The Centers for Medicare and Medicaid Services is ramping up attention to healthcare fraud.After Minnesota’s scandal, the Trump administration targeted mostly Democratic states.Medicaid fraud usually involves providers, not low-income people trying to game the system.<\/p>\n
Is Medicaid rife with fraud, as the Trump administration suggests? It\u2019s a claim that was bolstered in late 2025 with news that Minnesota\u2019s Medicaid program paid millions for fraudulent services including adult day care for people with disabilities, home health services and autism therapy, among others.<\/p>\n
That discovery put new energy \u2014 and more headlines \u2014 into the search for Medicaid scofflaws.<\/p>\n
The responsibility for ensuring program integrity day to day falls largely on states.<\/p>\n
Experts agree that it\u2019s \u201creally hard\u201d to measure if a state is doing well at catching Medicaid fraud. While every state receives federal funding for the healthcare program for low-income people and provides matching dollars, state procedures vary. <\/p>\n
Some who work with Medicaid say the federal government could do more to elevate best practices and provide solid tools to catch fraud both before and after it happens. The federal government seems to agree. <\/p>\n
Vice President JD Vance and Centers for Medicare & Medicaid Services administrator Mehmet Oz announced changes to Medicaid fraud detection earlier this month, detailing a 50-state workbook to promote best practices, and promised inquiries to all states about prosecution. <\/p>\n
Funding to state agencies charged with fraud detection will be shut off if state procedures are deemed unsatisfactory, they said. <\/p>\n
Medicaid fraud has made national headlines for months, starting in Minnesota, but while both Republican and Democratic-led states are included on the administration\u2019s lists the Trump administration\u2019s expanded efforts have a particular focus on states led by Democrats. <\/p>\n
The administration said it won\u2019t solely target blue states and the effort is bipartisan but that, \u201cunfortunately,\u201d most of the fraud happens in Democrat-led states. <\/p>\n
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Vice President JD Vance and Administrator for the Centers for Medicare & Medicaid Services Dr. Mehmet Oz walk to the podium ahead of their remarks on the administration’s efforts to combat fraud during a news conference in the Old Eisenhower Executive Office Building on the White House campus Wednesday, Feb. 25, 2026, in Washington. | Tom Brenner, Associated Press <\/p>\n
Critics of the Trump administration\u2019s hyper-focus on Democrat-led states said fraud likely exists in states led by Republicans, too, but may go undiscovered if the administration keeps its focus on blue states. <\/p>\n
Those tasked with finding fraud in the program agree Medicaid providers, not Medicaid recipients, commit most of the fraud. They say waste is another money-eater that prevents people who need help from getting it.<\/p>\n
What fraud is \u2014 and isn\u2019t<\/p>\n
In Utah, the Office of the Inspector General has a legal mandate to investigate problems with Medicaid, the goal to guard taxpayer dollars. Former interim inspector general Neil Erickson told the Deseret News that Utah\u2019s biggest money problem with Medicaid is waste. In Utah alone, officials recently documented<\/a> $24 million in unnecessary Medicaid payments. But it\u2019s hard to get a national tally.<\/p>\n Fraud, he said, is \u201cmuch less common.\u201d<\/p>\n Most fraud, Erickson said, comes from those contracted to provide care, not from low-income people taking advantage of the system. And often it\u2019s not fraud, but someone who needs better training on how to bill and how the program works.<\/p>\n Said Elise Napper, the office\u2019s policy and training manager, \u201cThere seems to be a big perception that a lot of beneficiaries are out there defrauding willy-nilly. In our experience, the majority of the funds that go out tend to be related to a provider situation.\u201d<\/p>\n Deliberate fraud by providers can include:<\/p>\n Billing for services never provided or provided by someone who\u2019s not qualified.Upcoding \u2014 claiming the provider performed a service that is paid at a higher rate than the actual service would have been.Taking pieces of a procedure that should be billed together and billing them separately to inflate cost.<\/p>\n The primary line of defense against Medicaid fraud is the state Medicaid agency and state law enforcement, typically Medicaid Fraud Control Units, said Andy Schneider, a Georgetown University Center for Children and Families researcher.<\/p>\n Often, attorneys general\u2019s offices also investigate healthcare fraud but there\u2019s wide variation. Utah, for example, also tasks its Office of Inspector General with investigating Medicaid fraud, while California has a Division of Medi-Cal Fraud and Elder Abuse that each year recovers money as part of the attorney general\u2019s efforts.<\/p>\n Kaye Lynn Wootton, director of the Utah Medicaid Fraud and Patient Abuse division in the Utah Attorney General\u2019s Office, is president of the National Association of Medicaid Fraud Control Units. She described different Medicaid schemes, some quite complex, and recently testified before Congress, outlining several types of fraud seen in multiple states. <\/p>\n Her list includes hospice fraud that enrolls patients who are not terminally ill. Patients may be recruited specifically to defraud Medicaid and taxpayers. A hallmark is a very long stay in care, followed by a live discharge because hospice services were never needed.<\/p>\n Some people do get better legitimately, defying expectations. \u201cMaybe they\u2019re actually providing great service, right?\u201d Wootton said. \u201cIt takes a lot of expertise from nurses, auditors, investigators, attorneys to figure out what part is truly fraudulent and should be either prosecuted or handled civilly.\u201d<\/p>\n \u201cBy the time a referral comes to our division,\u201d she said, \u201cpeople are viewing it as a credible allegation of fraud.\u201d <\/p>\n Individuals commit fraud, but it\u2019s rare While far less common, individuals can take advantage of Medicaid, Napper said. Both income thresholds and asset limits can be falsified.<\/p>\n She noted a case where someone with insurance didn\u2019t want to pay the copay, so he didn\u2019t tell Medicaid he had insurance. That\u2019s fraud. Medicaid pays only if no one else can be billed.<\/p>\n Deliberate fraud can include sharing an ID number so someone else receives services. That can also make medical records inaccurate and impact future care, among other challenges.<\/p>\n Fraud usually has a money motive, Napper said, and may create risk to an individual. Sometimes both. People are harmed if their provider isn\u2019t qualified. <\/p>\n A news release<\/a> from the Utah Attorney General\u2019s office last October highlighted a case, noting the conviction of a former program director of a behavioral health company sentenced in a $13 million fraud scheme involving Utah Medicaid. Medicaid received more than 7,700 false claims for substance abuse treatments that didn\u2019t happen or were not provided by qualified staff. Others have also been convicted in the case or have cases in the court system. <\/p>\n Transportation fraud is another category. Drivers may bill for what Wootton called \u201cghost rides,\u201d where no ride was provided or the person on Medicaid was driven long distances for non-medical reasons.<\/p>\n Erickson said the Utah Inspector General\u2019s Office has even seen cases where a relative refilled a prescription after the Medicaid beneficiary died.<\/p>\n Among those hurt by Medicaid fraud are people who qualify for Medicaid but are on waiting lists because there aren\u2019t enough resources.<\/p>\n A small sampling of real cases that hurt individuals who were supposed to be served by the program: <\/p>\n U.S. Assistant Attorney General Colin Michael McDonald said<\/a> a Minnesota man with disabilities was supposed to receive constant care. Instead, he fell victim to a fraudster and died.Per Napper, people may lose access to a benefit because someone obtained their Medicaid information and used it, like by getting a vaccine or a procedure. If that benefit has been used, the person entitled to it can\u2019t get it without a battle. It also creates an inaccurate medical record that could be nightmarish to fix.The Wisconsin Department of Justice<\/a> cited a case where a private duty nurse received a suspended sentence, probation and a fine. She was charged with billing Medicaid for dates and times she was not at the patient\u2019s residence. The nurse was charged with child neglect causing bodily harm because the child needed emergency treatment for dehydration and malnutrition. That child died.Wootton cited a Utah case where a woman used her power of attorney to drain her grandfather\u2019s assets, forcing him onto Medicaid.Between 2016 and 2024, there were at least 710,000 people on waiting lists to receive home and community-based Medicaid services, KFF reported<\/a>. Many states have waiting lists.<\/p>\n Napper said her office provides fraud, waste and abuse prevention training to Medicaid providers, helping them understand and comply with policies. The staff also looks into reports to their fraud hotline. <\/p>\n Training is especially important because the program is always changing. What was allowed at one time may no longer be and vice versa. \u201cWe wouldn\u2019t hold a provider responsible for a policy that was in place a year later,\u201d Napper said. <\/p>\n Utah\u2019s inspector general can follow Medicaid dollars into adjacent agencies. And adjacent issues can tangle up and become Medicaid fraud. <\/p>\n Wootton said Utah\u2019s fraud cases by Medicaid beneficiaries are handled through the Department of Workforce Services, with an assistant attorney general assigned. Her office looks at recipient fraud if it\u2019s committed in collusion with a provider.<\/p>\n YouTube sensation sparks Medicaid frenzy In December 2025, independent Utah YouTube journalist, Nick Shirley, now 24, posted a video looking into the allegations of billions of dollars in fraud in Minnesota. The video showed Shirley investigating Somali-owned healthcare companies and knocking on adult-daycare facility doors in the state. It racked up millions of views. <\/p>\n It caught the eye of Vance and tech billionaire Elon Musk, propelling Shirley to stardom. However, some of the claims in Shirley\u2019s video have been disputed or remain unverified. The viral video likely fueled the heightened attention on Minnesota, but investigations there were already ongoing, as the Deseret News<\/a> reported. <\/p>\n Scrutiny of Minnesota\u2019s public services began during the Biden administration. In December 2024, the FBI raided two autism treatment providers and attention grew from there. <\/p>\n The U.S. House Oversight Committee last December began investigating Minnesota\u2019s social programs, including Medicaid. A hearing was held in January \u2014 a tense time for all things Minnesota with federal officials conducting immigration enforcement raids, which resulted in protests and the deaths of two American citizens<\/a>.<\/p>\n Vance, dubbed America\u2019s \u201cfraud czar,\u201d had already been tasked with investigating fraud in Minnesota, but President Donald Trump signed an executive order<\/a> in March creating the new task force. He directed Vance to look at social services and fraud nationally.<\/p>\n The focus on Minnesota heightened when Gov. Tim Walz announced<\/a> he would not seek a third term amid fraud case pressure. <\/p>\n Meanwhile, state prosecutors charged individuals in multimillion-dollar Medicaid fraud cases. The state halted or delayed payments to providers in many programs even before fraud findings expanded. They also stopped enrolling new providers and launched a massive review of existing providers in programs state officials deemed high risk.<\/p>\n Under the administration\u2019s Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative, CMS increased its focus in Minnesota, California, Maine, New York and Florida. CMS wants answers to questions about state practices to \u201cuncover suspicious healthcare.\u201d<\/p>\n Is CRUSH initiative partisan?<\/p>\n The initiative shows that CMS is shifting from a stance of \u201cpay and chase\u201d to withholding money from states where fraud is suspected.<\/p>\n \u201cCertainly the administration has been placing a sort of new emphasis on addressing fraud in the government at large with a particular focus on Medicaid,\u201d Robin Rudowitz, vice president of KFF, told the Deseret News. <\/p>\n Rudowitz, who authored an article detailing changes at CMS, compiled a list<\/a> of CMS and congressional inquiries. CMS has inquiries out in the five states and the House Energy and Commerce Committee sent inquiries to those and seven others. Of the states currently being examined by Congress or CMS, just Nebraska and Florida are led by Republican governors. <\/p>\n Rudowitz said it\u2019s not known why some states stood out to the administration originally, but critics accuse the choices as political. <\/p>\n Florida in particular is causing some controversy. The CMS letter to Republican Gov. Ron DeSantis was sent the same day the House Energy and Commerce Committee held a hearing with CMS deputy administrator Kim Brandt. <\/p>\n Democrats on the committee said it was \u201cpainfully obvious\u201d the administration was targeting blue states and \u201cweaponizing\u201d fraud. GOP members countered that \u201cif anything could be bipartisan,\u201d it would be rooting out fraud in Medicaid. They pointed to the Florida letter as proof the administration isn\u2019t targeting Democratic states alone. Utah GOP Rep. Mike Kennedy also joined the conversation, saying at a roundtable event<\/a> that fraud should concern Republicans and Democrats alike. <\/p>\n Still, Schneider highlighted how the letters sent to Democrat-led states differed from the CMS\u2019 letter to Florida. <\/p>\n Schneider, who acknowledged he\u2019s partisan and was a political appointee under former President Barack Obama, said that \u201cyou can draw your own conclusions\u201d about the letters, but noted the Democratic governors received letters written in a \u201cpretty belligerent and aggressive tone,\u201d while the one to DeSantis had \u201cfar less questions\u201d and was \u201cfar more deferential.\u201d <\/p>\n But Vance maintains \u201cthis does not have to be a red state or blue state issue. This is just basic good government.\u201d Still, the administration\u2019s focus is on Democrat-led states, he said, because \u201cwe also unfortunately have some states\u201d not taking fraud seriously. <\/p>\n More federal help to streamline<\/p>\n \u201cThere\u2019s an old adage \u2026 \u2018If you\u2019ve seen one Medicaid program, you\u2019ve seen one Medicaid program,\u2019 because they all operate within broad federal rules in different ways,\u201d Rudowitz said. <\/p>\n \u201cThere\u2019s an old adage \u2026 \u2018If you\u2019ve seen one Medicaid program, you\u2019ve seen one Medicaid program,\u2019 because they all operate within broad federal rules in different ways.”<\/p>\n \u2014 \u00a0 Robin Rudowitz, vice president of KFF<\/p>\n Long-time Medicaid experts agree it\u2019s hard to track fraud across states. States differ on how they administer Medicaid, but also on fraud detection, prosecution and prevention. <\/p>\n Schneider, with more than 50 years\u2019 experience with Medicaid, said fraud in Medicaid or Medicare can\u2019t be quantified. <\/p>\n \u201cWhat we do have data on is successful prosecutions and we do have data on the number of investigations at the state level,\u201d Schneider said.<\/p>\n Wootton said the national association not only trains and meets regularly nationwide, but convenes regionally so chief investigators and directors discuss fraud trends proactively. While most investigations are done quietly, she said when a scheme in Nevada spilled into Arizona, the two shared it with others, believing it would move to other states. Within a week, it did. <\/p>\n She emphasized there are many good providers, but fraudulent ones are becoming \u201cmore sophisticated and brazen to try to hit multiple states before getting caught.\u201d<\/p>\n Asked by the federal government what else can be done at the federal level, several states and experts offered suggestions. <\/p>\n The 2025 report<\/a> from the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) compiles each state\u2019s data on how many investigations have been started, the number of indictments and convictions related to Medicaid fraud, staff size and how much money each state recovered from fraud. <\/p>\n But Schneider called that data incomplete and unable to prove more fraud happens in one state or another. One may pour more resources into prosecuting fraud, while another might put more into preventing it. MFCU staff sizes vary and include different combinations of experts, including those from medical, investigative and legal fields. <\/p>\n He said the report provides a basis for states doing well to consider why and whether they could do better. States doing poorly could consider ways to improve. \u201cBut honestly, for me, those are the kinds of things that OIG and CMS and (the Center for Program Integrity) should be doing. That\u2019s where the federal government can be helpful.\u201d <\/p>\n Scott Peterson, spokesman for the Minnesota Department of Human Services, said both state and federal agencies are tasked with preventing, tracking and dealing with fraud. Among Minnesota\u2019s \u201clong-running partnerships\u201d are Minnesota\u2019s MFCU, Minnesota\u2019s Bureau of Criminal Apprehension, and federal agencies, including Health and Human Services, the FBI and Minnesota\u2019s branch of the U.S. Attorney\u2019s Office. <\/p>\n His department must refer fraud suspicions to the MFCU, but has increasingly sent cases to other prosecuting agencies when MFCU can\u2019t take on a case. \u201cWe have especially increased our cases sent to BCA in recent years,\u201d he said by email.<\/p>\n Tackling fraud together<\/p>\n \u201cThe federal government can support those efforts financially. It can help provide information about what\u2019s working in one state to other states, best practices, tool kits and it can do periodic \u2026 reviews of how each state is doing so they get a better sense of how they\u2019re doing vis-a-vis their peers,\u201d Schneider said.<\/p>\n Brandt told the House committee in March that the federal government plans to improve how it works with states on Medicaid fraud. <\/p>\n She didn\u2019t confirm how many more letters will go out and which states they would focus on, but said CMS wants to create a \u201c50-state playbook\u201d this year that highlights best practices. <\/p>\n CMS declined to provide an on-the-record response, but according to public comments made by Vance, Oz and Brandt, the administration plans a more aggressive stance on fraud and will play a larger role in leading states \u2014 a departure from the administration\u2019s stated policy of returning more power to states and leaving the federal government out of certain matters. <\/p>\n Oz said he believes that half of the country\u2019s fraud is related to healthcare. The administration created a \u201cMedicaid War Room,\u201d using artificial intelligence<\/a> and sought public comment<\/a> earlier this year to improve CMS fraud detection efforts. <\/p>\n The planned playbook will help officials understand \u201cstates where their data shows there\u2019s high instances of fraud, what is it that\u2019s working, what is it that\u2019s not working and how can we help them to learn from others or how can we help other states be able to build better safeguards,\u201d Brandt said. <\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2026\/05\/XEEQVBKM5BCKJLHGN33SZNBTGY.JPG\")
The door to the office of Utah Attorney General Derek Brown at the Capitol in Salt Lake City on Monday, June 30, 2025. | Scott G Winterton, Deseret News <\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2026\/05\/EXINL2A2PBF7PC6N4DFDF5O43Q.JPG\")
Nick Shirley speaks during an event held by the Utah Federation of College Republicans at the University of Utah in Salt Lake City on Friday, April 10, 2026. | Isaac Hale, Deseret News <\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/us\/wp-content\/uploads\/2026\/05\/ZAYBLWKTMFBPRO3KWBDKUDFQII.png\")
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