Field guides for enrollment fraud detection
Analysis for teams detecting fake documents, synthetic identities, outstanding-verification abuse, and broker-driven enrollment fraud.
How to Build a Program Integrity Scoring Worksheet That Holds Up
A transparent scoring worksheet for enrollment review: six scored dimensions, weights your team sets, documented exceptions, and clear rules for routing uncertain cases to people.
Reviewing Duplicate Medicaid and Marketplace Coverage Overlaps
A reviewer-level pattern for separating transition-month coverage overlaps from sustained duplicate enrollment, using identity resolution, coverage spans, reason codes, and human routing.
How to Build Referral Packets MFCUs and CMS Can Actually Use
A section-by-section referral packet outline for enrollment fraud cases: preserved originals, evidence index, reviewer determinations, broker consent records, and chain of custody.
How to Triage an Outstanding Verification Queue Without Guessing
A practitioner triage worksheet for income, citizenship, and special-enrollment evidence: risk tiers, document sufficiency standards, reason codes, and named human escalation owners.
A Broker Consent Review Checklist to Run Before Open Enrollment
Test whether your team can retrieve the two distinct records behind an assisted Marketplace enrollment: consumer consent and confirmation of application information.
Verify vs. Detect: Why Identity Proofing Alone Misses Enrollment Fraud
Identity proofing evaluates one application. Fraud detection connects behavior across applications. Here is how to find and close the gap.
SEP Abuse: Catching Special-Enrollment Fraud Without Blocking Real Life Events
How to separate manufactured qualifying life events from real ones using velocity signals, coverage-loss letter forensics, and broker patterns, without cutting off legitimate enrollees.
5 Best Public Benefits Fraud Detection Platforms in 2026
Compare fraud detection platforms for health marketplaces and public-benefit programs by document forensics, identity proofing, network analytics, case evidence, and applicant friction.
MARS-E and NIST 800-63 for Fraud Platforms: A State Exchange Roadmap
A plain-language guide to sequencing SOC 2, MARS-E, NIST 800-63 IAL2, StateRAMP, and FedRAMP so a fraud-detection vendor can sell to state marketplaces.
The $186B Problem: A Program-Integrity Playbook for Improper Payments
Turn the GAO Fraud Risk Framework into an operational playbook: where to instrument detection, how to triage cases, and how to measure catch rate without raising premiums.
Synthetic Identity in Public Benefits: Catching SSN Reuse Before Coverage
How to spot synthetic and duplicate-identity patterns in benefit enrollment, from one SSN across many policies to issuance-date anomalies, and stop them at the front door.
Document Forensics at Scale: Catching Fake Paystubs and SEP Letters
Template-deviation, font-substitution, metadata, and OCR-consistency signals expose fabricated income and coverage-loss documents that overloaded human reviewers miss.
Referral-Grade Evidence: Audit Trails That Survive CMS and an MFCU
When California froze unemployment benefit accounts over fraud concerns, legitimate claimants were caught in the freeze. Here is what a defensible, human-in-the-loop referral packet contains and how confidence scoring prevents wrongful terminations.
Broker Rings, Not Bad Forms: Detecting Organized Enrollment Fraud
Single-application document checks miss the fraud pattern. Graph analytics across applications reveal the broker clusters, shared SSNs, and coordinated SEP velocity that define organized fraud.
Why 23 of 24 Fake Applications Were Approved and How to Close the Front Door
In GAO covert testing, the federal Marketplace approved coverage for nearly all of GAO's fictitious applicants in plan years 2024 and 2025. We break down each fraud vector and map the front-door detection architecture that stops them.