Pennsylvania Leads the Nation in Fighting Medicaid Fraud

Public assistance programs are critical resources that literally keep Pennsylvanians alive. People who rely on the Supplemental Nutrition Assistance Program to put food on the table or count on Medicaid coverage to stay healthy are our neighbors and friends, coworkers, brothers and sisters, mothers and fathers. So many Pennsylvanians are working hard to make ends meet and support themselves and their families — and our public assistance programs give them opportunities and stability necessary to succeed.

Every day, staff at the Pennsylvania Department of Human Services (PA DHS) work hard to administer these essential services to millions of Pennsylvanians in need of support. And we do so with strict program integrity measures in place that ensure taxpayer dollars are used as intended: by the Pennsylvanians eligible for them, in accordance with all rules and policies about how these programs should be run. High quality service provision and program integrity can coexist — and Pennsylvania is proof of this.

The phrase "fraud, waste, and abuse" is one I hear often. It is typically framed as an accusation of either program mismanagement or misuse by public benefit recipients. Yet these blanket accusations bear no relationship to the reality of the work that the PA DHS does every day.

PA DHS actively monitors our programs to prevent, identify, and stop fraud and misuse and regularly makes referrals to law enforcement partners to investigate and pursue criminal charges.

To make certain that Medicaid providers meet qualifications to operate in Pennsylvania's program and are not barred from doing so federally or by other states, PA DHS staff reviews records from state licensing boards, other states, and the federal government to verify that applications are accurate, the provider is able to participate in Medicaid, and there is no criminal or conduct history that would prevent participation. Providers are revalidated at a minimum of every five years and more frequently if there are concerns.

PA DHS takes action when it has evidence of provider fraud, including removing those providers from Medicaid, banning them from future participation, and referring misconduct to professional licensing boards for further action. In the 2024-25 fiscal year, we terminated 330 Medicaid providers from the program to prevent fraudulent charges and misuse. These actions saved taxpayers nearly $36 million last year.

At the individual recipient level, PA DHS has had robust processes in place for years — well before the federal government's sudden interest in fraud prevention — to prevent fraud before it can start. All individual applications for benefits are checked against 15 databases to verify accuracy of information provided and screen for potential flags that may make a person ineligible for benefits.

We check applicants' income and assets, citizenship, residency, household composition, health or disability status, and more to ensure information is accurate and benefits are given only to those who qualify. We also check the Social Security Administration's Death Master File, the Department of Health's Vital Statistics, reports from managed care organizations, and federal and other states' databases to identify any possible duplication of benefits. If information in any of these databases is contradictory or unverified, then we request more information from the individual before making an eligibility decision and providing any benefits. PA DHS performs the same extensive verification process before benefits are renewed, meaning that an individual's information is checked at minimum every 6-12 months.

If these checks trigger questions or suspicions of fraud or intentional misuse, PA DHS makes referrals to the Office of State Inspector General (OSIG), which investigates further to validate information and can seek criminal charges and damages to the commonwealth when warranted. Thanks to this close partnership, OSIG prevented nearly $179 million of benefits from being erroneously distributed and filed public benefits theft charges against nearly 1,500 people since the start of the Shapiro administration. Clearly, our integrity measures work and are saving taxpayers from footing the bill that fraudsters cause.

In fact, our integrity work has made Pennsylvania a national leader in this space. Last year alone, PA DHS referred 744 cases of suspected provider fraud to Pennsylvania's Office of Attorney General. As a result, Pennsylvania was ranked number one nationally in the number of Medicaid fraud convictions and third overall in charges filed against bad actors. We are proud of our work with the Office of Attorney General Medicaid Fraud Control Section and OSIG to protect our public assistance programs and the taxpayer resources that make these services possible.

Finally, PA DHS staff also monitor benefits programs for unintentional misuse and errors by both providers and recipients. Staff review Medicaid claims looking for potential overpayments, underpayments, or errors in filing that could result in billing errors. Based on recent performance, PA DHS is outperforming many other states. In 2025, Pennsylvania's Medicaid payment error rate was 0.26% — well below the national average of 6.12%. PA DHS staff also review claims looking for instances where other insurance coverage is available, allowing us to reclaim taxpayer funds. This work saved the commonwealth more than $486 million in the 2024-25 budget year alone.

Pennsylvania is a national leader in fighting fraud, and we're proud of our work to ensure that vital public benefits programs are available to Pennsylvanians who are eligible. Efforts that cause instability, change eligibility requirements, or add additional bureaucracy do not stop fraud; instead, they make it more difficult for our neighbors to get the medical care and assistance with feeding their families they need. Let's continue to focus on what we know works: policy that helps our fellow Pennsylvanians achieve better health, dignity, and self-sufficiency that makes our communities strong and safe coupled with the robust processes and systems that are proven to effectively fight fraud.