State Medicaid fraud control unit aims to target more than health care providers

Indiana’s Medicaid Fraud Control Unit recently caught the attention of federal officials, and now investigators want to expand their reach to even more potential targets.

The unit of Attorney General Todd Rokita’s office was lauded by the U.S. Department of Health and Human Services earlier this month for a busy 2025 in which it secured 37 convictions and recovered $144 million.

That came from focusing on catching fraud committed by health care providers like doctors or nursing homes. Now, unit director Matt Whitmire is asking federal officials to allow it to investigate any kind of fraud, including that committed by people who receive the benefits.

“This will allow the (unit) the ability to address more issues impacting Indiana taxpayers,” he wrote in an e-mail.

An evolving target

Medicaid is the state- and federally funded insurance program that pays for health care for people with low incomes. More than 1.8 million Indiana children and adults were enrolled in the program last year, according to the nonprofit KFF, a health policy research organization.

Medicaid spending in the state totaled more than $17 billion, according to KFF.

Whitmire said he couldn’t say whether fraud cases have increased or decreased in the state. But he did note that fraudsters’ schemes change as the program’s weaknesses are discovered.

“Over the years, different provider types or specific programs have been more vulnerable to attack than others,” he wrote in an e-mail. “The target and method of welfare fraud certainly change, but the amount of change is only commensurate with the change in the size of the program — which has increased with the Affordable Care Act expansion of Medicaid.”

Indiana is one of 41 states, including Washington, D.C., that have expanded Medicaid eligibility under the federal act, according to KFF. The Medicaid expansion made coverage available to individuals with incomes up to $21,597.

Federal officials recognized Indiana’s fraud control unit as one of the best in the country during an Aug. 11 ceremony at the Statehouse. Indiana Attorney General Todd Rokita noted that Indiana’s fraud unit was singled out by Vice President JD Vance.

“Recently, in assuming leadership of the federal government’s Anti-Fraud Taskforce, Vice President Vance pointed to you. He pointed to Indiana’s fraud unit as an example to other states of how to run their units,” he told unit members during the ceremony.

Rokita also noted that within the past 12 months, the Indiana unit secured more than 50 indictments or charges, more than 40 convictions, and referred 60 individuals for exclusion from the Medicaid program.

How is Medicaid fraud discovered?

How often Medicaid fraud happens is also not something that can be reliably measured, according KFF. Its researchers say measuring fraud is difficult partly because it can only be determined with certainty after the fact.

That doesn’t mean fraud isn’t recognizable.

In July, Indiana’s fraud unit charged six people stealing $10.9 million from Medicaid.

The six individuals were affiliated with Senior Home Care Agency, a Mooresville-based agency. That included Alexander Byrnes, 39, who authorities say was the acting owner of the agency.

According to the Indiana Attorney General’s Office, Byrnes is barred from operating a personal services agency because of his criminal record. To get around that restriction, arrest records allege, Byrnes used a proxy to claim ownership of the company on paper and obtain a personal services agency license.

Indiana’s fraud unit says Byrnes established a practice of billing for maximum authorized hours despite no services being provided.

Byrne’s attorney did not respond to The Indiana Lawyer’s request for comment. She told IL “no comment” for a previous story about the allegations.

In 2025, Indiana, New York, Colorado and Georgia accounted for half of the $706 million in total Medicaid civil recoveries, according to a report from the United States Department of Health and Human Services Office of Inspector General.

In its report, HHS cites a case in which the Indiana fraud unit investigated an unnamed hospital system, which eventually paid out a $135 million settlement after a whistleblower filed a suit alleging the system paid physicians it directly employed or contracted with to refer patients to the network’s facilities.

Such conduct is considered a “kickback,” which, according to the National Association of Attorneys General, is one of the most common avenues for fraud.

Other schemes include providers billing Medicaid for a service that was never provided (phantom billing) and billing Medicaid for a more expensive good/service than the one provided (upcoding).

Providers engaged in these schemes are investigated by Medicaid fraud units that are established by federal statutes, but they investigate fraud in accordance with their state’s laws.

Indiana’s Medicaid Fraud Control Unit was first certified June 24, 1982, and is recertified each year by the U.S. Department of Health and Human Services Office of Inspector General.

Units must be recertified to receive an annual grant from the federal government. Indiana’s unit receives approximately $8.9 million each year, according to a 2026 recertification letter from HHS.

Approximately 75% of the unit’s funding comes from the federal government, according to a press release from the Indiana attorney general.

Recertification also accompanies a performance review. Federal officials look at the unit’s referrals, staffing and how effectively it prosecutes fraud.

How many alleged fraud cases are prosecuted?

Indiana’s unit employed 58 members as of Aug. 11, according to Josh DeFonce, the Indiana AG’s director of communications.

Those members include attorneys, criminal investigators, auditors and other support staff, according to Whitmire, who develop investigations based on data mining leads and complaints received.

“After investigators complete an investigation with the assistance of auditors and attorneys, the case is evaluated for criminal, civil, or licensing action,” he said, explaining the investigation process. “The cases are prosecuted, for the most part, by attorneys in the (fraud unit) when cases are referred from county prosecutors for litigation pursuant to Indiana Code. Otherwise, local prosecutors or the various U.S. attorney offices prosecute (the fraud unit’s) cases.”

“The (fraud unit) also litigates civil cases to recoup lost taxpayer money and/ or licensing cases before the Indiana Professional Licensing Agency to hold license holders responsible for violations,” Whitmire continued.

Whitmire noted that only a small number of investigations are prosecuted after investigators establish both the facts and that the subject intended to defraud Medicaid.

“At any one point, the (fraud unit) might have over 600 fraud cases under investigation — certainly not all those cases will result in a prosecution,” he explained. “Criminal, civil, and licensing enforcement options are all considered at the conclusion of each (fraud unit) investigation — all three actions or no action might be appropriate based on the facts of any given case.”

The attorney general’s office has been advocating for the “STOP FRAUD in Medicaid Act,” which was introduced in Congress and would expand the unit’s jurisdiction to cover individual Medicaid recipients.

Whitmire said that while Medicaid fraud has always existed, more resources and attention are being expended to fight it.

“This is a positive step in ensuring the limited benefits in the Medicaid program are being allocated to our most vulnerable neighbors,” he said. •