CMS Cracks Down on Federal Marketplace Fraud: What it Means for Program Integrity and How Verisys Helps Protect Your Bottom Line

The $2.2 Billion Shift in Federal Marketplace Integrity

The Centers for Medicare & Medicaid Services (CMS) recently announced sweeping actions to eliminate fraud, waste, and abuse across the Federal Health Insurance Marketplace®. Backed by the White House Task Force to Eliminate Fraud, CMS cancelled approximately 315,000 unauthorized enrollments covering more than 760,000 individuals. This aggressive oversight push is slated to claw back roughly $2.2 billion in taxpayer-funded subsidies.

Led by HHS Secretary Robert F. Kennedy, Jr. and CMS Administrator Dr. Mehmet Oz, federal regulators are making one point abundantly clear: Data-driven enforcement and strict identity controls are no longer optional—they are the new baseline.

With a dedicated Federally-facilitated Exchange (FFE) anti-fraud coordination group now established, CMS is rolling out tighter requirements for brokers, agents, and health plans:

• Temporary Moratoria: A pause on 2027 plan year registrations for new brokers without active 2026 agreements.
• Strict ID Verification: mandatory re-identity proofing via Login.gov or ID.me for existing brokers.
• Data Verification Mandatory: Mandatory submission of verified Social Security Numbers (SSNs) or immigration IDs for non-newborn applications across all channels.
• Consumer Safeguards: Updating platforms to block brokers from hijacking self-service accounts on HealthCare.gov and mandating electronic consumer authorizations.

As CMS ramps up enforcement—issuing hundreds of termination notices to bad actors—health plans, clearinghouses, and health systems must ask themselves: Is our provider and broker data protected against these systemic vulnerabilities?

The Hidden Compliance Gap: Bad Data Drives Fraud

Whether it’s unauthorized broker enrollments or ineligible provider claims, fraudulent activity almost always exploits gaps in primary source data. Manual checks, name-only database searches, and periodic audit cycles create delays that bad actors exploit to process millions of dollars in improper subsidies or claims before being flagged.

To keep pace with CMS’s heightened enforcement standards, healthcare organizations need more than static point-in-time checks—they need a dynamic, continuously updated single source of truth.

How Verisys Shields Organizations from Healthcare Fraud and Abuse

At Verisys, we provide the data infrastructure, real-time primary source verification, and continuous monitoring needed to protect payment integrity and network compliance.

Here is how Verisys helps health plans and healthcare organizations meet CMS’s growing standards:

1. Industry-Leading Exclusion & Sanction Screening (FACIS®)

Unauthorized transactions often trace back to previously disciplined or sanctioned entities. Verisys’s proprietary FACIS® (Fraud, Abuse Control Information System) database aggregates data across more than 5,000 primary sources—including state boards, OIG, SAM, and federal exclusion lists. By screening brokers, providers, and entities against the industry’s most comprehensive dataset, you eliminate blind spots and avoid costly civil monetary penalties.

2. Continuous True Monitoring vs. Point-in-Time Verification

Standard annual or monthly re-credentialing leaves months of potential risk exposure. Verisys delivers continuous primary source monitoring. The moment a license changes status, a disciplinary action is filed, or an exclusion occurs, automated alerts trigger instantly—ensuring non-compliant actors are identified before claims or enrollments are processed.

3. Identity Verification & Decisional Data Integrity

CMS is enforcing strict identity verification through SSN checks and electronic authorizations. Verisys’s Decisional Data Verification validates provider identities, credentials, licenses across all 56 U.S. jurisdictions, and background histories. Replacing manual reviews with automated robotics and true primary-source data prevents identity misrepresentation at onboarding.

4. Automated Payment Integrity

Improper payments erode operating margins and risk regulatory penalties. Verisys integrates seamlessly into payer workflows via API to verify provider credentials and eligibility before claims are adjudicated. This real-time validation supports pre-claim payment integrity and ensures federal subsidies and benefit dollars go where they belong.

Turn Regulatory Pressure into Network Security

The CMS crackdowns signal a broader shift toward proactive, data-driven integrity across the health insurance landscape. Organizations that rely on legacy auditing will remain exposed to compliance risk, while those leveraging continuous automated data verification will build stronger, more resilient networks.

Don’t wait for an audit or enforcement notice to expose vulnerabilities in your network.

👉 Discover how Verisys Provider Credentialing & Verification Solutions can automate your compliance workflows, mitigate fraud, and safeguard your health plan.