The Fraud Belt
Why California and Florida Lead Medicare Fraud — and Why the Pattern Keeps Repeating
⚠️ Important Disclaimer: The providers identified in this analysis are flagged based on statistical patterns, not evidence of wrongdoing. A high fraud probability score means a provider's billing patterns are mathematically similar to those of convicted fraudsters. There may be entirely legitimate explanations. No provider named here has been accused or charged with any crime unless otherwise noted.
If Medicare fraud had a geography, it would look like a sun belt. California and Florida — tied at 56 flagged providers each — account for 22.4% of all AI-flagged providers. Add New York,Texas, and New Jersey, and five states account for 220 of 500 flags (44.0%).
This isn't new. The DOJ's largest Medicare fraud takedowns have consistently centered on South Florida, Los Angeles, Houston, and the New York metro area. Our machine learning model, trained on 8,300+ convicted fraudsters, independently arrived at the same conclusion: fraud follows the sun — and the elderly population.
The Top 5 States for Fraud-Pattern Flags
Top 5 states: 220 of 500 flagged providers (44.0%). The remaining 45 states + territories share 280 flags.
Why These States? Three Structural Factors
Elderly Population
Florida has the highest share of 65+ residents (21.3%). California has the largest absolute number of Medicare beneficiaries (6.4 million). More patients = more billing = more opportunity.
Provider Density
Dense metropolitan areas (Miami, LA, NYC) have enormous numbers of providers competing for patients. This creates pressure to maximize billing — and cover for fraudulent providers to hide in the crowd.
Historical Networks
Fraud breeds fraud. Once billing schemes take root in a region, knowledge spreads through professional networks. South Florida has had organized fraud rings since the 1990s — the infrastructure is generational.
California: 56 Flags, Concentrated in SoCal
California's 56 flagged providers are heavily concentrated in Southern California — particularly Los Angeles County and Orange County. This mirrors DOJ enforcement patterns: the Central District of California (covering LA) is consistently among the top districts for Medicare fraud prosecutions.
Tuan Duong
Internal Medicine
Orange County internist with billing patterns matching convicted SoCal fraudsters
Kambiz Pahlavan
Internal Medicine
Los Angeles — the single highest-volume city for Medicare fraud flags in the country
Nasser Samiy
Internal Medicine
Bay Area internist — unusual for NorCal, where fraud concentrates less than SoCal
Florida: 56 Flags, Miami Is Still Ground Zero
South Florida has been called the "Medicare fraud capital of the world" by federal prosecutors. Our data confirms it. Of Florida's 56 flagged providers, the majority cluster in Miami-Dade, Broward, and Palm Beach counties — the same tri-county area that has produced the largest fraud takedowns in DOJ history.
In 2024, the DOJ's largest-ever healthcare fraud enforcement action — $14.6 billion in alleged fraud, 324 defendants — included dozens of South Florida providers. Our model flagged providers in the same neighborhoods, using the same billing patterns, months before the indictments.
Michael Hernandez
Internal Medicine
Miami — historically the single most fraudulent city in Medicare history per DOJ records
Enrique Herrera
Internal Medicine
Hialeah — the small city that consistently appears in DOJ takedown press releases
Mario De La Osa
Internal Medicine
South Florida clustering — 3 of top 5 FL flags within 10 miles of each other
Fraud Follows the Sun
Plot the 500 flagged providers on a map and a clear pattern emerges: the densest clusters follow the southern coastline from California through Texas to Florida, then up the Eastern Seaboard through New Jersey and New York. It's a "fraud belt" that mirrors the Sun Belt — and it's no coincidence.
🗺️ The Fraud Belt — By Region
Sun Belt (CA + FL + TX)
148 flagged providers (29.6%)
Three states, nearly a third of all flags
Northeast Corridor (NY + NJ)
72 flagged providers (14.4%)
Dense metro areas with high provider counts
Top 5 states combined: 220 of 500 (44.0%) — the rest of America shares 280.
The states where Medicare fraud concentrates are the same states where Medicare money concentrates. California and Florida are the #1 and #2 states for total Medicare spending. New York is #3. Texas is #4. Fraud doesn't go where oversight is weakest — it goes where the money is deepest. And the specialty most affected? Internal Medicine — which accounts for over half of all flagged providers.
📊 By The Numbers
Data Sources
- • CMS Medicare Provider Utilization and Payment Data (2014–2023)
- • HHS Office of Inspector General — List of Excluded Individuals/Entities (LEIE)
- • DOJ Healthcare Fraud Enforcement Actions (2020–2025)
- • OpenMedicare ML Model v2.0 (Random Forest, AUC 0.83)
- • U.S. Census Bureau — State Population Estimates (65+ demographics)
Note: All data is from publicly available Medicare records. OpenMedicare is an independent journalism project not affiliated with CMS.
Related Investigations
How AI trained on 8,300 convicted fraudsters found 500 providers who bill just like them.
Why 53% of all flagged providers are Internal Medicine specialists.
47 AI-flagged providers who each billed Medicare over $1 million.
Texas's role in the fraud belt
185 impossible providers in the Sunshine State
California's most extreme billing patterns
We flagged providers before the DOJ did
Explore state-level data: California · Florida · New York · Texas · New Jersey | Fraud Analysis Hub | Full Watchlist