How Pennsylvania Became America's Top Medicaid Fraud Prosecutor — and What That Really Means

Pennsylvania's Medicaid Fraud Control Section secured more criminal convictions than any other state in fiscal year 2025, according to the U.S. Department of Health and Human Services Office of Inspector General [1]. The 115 convictions put the state well ahead of Ohio, New York, Texas, and California, and recovered more than $41 million in misused Medicaid funding [2]. Attorney General Dave Sunday has made the achievement a centerpiece of his office's public messaging, but the numbers invite a harder question: does leading the nation in convictions mean Pennsylvania is better at catching fraud, or does it mean something more complicated?

The Numbers Behind the Lead

During FY 2025, the HHS-OIG's annual report on Medicaid Fraud Control Units ranked Pennsylvania first nationally in total criminal convictions and third in total charges filed [1]. The office filed charges in 115 cases and secured 115 convictions, including cases initiated in prior years [2]. The $41 million in recoveries came predominantly through criminal prosecutions rather than civil settlements [2].

Source: HHS OIG MFCU Annual Report FY 2025

Data as of Mar 1, 2026CSV

The previous fiscal year told a similar story. In FY 2024, the section filed fraud charges against 113 individuals, filed neglect and abuse charges against 6 more, and secured convictions in 74 cases, recovering more than $11.3 million [3]. The jump from 74 convictions in FY 2024 to 115 in FY 2025 — a 55 percent increase — represents a steep upward trajectory.

Nationally, all 53 MFCUs combined for 1,185 convictions in FY 2025: 856 for fraud and 329 for patient abuse or neglect [4]. Pennsylvania's 115 convictions accounted for roughly 10 percent of the national total, a significant share for one of 53 units [1].

What Pennsylvania Says It's Doing Differently

Sunday has pointed to inter-agency collaboration as the primary driver. "The reason why we are so successful and the reason the states that are successful are is because they're working as a team together. This is much greater than any individual office," he told Fox News [5]. That teamwork extends across partisan lines — Sunday, a Republican, has emphasized coordination with Democratic Governor Josh Shapiro's administration [5].

The state's Department of Human Services has also invested in front-end fraud prevention. Pennsylvania uses data analytics and predictive monitoring to review billing patterns for anomalies, with particular attention to service categories historically prone to fraud [6]. In the 2024-25 fiscal year, the state identified 657 cases of fraud through Electronic Visit Verification — a system that uses GPS and telephony to confirm that home-care workers are actually present when they clock in — recovering $584,000 [6]. Providers' billing records are also cross-referenced against death records to catch claims filed for deceased patients [6].

The AG's office receives approximately $12.8 million in federal HHS grant funding, which covers 75 percent of the unit's budget [5]. The remaining 25 percent comes from state appropriations.

The Return on Investment Question

Across all MFCUs nationally, the return on investment in FY 2025 was $4.64 recovered for every $1 spent, with combined criminal and civil recoveries approaching $2 billion [4]. Criminal recoveries alone reached $1.3 billion, a 35 percent increase over FY 2024 [4].

Source: HHS OIG MFCU Annual Reports

Data as of Mar 1, 2026CSV

Pennsylvania's $41 million in recoveries relative to its roughly $17 million budget (estimated from the federal share) suggests a return roughly in line with the national average. But ROI comparisons between states are imprecise because states vary widely in how they account for staff time, what counts as a "recovery," and whether civil settlements are included alongside criminal restitution orders.

The national ROI has also declined from historical highs. In FY 2012, MFCUs returned $13.54 per dollar spent; in FY 2021, $6.10 [7]. The FY 2025 figure of $4.64 represents a partial rebound from FY 2024's $3.46, but remains well below the levels seen a decade ago [7].

Who Gets Convicted: Provider Categories and Case Types

Nationally, personal care service attendants — workers who assist Medicaid beneficiaries with daily activities in their homes — accounted for 326 of 856 fraud convictions in FY 2025, or 38 percent [4]. This category dominates fraud statistics across all states, not just Pennsylvania.

Source: HHS OIG MFCU Annual Report FY 2025

Data as of Mar 1, 2026CSV

In Pennsylvania specifically, high-profile cases have spanned multiple provider types. The Broad Street Family Pharmacy case in Philadelphia involved nine individuals charged in a scheme to fraudulently bill up to $12 million for HIV drugs and antipsychotic medications that were never dispensed, resulting in $12.25 million in restitution [5]. Home care fraud has also featured prominently: a Berks County home care agency owner was sentenced to prison and ordered to pay more than $235,000 in restitution for billing Medicaid for services not provided [8]. In the western part of the state, twelve individuals were charged in an extensive conspiracy to defraud the Medicaid home care program [9].

These cases illustrate that Pennsylvania's convictions are not concentrated in a single provider sector but cut across pharmacies, home health agencies, and personal care services.

The Classification Question: Are Convictions an Apples-to-Apples Comparison?

Conviction counts alone can be misleading. States differ substantially in how they handle Medicaid fraud. Some pursue criminal prosecution aggressively; others resolve comparable cases through civil settlements, administrative sanctions, or provider repayment agreements. A state that secures more convictions is not necessarily finding more fraud — it may be choosing criminal charges where another state would impose a civil penalty.

The FY 2025 HHS-OIG report recorded 674 civil settlements and judgments alongside the 1,185 criminal convictions nationally [4]. States like New York and California — which have larger Medicaid programs and higher absolute spending — rely more heavily on civil recoveries. The largest civil recoveries by entity type in FY 2025 came from hospitals ($154 million), pharmaceutical manufacturers ($121 million), and clinical labs ($112 million) [4]. These high-dollar civil cases do not appear in conviction statistics but represent substantial enforcement activity.

Ohio, despite having the largest number of open investigations in FY 2025 (1,058), ranked behind Pennsylvania in convictions [1]. This gap may reflect a longer investigative pipeline, different charging standards, or a preference for building larger, more complex cases that take longer to resolve.

The Kaiser Family Foundation has noted a critical caveat in all Medicaid fraud statistics: "There is no comprehensive measure of actual fraud in Medicaid" [10]. Improper payments — which include documentation gaps, coding mistakes, and administrative errors — are routinely conflated with intentional fraud in public discourse. The distinction matters: 79 percent of Medicaid's improper payments in recent years resulted from insufficient documentation or missing administrative steps, not intentional deception [11].

The Political Landscape of Fraud Enforcement

Medicaid fraud enforcement has become increasingly politicized. In early 2026, the Republican-controlled House targeted ten predominantly Democratic-leaning states — including Pennsylvania — for Medicaid program integrity inquiries [11]. President Trump named California, Maine, Massachusetts, and Minnesota in his State of the Union address as states with fraud problems [11].

The Minnesota case has become a national reference point. Federal prosecutors described "industrial-scale" schemes in that state's personal care services sector, where the Integrated Community Supports program grew from $4.6 million to $170 million in payments between 2021 and 2024 [11]. CMS froze $260 million in Minnesota Medicaid payments in February 2026 [11]. Minnesota ranked seventh nationally in convictions for FY 2025 despite the scale of fraud identified there [5].

Pennsylvania occupies an unusual position in this political landscape. As a purple state with a Republican AG and a Democratic governor, it has been cited as a bipartisan success story — a contrast to the partisan framing that has defined fraud enforcement debates elsewhere [5].

Impact on Beneficiaries

When providers are convicted of fraud, the patients they served face immediate practical consequences. Beneficiaries who relied on a now-shuttered home care agency or pharmacy must find replacement providers, often in areas where Medicaid-accepting providers are already scarce.

The Georgetown University Center for Children and Families has documented this dynamic: when fraudulent providers bill for services not actually delivered, "enrollees who need services don't receive them, honest providers who would deliver the services are not being paid, and federal and state taxpayers are being bilked" [12]. The harm is double — patients lose access to care they thought they were receiving, and the Medicaid system loses resources that could have funded legitimate services.

The Kelly R. Gonzalez case in Pennsylvania illustrates the human stakes. Gonzalez, a caretaker, was convicted of felony neglect in February 2026 after failing to refill a patient's seizure medication. The patient died after ten days without the medication [5]. Cases like this fall under the abuse and neglect category — 329 of the 1,185 national convictions in FY 2025 — rather than financial fraud, but they represent a parallel track of enforcement activity that directly addresses patient safety.

Systematic data on how many beneficiaries lose access to care following provider fraud convictions, or how quickly replacement providers are found, is not routinely collected or published by HHS-OIG or state agencies. This represents a significant gap in the evidence base for evaluating the downstream effects of fraud enforcement.

The Defense Bar's Perspective

Healthcare fraud defense attorneys in Pennsylvania argue that the complexity of Medicaid billing creates inherent risk for providers, particularly smaller practices. Billing and coding rules span thousands of pages of regulations, and what prosecutors characterize as fraud can sometimes reflect confusion, inadequate training, or documentation failures rather than criminal intent [13].

The legal distinction between a billing error and fraud turns on intent — whether the provider knowingly submitted false claims. But proving intent is often ambiguous, and defense attorneys contend that aggressive prosecution can discourage providers from participating in Medicaid at all [13]. This concern is particularly acute for small or independent providers who lack the compliance infrastructure of large health systems.

Sunday's office has pushed back on this framing. In public statements, the AG has characterized prosecuted cases as involving clear criminal conduct rather than technical billing disputes. "We have an absolute moral duty to protect the most vulnerable amongst us," Sunday said [5]. The office has pointed to cases like the Broad Street Family Pharmacy — where medications were billed but never dispensed — as examples of unambiguous fraud rather than gray-area billing questions.

No published data specifically tracks whether Pennsylvania's Medicaid fraud convictions disproportionately affect immigrant-owned or minority-owned providers. The HHS-OIG does not collect demographic data on convicted providers, and the Pennsylvania AG's office does not publish such breakdowns. Without this data, claims about disproportionate enforcement remain difficult to evaluate in either direction.

What Other States Can Learn — and What Remains Unclear

Pennsylvania's conviction numbers are real, and the state's emphasis on collaboration between the AG's office, the Department of Human Services, and federal partners appears to produce measurable results. The use of Electronic Visit Verification and data analytics for billing anomaly detection represents a concrete, replicable approach.

But the evidence for whether peer states that adopt similar tools see comparable gains is limited. Minnesota expanded its own fraud unit from 32 to 50 staff in 2025-2026 and implemented its own data-driven approaches, yet its fraud problems were described as worse, not better [11]. This suggests that detection tools alone do not determine outcomes — the underlying structure of a state's Medicaid program, the provider landscape, and the political will to pursue criminal charges all play roles that are difficult to isolate.

The broader question of whether criminal conviction counts are the right metric for fraud enforcement effectiveness remains open. Civil recoveries, provider exclusions, and deterrence effects are harder to measure but may matter more for program integrity than headline conviction numbers. Pennsylvania leads on one metric. Whether that metric captures what matters most is a question the data alone cannot answer.

Data in this article is drawn from the HHS Office of Inspector General's Medicaid Fraud Control Units Annual Report for Fiscal Year 2025, the Pennsylvania Office of Attorney General, and independent policy analyses. Where specific state-by-state conviction figures beyond the top-ranked states were not available in published sources, this article notes the limitation.