming is real—and debated in scale. Analysts and officials disagree on the exact magnitude, but there is bipartisan acknowledgment that income misreporting and unauthorized enrollments require stronger front-end verification and broker oversight.
- Organized crime + money laundering. In June 2025, DOJ announced the largest health-care fraud takedown in history: 324 defendants, $14.6B in alleged fraud, >$4B prevented from being paid, and $245M in assets seized. Cases included transnational networks acquiring DME companies via straw owners and pushing false claims at national scale.
- “Operation Gold Rush.” EDNY charged a Russia-linked organization that stole >1,000,000 identities, bought dozens of DME suppliers through nominees, and submitted >$10.6B in false Medicare claims—then laundered proceeds via shells and crypto.
- Improper payment context. In FY2024, CMS estimated $31.7B in Medicare FFS improper payments (7.66%), $19.07B in Medicare Advantage (5.61%), and $3.58B in Part D (3.70%)—not all fraud, but exactly the verification gaps criminals exploit.
What leaders should measure (and expect) with CITIZ3N Verify
Identity, Employment, Income, and Asset/Ownership verification—embedded at application, broker action, and payment.
Program Integrity KPIs (12–24 months):
- Broker abuse: ≥60% reduction in unauthorized enrollment/switch complaints per 10k enrollments; TTR <14 days to fully remedy a flagged case with evidence-grade audit trails. (CMS’s 2024 baseline: 90,863 plan-switch and 183,553 enrollment complaints; 850 broker suspensions.)
- Identity assurance: ≥98% automated first-pass proofing; <0.1% synthetic-ID false accept; sub-second risk-score latency. (Front-door control that directly counters large-scale identity theft schemes described by DOJ/EDNY.)
- Income & employment: ≥85% of determinations cross-verified against wage/payroll/benefit data pre-APTC; ≥25% YoY reduction in post-enrollment income discrepancies; <2% manual review rate.
- Asset/ownership risk: >90% of high-risk supplier relationships (beneficial ownership, shell layering) flagged before payments; ≥70% precision on first-pass beneficial-ownership matching. (Pre-empt the nominee-owner tactic highlighted in Gold Rush.)
- Dollar impact: >$X prevented/quarter (agency-reported), aiming for >5:1 ROI in year one (prevented payouts ÷ platform cost). (Aligned to DOJ/CMS prevention reporting practices.)
How CITIZ3N Verify stops FWA at the source
- Broker Conduct Analytics
Device binding + consumer OTP + “known-agent-only” changes; pattern-based red flags (e.g., midnight switches, cross-county bursts, seasonal spikes), and instant commission-change locking. Designed to reinforce the CMS July 19 controls by making every broker action non-repudiable.
- Identity Proofing that Actually Bites
Multi-factor person-to-device-to-account binding; SSA/credit-header triangulation; synthetic ID detection; repeat-victim safeguards that auto-alert when a known consumer is targeted for a switch. (Direct antidote to identity theft leveraged in transnational schemes.)
- Employment & Income Verification (Pre-APTC / Pre-Activation)
Real-time wage/payroll checks; discrepancy scoring against declared income bands most prone to manipulation; consumer-first UX to correct miskeys (not penalize honest users).
- Asset & Ownership Graph for Suppliers/Entities
Beneficial ownership resolution, shell-risk heuristics, sanctions/PEP screening, and payment holds—with case files that prosecutors and auditors can replay 1:1. (Turn suspected laundering into prevented payouts.)
From “pay-and-pursue” to “prevent-and-prove”
We’re proud of what the community has already done—CMS’s July 2024 changes produced immediate drops in suspicious activity. Now let’s build on that momentum: identity bound to every account, verified wages before subsidies flow, broker changes that require true consumer engagement, and ownership transparency before payments leave the building. That’s how we get 1% better every day—and 100% committed to integrity.
Artificial intelligence is furthermore quickly becoming indispensable in the fight against fraud, waste, and abuse because of its ability to process signals at scale, detect hidden patterns, and adapt in real time. With models trained to flag anomalies across broker conduct, eligibility data, and financial ownership structures, AI transforms what used to be manual audits into automated prevention. By binding identity to every enrollment, cross-verifying income with payroll and benefits data, and graphing beneficial ownership to uncover shell risks, AI makes fraud harder to initiate and easier to prove. When embedded into solutions like CITIZ3N Verify, these capabilities shift agencies away from costly “pay-and-pursue” models toward proactive “prevent-and-prove” strategies—empowering leaders to close verification gaps, protect vulnerable populations, and strengthen the integrity of health programs from the very first transaction.
If you lead an ACA marketplace, Medicaid agency, or Medicare contractor and want a measurable, audit-ready way to cut FWA at the front door, let’s talk. CITIZ3N Verify exists to make prevention the default and proof the by-product.
References & further reading:
- CMS: unauthorized enrollments/switches, system changes (7/19/24), and broker suspensions.
- KFF Health News: exploitation of people experiencing homelessness by commission-seeking agents.
- DOJ / HHS-OIG: 2025 national takedown (324 defendants; $14.6B alleged; >$4B prevented; $245M seized).
- EDNY (“Operation Gold Rush”): >1M stolen identities; $10.6B in false claims; shell/crypto laundering.
- CMS FY2024: Medicare improper payment estimates (FFS, MA, Part D).
