Medicare Fraud Analysis
Data-driven tools to detect billing anomalies, impossible volumes, and statistical red flags in Medicare claims data.
Our analysis identified 10 statistical anomalies across 10 specialties. While anomalies are not proof of fraud, the DOJ 2025 healthcare fraud takedown — involving $14.6B in alleged fraud and 324 defendants — shows that billing irregularities are a serious and ongoing problem.
Analysis Tools
Upcoding Detector
Compare E&M code distributions by state to spot suspicious billing patterns.
Volume Outliers
Find providers billing impossibly high volumes — more patients than hours in a day.
Excluded Providers
Explore the OIG exclusion list and check if excluded providers are still billing Medicare.
Benford's Law Analysis
Apply Benford's Law to Medicare charges to detect anomalous digit distributions.
Common Fraud Types
Upcoding
Billing for a more expensive service than what was actually provided. E.g., billing a complex office visit (99215) when a simple one (99213) occurred.
Phantom Billing
Charging for services or procedures that were never actually performed.
Kickbacks
Receiving payment for patient referrals. Illegal under the Anti-Kickback Statute.
Unbundling
Billing separately for procedures that should be billed together at a lower combined rate.
⚖️ See healthcare crime data on OpenCrime
📖 The $100 Billion Problem: The Economics of Medicare Fraud
A comprehensive look at the scope, economics, and detection of Medicare fraud — and what the data reveals.