Medicare fraud by state
Executive summary
Medicare fraud manifests unevenly across the country but the public record available in these sources does not provide a single, authoritative per‑state dollar tally; instead, enforcement actions and high‑profile cases point to concentrated activity and prosecutions in large states such as California, Texas and Florida while every state maintains investigative capacity through Medicaid Fraud Control Units (MFCUs) [1] [2] [3] [4]. Major federal sweeps and corporate settlements—most recently a $556 million Medicare Advantage settlement involving Kaiser affiliates in California and Colorado—underscore both the scale of alleged abuse and limits of public data for mapping fraud purely by state [5] [1].
1. How the map of Medicare fraud is drawn: prosecutions, recoveries and gaps in the data
Federal and state enforcement produce the clearest signals of where fraud is detected: the Justice Department’s 2025 national takedown charged defendants in dozens of states and identified schemes that caused roughly $703 million in alleged fraudulent claims to Medicare (with about $418 million paid on those claims) and involved participating state MFCUs from many named states including California, Florida, New York, Texas and others [6]. These aggregated enforcement figures are useful but incomplete because recoveries and indictments reflect investigations that concluded, not the totality of fraud that may be ongoing or undetected, and federal oversight sources such as HHS‑OIG publish enforcement actions but do not publish a consolidated, state‑by‑state fraud loss table in the materials referenced here [7] [6].
2. Hotspots and high‑profile cases that shape the state picture
California stands out in the recent reporting because the largest Medicare Advantage settlement to date involved five Kaiser Permanente affiliates based in California and Colorado that agreed to pay $556 million to resolve allegations they pressured clinicians to upcode diagnoses to inflate MA payments; Kaiser did not admit wrongdoing and characterized the case as reflecting industrywide challenges [5] [1]. Texas has seen headline schemes—state prosecutors and the Texas Attorney General’s Medicaid Fraud Control Unit have publicly tied arrests and large alleged billings to companies like ApolloMDx and other actors accused of fraudulently billing Medicare hundreds of millions—illustrating that enforcement in Texas is active at both state and federal levels [2]. Florida remains prominent in strike‑force and ICE announcements tied to schemes that used kickbacks, patient recruiters, and falsified orders to seek Medicare payments [3] [8].
3. Why large, populous states often show more fraud activity—detection, not necessarily more criminality
The convergence of large beneficiary populations, more providers and more complex Medicare Advantage markets means states such as California, Texas and Florida will naturally appear frequently in enforcement results; DOJ press releases and multi‑district takedowns routinely list these states among participants, but that pattern can reflect greater detection resources, larger fraud markets and multi‑jurisdictional investigations rather than a simple per‑capita measure of criminality [6] [8]. Moreover, Medicaid MFCUs operate in all 50 states (plus territories), and their annual reporting documents convictions and recoveries state by state for Medicaid, but the documents cited here do not translate directly into a neat Medicare fraud ranking by state [4].
4. Trends to watch that will reshape where and how fraud occurs
Enforcement is increasingly multi‑agency and technology‑focused: DOJ, HHS‑OIG, FBI and Strike Force teams have expanded actions against telemedicine and lab referral schemes that produced more than $1.1 billion in alleged Medicare claims in some telemedicine cases, and outside counsel predicts algorithmic and AI‑related risks will be next frontiers for scrutiny—factors that could shift both the geography and modality of fraud [8] [9]. Meanwhile, outreach and beneficiary education programs such as Medicare’s fraud reporting guidance and Medicare Fraud Prevention Week aim to improve detection at the local level, which will influence where fraud is reported and pursued [10] [11].
5. What the record does and does not allow: a cautious takeaway
The available sources document large multistate enforcement operations and notable state focal points—California, Texas and Florida recur in high‑value cases and takedowns—but none of the cited materials provides a definitive, up‑to‑date table of Medicare fraud losses by state, and recoveries are a lower bound on actual fraud given undetected schemes and administrative “improper payments” that may reflect error as well as criminality [6] [12]. Readers should treat state mentions in DOJ and state AG releases as indicators of enforcement activity and investigative prioritization rather than a precise measure of per‑state fraud prevalence; further, published trends indicate enforcement will continue to target Medicare Advantage coding, telemedicine and lab referral networks while expanding scrutiny of AI and platform‑driven conduct [5] [8] [9].