Centers for Medicare & Medicaid Services administrator Dr. Mehmet Oz speaks before Vice President JD Vance at the Wisconsin Air National Guard facility at Milwaukee Mitchell International Airport, Wednesday, July 8, 2026, in Milwaukee. (AP Photo/Mark Schiefelbein, Pool) Last month, the Department of Justice announced its 2026 National Health Care Fraud Takedown: 455 defendants charged and $6.5 billion in alleged false claims, with cases spanning 56 federal districts. The number of defendants charged was nearly 40 percent higher than in the prior year.
This week, the House Energy and Commerce Subcommittee on Oversight and Investigations convened a hearing on exactly this problem, taking testimony from state Medicaid directors in California, Minnesota, New York and Ohio.
These announcements follow a familiar rhythm: Charges are filed, hearings are held and the numbers get bigger. What does not change is the underlying vulnerability.
Earlier this year, my team conducted a field investigation of home healthcare agencies in Columbus, Ohio, starting with public data: provider-level reimbursement records from the Department of Health and Human Services Open Data Platform, corporate registrations and licensing filings.
One agency had received approximately $11.1 million in Medicaid payments since 2018. Its website used stock photographs. Its contact email was a Gmail address. When we called, someone answered with a single word: “Hello.” We didn’t see a business name, and we didn’t receive a proper business greeting. We explained that we were looking for a caregiver for an elderly relative, and the person on the line said no caregivers were available before ending the call. We visited in person and found an office with cubicles but no intake process and no available caregivers. We left our number, but no one called back.
None of that proves fraud conclusively. Home healthcare is a sector where small offices are legitimate, staffing shortages are real, and a Gmail address is not a crime. But all of those observations create is a signal, and the point of our investigation was methodological: That signal was visible in public data before we drove to Columbus.
That all matters, because a mid-sized home healthcare agency billing several million dollars annually in Medicaid reimbursements typically supports 150 to 250 active patients, employs 12 to 18 administrative staff and operates from a commercial office of 2,500 to 4,000 square feet. This reflects the operational reality of coordinating hundreds of caregivers, processing thousands of billable hours weekly and managing payroll, compliance and billing simultaneously.
Billing volume, in other words, is a proxy for operational scale. When those two things clearly diverge, that divergence is observable in data that is already public.
The House Oversight Task Force examining Ohio Medicaid waiver fraud put estimated losses in Ohio’s personal care services program alone at $1.2 billion. A March 2025 Inspector General report found that 36 percent of all convictions reported by state Medicaid Fraud Control Units in fiscal year 2024 involved personal care services — more than any other program type.
This is the dominant fraud category in Medicaid enforcement, concentrated in exactly the sector where providers’ physical footprints are hardest to verify and where billing volume most clearly signals what the operational reality should look like.
The deficiency at the center of this problem is not complicated. The systems responsible for enrolling and paying Medicaid providers are not routinely asking whether a provider’s operational reality matches its billing profile. They should be.
Enrollment processes check licenses, verify provider numbers and confirm tax IDs, but they do not systematically ask whether the address associated with a $5 million annual billing operation looks like one. That question is answerable with public data, without even so much as a site visit. It requires only an analytical framework that treats billing volume as a proxy for operational scale. This can flag cases where the two diverge for a closer look.
Florida has already moved in this direction recently. Gov. Ron DeSantis (R) announced a Medicaid integrity initiative that includes enhanced provider screening, an enrollment moratorium in high-risk provider categories and a comprehensive statewide revalidation of all active Medicaid providers.
The question is whether other states will follow before the next round of criminal charges is filed.
The fraud targeting Medicaid home healthcare does not require sophistication. It requires only a registered address, a provider number and a system that processes paperwork without checking whether any of the filings reflect reality.
The operational reality of a functioning agency is harder to fake than the documents that describe it — but only if someone is actually looking.
The data to support that scrutiny is already public. All that has been missing is the institutional commitment to treat mismatches between billing and observable reality as a signal worth following up on every time — not just when a research team drives to Columbus and knocks on a door.
David Maimon is head of Fraud Insights at SentiLink and director of the Evidence-Based Cybersecurity Research Group at Georgia State University. SentiLink provides identity verification services to state Medicaid programs, including Florida’s Medicaid integrity initiative.
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