New York's Hidden Medicare Fraud
39 AI-Flagged Providers — The #3 State That Flies Under the Radar
⚠️ 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.
While California and Florida grab the headlines, New York quietly ranks #3 with 39 AI-flagged Medicare providers. These providers billed Medicare over $30 million combined, and the flags cluster heavily in Brooklyn and Queens — two boroughs with long histories of Medicare fraud enforcement actions.
The Brooklyn and Queens Connection
If South Florida is America's #1 Medicare fraud hotspot, Brooklyn and Queens are a close second. The DOJ's Eastern District of New York — which covers Brooklyn, Queens, Staten Island, and Long Island — has been one of the most active jurisdictions for healthcare fraud prosecutions for over two decades.
The reasons mirror South Florida in many ways:
- Dense elderly population: Brooklyn alone has more Medicare beneficiaries than many entire states
- Ethnic enclaves: Tight-knit communities where patient recruitment for fraud schemes can operate through word-of-mouth
- Small practice density: Thousands of solo and small-group practices, many in storefront clinics that are difficult for CMS to audit
- Established fraud infrastructure: Decades of prosecution have not eliminated the underlying networks
Brighton Beach, Flatbush, and parts of southern Brooklyn have been particularly targeted in DOJ actions. Queens neighborhoods including Flushing, Jamaica, and Elmhurst have also featured prominently in Medicare fraud cases.
A Different Specialty Mix
One thing that distinguishes New York from California and Florida is the specialty diversity among flagged providers. While CA is dominated by Internal Medicine and FL shows a mix of IM and Family Practice, New York's flags include:
- Internal Medicine — still the most common, consistent with national patterns
- Family Practice — the second most common specialty among NY flags
- Nurse Practitioner — the highest-probability flag in NY is an NP, reflecting the growing role of mid-level providers in Medicare billing
- Physical Medicine & Rehabilitation — a specialty that has seen increasing fraud attention, particularly around unnecessary therapy and pain management services
The inclusion of Physical Medicine is notable. PM&R fraud often involves billing for unnecessary physical therapy sessions, pain injections, and rehabilitation services. Several recent DOJ actions in the New York area have targeted PM&R practices, particularly those offering "comprehensive pain management" that amounts to assembly-line billing.
Top 5 Flagged New York Providers
These five providers have the highest fraud probability scores among New York's 39 flagged providers.
Highest fraud probability among NY providers. Over $1.6M in Medicare billings — unusually high for a Nurse Practitioner, a pattern commonly seen in fraud schemes where NPs bill under physician supervision arrangements.
Brooklyn Family Practice provider flagged for billing patterns matching convicted fraudsters. Brooklyn has historically been one of the highest-fraud zip codes in the country.
Another Brooklyn internist — the borough's dense healthcare market and Medicare population make it a natural fraud concentration point.
Queens-based provider with over $1.3M in billings. Queens and Brooklyn together account for a disproportionate share of NYC Medicare fraud flags.
Queens internist with lower payment volume but billing patterns that still match convicted fraudsters — proof that fraud detection isn't just about dollar amounts.
Historical Enforcement in New York
New York has been the target of numerous major Medicare fraud enforcement actions:
- Brighton Beach Medical Mill Prosecutions (2012–2018): A series of cases targeting clinics in Brighton Beach, Brooklyn, that billed Medicare for unnecessary diagnostic tests and services
- Queens Physical Therapy Ring (2019): Multiple physical therapy practices in Queens charged with billing for sessions that never occurred or were medically unnecessary
- Brooklyn Home Health Sweep (2016): DOJ action against home health agencies billing for phantom visits to homebound patients
- Long Island Prescription Mill Cases (2020): Providers on Long Island charged with running prescription mills and billing Medicare for unnecessary office visits
Why "Hidden"?
We call New York's fraud problem "hidden" not because it's unknown to law enforcement — it's not — but because public attention and media coverage disproportionately focus on Florida and, to a lesser extent, California. New York's 39 flags represent 7.8% of all 500 flags, making it the clear #3 state. Yet it rarely appears in the same "fraud capital" narratives as Miami or LA.
This matters because attention drives resources. The Medicare Fraud Strike Force has operations in New York, but the scale of enforcement has historically been smaller than in South Florida. As our data shows, the billing patterns that match convicted fraudsters are alive and well in Brooklyn, Queens, and across the New York metro area.
New York Medicare Fraud — Key Numbers
Data Sources
- • CMS Medicare Provider Utilization and Payment Data (2014–2023)
- • HHS Office of Inspector General — List of Excluded Individuals/Entities (LEIE)
- • DOJ Eastern District of New York — Healthcare Fraud Prosecutions (2012–2025)
- • OpenMedicare ML Model v2.0 (Random Forest, AUC 0.83)
- • U.S. Census Bureau — New York Population Estimates (65+ demographics)
Note: All data is from publicly available Medicare records. OpenMedicare is an independent journalism project not affiliated with CMS.