Methodology

Flags providers whose total Medicaid payments exceed the state p99 (99th percentile).

Threshold: Total paid > state 99th percentile

Catches: Unusually large billing operations within a state

Compares each provider's average cost per claim against the national median for the same HCPCS code, using Median Absolute Deviation (MAD) instead of standard deviation for robustness.

Threshold: MAD score > 5.0 (5+ MADs above the median for their top HCPCS code)

Catches: Upcoding, billing at rates far above peers for the same procedure

Retired in IN, LA, MS, MT, OH and VA, where published fee-schedule rates cover at least 90% of flagged dollars; replaced there by the in-state peer implied-units test.

Extends cost outlier analysis across all HCPCS codes a provider bills, weighted by volume. Providers whose volume-weighted average MAD score is extreme are flagged.

Threshold: Weighted MAD score > 3.0 across all billed codes

Catches: Providers systematically overbilling across their entire practice, not just one code

Retired in IN, LA, MS, MT, OH and VA (see above).

In states whose published Medicaid fee schedule covers at least 90% of flagged dollars (IN, LA, MS, MT, OH, VA as of September 2026), divides each provider's average cost per claim on a code by the state's published rate to obtain implied units per claim, then compares that with in-state providers billing the same code. Claims data carry no unit counts, so the figure reflects unit volume or billing cadence relative to peers; it is not evidence of payment above the schedule.

Threshold: Implied units > 4x the in-state peer median and above the peer 95th percentile; at least 20 peers, 50 claims and $100,000 paid on the code; run only in service families with 90% rate coverage

Catches: Providers whose claims carry far more units of a service than in-state peers billing the same code

Identifies providers where the ratio of claims to unique beneficiaries is abnormally high.

Threshold: Claims/beneficiary > state median + 5 * MAD, AND > 100 claims/beneficiary

Catches: Overutilization — performing unnecessary services on the same patients

Calculates claims per working day (22 days/month) to identify physically impossible billing rates.

Threshold: Individual providers: >50 claims/day; Organizations: >5,000 claims/day

Catches: Phantom billing — submitting claims for services never rendered

Flags providers who bill 90%+ of their claims under a single HCPCS code, suggesting a "mill" operation.

Threshold: >90% of claims under one code AND >1,000 total claims

Catches: Procedure mills (e.g., urine drug testing mills, therapy mills)

Compares each provider's E&M code level distribution (99211-99215) against their specialty peers in the same state. Upcoding patterns are among the most common findings in OIG program integrity reviews.

Threshold: Average E&M level > peer average + 0.5, chi-squared > 100, high-level code % > peer baseline + 20%

Catches: Systematic billing of higher-complexity office visit codes than justified — upcoding

Detects months where a provider's billing jumps >3x their median monthly billing.

Threshold: Any month > 3x the provider's median monthly paid amount

Catches: Sudden ramp-up in billing -- a pattern that warrants further review

Compares the last 12 months of billing to the previous 12 months.

Threshold: Second-half billing > 3x first-half billing

Catches: Rapidly growing billing operations

Flags providers who appear in only the last 2 years of data but already bill above the state median.

Threshold: Active ≤ 24 months AND total paid > state median

Catches: New providers who immediately bill at high volumes — potential shell companies

Uses Cumulative Sum (CUSUM) control charts to detect the exact month when a provider's billing pattern underwent a permanent, sustained shift.

Threshold: Post-change mean > 3x pre-change mean, minimum 6 months of data

Catches: Abrupt regime changes in billing behavior, pinpointing the exact month

Cross-references all providers against the OIG List of Excluded Individuals/Entities (LEIE). Excluded providers are legally barred from billing federal healthcare programs.

Threshold: NPI match in LEIE database (82,714 excluded entities)

Catches: Providers billing Medicaid while officially excluded — potentially illegal

Matches providers against the payment-suspension, termination and state-exclusion rosters published by state Medicaid agencies (17 states parsed so far). Matches are by the NPI the state lists, or by exact name confirmed against NPPES. A suspension or termination is a pending administrative matter, not a finding; every entry links to the state roster.

Threshold: NPI listed on a state roster, or exact-name match confirmed by NPPES; active entries score at the amber tier

Catches: Providers a state has already acted against that the federal LEIE does not yet carry

An organization in a control cluster (shared authorized-official telephone, or the same official at the same suite or mailing address; see Control Clusters below) where another member is under an OIG exclusion, a confirmed state suspension or termination, or a red research badge, and the organization itself has none. Cluster membership on its own is not a risk marker and never scores: held-out testing put its lift below one. Public actions do cluster within control groups far above chance (five of fifteen clusters with two or more actions against a size-matched expectation of 0.7), which is the only thing this indicator reports. It is an indicator of common control, not of conduct; the action belongs to the other member only.

Threshold: Paid member of a qualifying control cluster (three or more paid members, at least half of cluster paid in the target families) whose control-edge path to a member under public action is one hop or more; amber tier

Catches: Organizations under the same control as a provider a public body has already acted against

Alaska Medicaid pays ISDEAA 638 tribal facilities the OMB-published IHS all-inclusive encounter rate per visit-day rather than fee-for-service prices, at 100% federal share. In T-MSIS this appears as one line paid at the encounter rate regardless of HCPCS code, so per-code cost-per-claim (e.g. 36415 at $496 vs $13 state average) and multi-code p90 tests fire on every large tribal facility. The code_cost_outlier and rate_outlier_multi_code tests are fully explained for this class, while volume and growth tests remain valid. The recommendation is a separate peer group for tribal 638 providers, dropping them from cost-per-claim tests.

Hearing aids (7 AAC 145.340, $3,000 device maxima), dental, dental anesthesia, and community behavioral health per-hour/per-diem codes all price far above the national medians the code_cost_outlier test uses. Ten of the 25 adjudicated flags resolved this way. A state-specific benchmark, or the published state fee schedule used as a ceiling test, would remove most of them.

Alaska charged five providers with Medicaid fraud on 2026-07-08: Graystone Assisted Living, Heritage Assisted Living / Heritage Home / Alaska Life Group Homes, Peninsula Family Dental Center, and Joseph Mirci. All have NPIs and appear in Sentinel's providers table, but only Joseph J Mirci DMD (1346658127) appears in provider_summaries, where Sentinel already carried him at high with two flags. A full scan of the 10GB raw HHS file finds zero rows for Graystone (1588216097), Heritage (1073852638, 1336694223, 1568863942, 1982077319), or Alaska Life Group Home (1184436883), while the same scan finds 524 rows and $849,347 for Mirci, matching Sentinel exactly. The homes are therefore absent from the HHS release itself, not dropped by the ETL: Alaska pays assisted-living and other HCBS waiver providers under state-assigned atypical IDs (e.g. A430617100 on T1019 personal care), which the HHS release does not map back to the facility's NPI, with low-volume suppression as a second possibility. In the first 3M rows of the raw file about 0.5% of rows carry a non-NPI billing ID. The consequence is that Sentinel cannot see the assisted-living segment in Alaska at all, which is where the state's own MFCU is currently charging cases; recovering it needs the state's own claims extract or a crosswalk from Alaska atypical IDs to facility licenses.

Seventeen of 39 Kentucky Medicaid enforcement actions published since January 2024 involve behavioral health, addiction treatment, peer support, or sober homes, and the flagged private roster is almost entirely the same segment. The two providers adjudicated as referrals, Addiction Recovery Care and Recovery Center of Kentucky, both resolved federal False Claims Act judgments in 2026 ($16.2M and $15.2M) over lower-credentialed staff billed under higher-licensed codes. Both were on the watchlist before the research ran; ARC's Owingsville NPI was the top-ranked private entry. In the claims this mechanism appears as a per-claim step change on flat volume, which the current tests catch only indirectly through the change-point test.

Of 39 Kentucky enforcement actions published since 2024, 10 named providers have claims in the source data, 9 of those carried anomaly rows or watchlist flags, and 3 sat at high or critical. The misses are concentrated in individuals, sober homes, and small behavioral-health LLCs.

Three genetic and toxicology laboratories sit in the Texas flagged roster. Genview Diagnosis shows an 18x 2022-to-2023 surge and a same-building, same-owner three-lab cluster with no enforcement found. Residential HCS providers resolve mostly to documented Texas payment-system events. No Texas provider was adjudicated as a referral; one amber context badge records a New York False Claims Act settlement by the same legal entity as a Dallas provider.

Nine independent Texas billing-shape reviews flagged dental code D0120 (periodic oral evaluation) paid at $300 to $420 per claim against a published Texas Medicaid rate near $28.85, at HCBS residential providers that advertise no dental program. Same code, same magnitude, unrelated providers: this is most likely a T-MSIS coding or bundling artifact rather than nine coincident overbillings. Until claim lines are checked, dental codes should not drive cost-per-claim flags for non-dental taxonomy classes.

Of 24 Texas enforcement actions published since 2024, 8 named providers have claims in the source data and 4 carried flags. Texas SOS Direct is paywalled, so registered-agent clustering could not be tested.

Two Massachusetts providers on the research roster have T-MSIS payments dated after their exclusion. A Framingham dentist excluded by OIG in August 2016 (1128(b)(4)) shows $90,573 paid on 2,361 claims in September and October 2018. A Wellesley-credentialed dentist convicted in federal court in 2023 for a MassHealth pass-through scheme shows paid months in 2023 and 2024 while state-excluded since May 2020. Both are indicators for claims-level review, not findings; the T-MSIS payment date may reflect adjudication lag or a group re-credentialing.

Six of the nineteen warrants-review dispositions are pediatric or primary-care groups that added integrated behavioral health or in-house testing in 2022 and 2023. Volume growth resolves to the new service line, but psychotherapy codes (90837 and related) at roughly two times the published MassHealth medicine fee schedule recur across unrelated groups. That is either a common billing configuration or a rate the schedule does not show, and it should be checked against MassHealth's behavioral health rate transmittals before any provider-level conclusion.

Of 36 Massachusetts enforcement actions since January 2024, 15 named providers have claims in the source data, 9 are on the watchlist or have anomaly rows, and 1 is watchlist high or critical. The misses are dominated by personal care attendants, adult foster care, and small home-health agencies. The network pass found two intra-chain clusters (Rainbow adult day health sites sharing an officer and hub address; two dental practices sharing an owner and a dental support organization) and no hidden cross-roster network. Massachusetts SOS CorpSearch is JavaScript-gated, so registered-agent clustering could not be tested. Validation-seeded research (tier V) then added ten providers named by the Massachusetts Attorney General or the U.S. Attorney that the statistical roster had not carried, the largest catch-up of any state: two home-health agencies and a laboratory that pleaded guilty or admitted sufficient facts (Union Home Health Care, $1.6 million; Optimum Labs, $4.7 million in sober-home urine testing), two providers indicted in March 2025 and since excluded or terminated by MassHealth (Patient Care Solutions, Direct Pay Dental's owner), one laboratory indicted for $7.8 million (amber, pending), and four recent settlements: Ophthalmic Consultants of Boston ($3.9 million federal, two NPIs), SaVida Health ($2 million), Elm Tree Clinic ($275,000), and Tural Pediatrics ($175,000). Massachusetts publishes named settlements and an NPI-keyed exclusion list, which is why the validation set converts so well here.

Eight of the thirty researched Montana providers are individual counselors or clinicians who appear on the OIG List of Excluded Individuals and Entities or the Montana DPHHS terminated-provider list. In every case the packet shows billing ending before the exclusion date, so the flag records a history, not ongoing risk. The predicate for several exclusions (the conviction or board action) is not stated on either list; three were confirmed against a DOJ release or an HHS Administrative Law Judge decision. One Great Falls entity carries a pending Montana Medicaid fraud charge against its owner, filed June 2026; charges are allegations.

Fourteen dispositions were benign. Most resolve to Montana's published per-diem and monthly waiver rates (T2016 SDMI group homes, T2031 Big Sky waiver, DD waiver monthly billing) or to timed codes billed in multi-unit bundles (T1019 at about 93 fifteen-minute units per claim). A public school district billing the CSCT school-based program and an Area Agency on Aging were adjudicated as institutional providers billing as designed; both are now excluded from outlier surfaces.

Of 23 Montana enforcement actions since January 2024, 2 named providers have claims in the source data and both are on the watchlist; none is watchlist high or critical. Montana's enforcement record since 2024 is dominated by individual practitioners and personal care attendants with small dollar amounts, which the current tests weight down. Validation-seeded research (tier V) tested two July 2026 exclusion entries reported by a secondary mirror of Montana's excluded-provider list; the verification lane found neither on the state's own list nor on the federal list, so one was refuted and one left unverifiable, and no badge was added.

Twenty-seven of the thirty researched Nevada providers are private behavioral-health, rehabilitative mental health, or personal-care LLCs in Las Vegas, North Las Vegas, Henderson, and Reno. Six referrals all rest on public enforcement: a Nevada Office of the Medicaid Inspector General Tier 2 termination in March 2025 with two same-address entities also terminated; a Nevada Attorney General Medicaid Fraud Control Unit conviction for services not provided in 2021 to 2023; an entity named in the MFCU global resolution against a convicted operator, with a federal 1128(a)(1) exclusion in January 2025; an entity and owner sentenced for Medicaid fraud followed by exclusion and a ten-year state termination; an owner disciplined for concealment with a surge immediately before termination; and an NPI payment-suspended by Arizona AHCCCS for a credible allegation of fraud in May 2023, the same month its Nevada billing stopped.

Two patterns recur that a single state's data cannot see on its own. First, successor entities: same-officer or same-address NPIs enumerated during or just after a fraud window, with the terminated NPI's billing collapsing as the sibling's begins. Second, cross-state action: an Arizona payment suspension coinciding with a Nevada billing stop. Both argue for the outward network pass and the cross-state entity cache planned in the pipeline. Nevada SilverFlume is JavaScript-gated, so officer and registered-agent clustering could not be completed from public pages; the network pass found one confirmed same-building cluster (Valley Medi Pro and Apollos Clinic, adjacent suites, different officers).

Of 26 Nevada enforcement actions since January 2024, 5 named providers have claims in the source data, all 5 are on the watchlist or have anomaly rows, and 1 is watchlist high or critical. Three benign dispositions resolve to the 2021 Specialized Foster Care benefit, a self-directed personal-care intermediary billing T1019 in fifteen-minute units, and a new therapy entrant at published rates. Validation-seeded research (tier V) then added six providers named in Nevada Attorney General, DOJ, or HHS-OIG actions that the statistical roster had not carried: two behavioral-health companies convicted of Medicaid fraud in 2024 and 2025 and since federally excluded (True Family Services, Building Resilience with $1 million restitution), a company in the Dix racketeering resolution now excluded, Conservatory of Hope Treatment Services under a 35-year agreed OIG exclusion across two NPIs, and Seven Hills Hospital, a facility expressly named in Acadia Healthcare's $19.85 million September 2024 False Claims Act settlement.

Ten of thirty dispositions were benign, and most resolve to Mississippi's published waiver payment design: personal care and respite at $4.41 per fifteen-minute unit aggregated into monthly claims (T1019, S5100, S5125), ID/DD day habilitation billed the same way, and private duty nursing billed hourly by single-service staffing agencies. These structures produce single-code, high-claims-per-beneficiary, and cost-per-claim flags by construction. Twenty warrants-review dispositions are mostly the same provider types where a 2024 rise in per-beneficiary intensity, a step change with no published trigger, or a by-report DME code (K0108, E1399) is left for a claims-level check.

Six individual practitioners on the roster appear on the OIG List of Excluded Individuals and Entities; the predicates confirmed against primary sources include a federal fraud conviction, a misbranded-drug conviction, and state medical board license suspensions. In every case billing ended before the exclusion date. These are history badges, not current dollars at risk.

Of 20 Mississippi enforcement actions since January 2024, 1 named provider has claims in the source data and is on the watchlist; none is watchlist high or critical. Mississippi's recent enforcement record is dominated by personal care attendants and individual beneficiaries, which the source data does not carry as billing providers. The network pass found one shared officer between two Pike County waiver personal-care networks and no cross-roster address, phone, or agent cluster. Validation-seeded research (tier V) added one provider the statistical roster had not carried: a Madison County individual indicted in June 2026 on one wire-fraud and one Medicaid-fraud count (amber, pending).

Twelve of thirty dispositions were benign and resolve to Arkansas payment design: personal care (T1019) billed per fifteen-minute unit at the published rate, Early Intervention Day Treatment day rates batched into claims, private duty nursing hourly and monthly bundling, ABA technician time (97153) at $15 per unit batched at about 56 units per claim, and startup-year denominators for NPIs enumerated in late 2021 or 2022. Seventeen warrants-review dispositions are mostly personal-care agencies with a 2023 to 2024 volume surge and tripled per-beneficiary intensity that rate and EVV timing only partly explain, plus two H2016 residential providers whose per-claim amounts sit far above published per-diem ceilings and need claim-line dates to resolve.

Five individuals on the roster appear on the OIG exclusion list; the referral is an owner convicted of felony Medicaid fraud in Arkansas Attorney General releases, with the entity's billing inside the charged window. In every other case billing ended before the exclusion date. One counseling clinic's owner carries a conviction and license surrender that postdate the claims window; it is recorded as context, not as a billing finding.

Of 33 Arkansas enforcement actions since January 2024, none names a provider present in the source data as a billing NPI. Arkansas's recent record is almost entirely personal care attendants, individual beneficiaries, and pharmacy technicians, none of whom bill under their own NPI. The network pass found no shared officer, agent, address, or phone across two roster NPIs; two plausible overlaps (a counseling chain under two NPIs, Optum as ultimate parent of two providers) are corporate-structure facts, not hidden networks.

Eleven of the thirty researched Minnesota providers are dental practices. Their growth and step-change flags coincide with two published policy events: the roughly 98 percent Medicaid dental base-rate increase effective January 1, 2022, and the restoration of comprehensive adult dental benefits including crowns on January 1, 2024. Six were adjudicated benign on that basis. The remaining dental practices are warrants-review because of uniform above-average unit costs or a by-report code (D2991) whose intensity is not pinned to a rate; the Clear Lakes Dental franchise appears under two roster NPIs with shared control persons.

Minnesota's Housing Stabilization Services and ARMHS programs produce fast ramps that resolve to program design and published unit bundling. Two interpreter agencies show real volume events (a 2.8x rise and a 20.7x step in August 2023) without an exclusion or charge. One recovery provider carries a September 2024 Minnesota DHS credible-allegation payment withhold corroborated by services-not-rendered reporting; it is recorded as a review item pending the withhold's outcome. A residential provider's July to October 2024 shift to near-daily S9125 per-diem billing at about $44,800 per beneficiary in one month is the single strongest unexplained shape.

Of 36 Minnesota enforcement actions since January 2024, 1 named provider has claims in the source data and is not on the watchlist; none is watchlist high or critical. Minnesota's recent enforcement record centers on the Feeding Our Future and autism-center cases, whose defendants bill through entities the source data mostly does not carry. The network pass found one confirmed cross-roster network (the Clear Lakes Dental franchise) and could not assess registered agents because the Minnesota Secretary of State portal is JavaScript-gated. Validation-seeded research (tier V) added one provider the statistical roster had not carried: a physician indicted federally in April 2025 with a co-defendant on wire-fraud and money-laundering counts alleging more than $15 million in overbilling through Golden Victory Medical (amber, pending).

Twenty-three of thirty dispositions are warrants-review and two are referrals, the highest review share of any state so far. The roster is dominated by small behavioral-health and personal-care LLCs in Chesapeake, Petersburg and the Tri-Cities, Annandale, Norfolk, Richmond and Henrico, and Virginia Beach. Crisis-intervention codes (H2011, S9482 after the December 2021 BRAVO conversion from H2019) surge across many unrelated providers. The two referrals are a North Chesterfield entity named in a pending federal criminal information alleging about $49.6M in false crisis-service billing, team-rate abuse, and kickbacks, and a Henrico counseling LLC whose CEO, program director, and staff were convicted by a federal jury in September 2026 in an $11M Medicaid fraud and kickback scheme; both windows match the packets' spikes. Charges in the pending case are allegations.

One Portsmouth provider bills $152.6M of personal care (S5121) and is flagged only for a $719 per-claim rate that the published tribal encounter rate fully explains. The research found the entity inside an unresolved Virginia DMAS credible-allegation-of-fraud payment suspension. The statistical tests had nothing to say about it, because concentration in one legitimate code at the published rate is not an anomaly; the enforcement record is. This is the clearest case for feeding state suspension and termination lists into the flag engine directly.

Of 38 Virginia enforcement actions since January 2024, 3 named providers have claims in the source data, all 3 are on the watchlist or have anomaly rows, and 1 is watchlist high or critical. The network pass swept 136 phone numbers, normalized street addresses, and compared officers and agents across the roster and found no shared control between two roster NPIs; what repeats is geography and code mix, not ownership. Five benign dispositions resolve to a new dental group NPI, a new personal-care agency, ARTS unit rates, an OB global-billing subpart, and DD-waiver rate rebasing. Validation-seeded research (tier V) then added two providers named in DOJ and Attorney General releases that the statistical roster had not carried: 1st Adult N Pediatric Healthcare Services, whose owners and operators were sentenced in March 2026 with $10 million restitution to Virginia Medicaid, and a provider who pleaded guilty to health care fraud in October 2024 (both red). Two Chesapeake Regional entities matched a January 2025 indictment of the hospital's former surgeon and were left at review because the charges name the individual, not these NPIs.

Twenty-five of thirty dispositions are warrants-review, and the recurring residual is price: per-claim amounts at 1.6 to 4 times the published Florida Medicaid fee-for-service rate for pediatric evaluation, dental (D0210, D9420, D9248), sedation, and home-health aide codes, at providers with no exclusion or enforcement record. Florida's managed-care share means T-MSIS paid amounts often reflect plan-negotiated or bundled payments rather than the fee schedule, so a schedule comparison alone cannot close these. Four benign dispositions resolve to partial-year startup arithmetic, a hospital NICU billing subpart, and fifteen-minute code bundling. Validation-seeded research (tier V) added Brandon Eye Associates, which paid $1.3 million in November 2024 to resolve False Claims Act allegations over a transcranial Doppler kickback arrangement (red settlement badge), and confirmed that a Miami-area individual charged in April 2025 has a benign billing profile in the source data.

The referral is an individual NPI billing in Florida that resolves to an Illinois physician convicted of health-care fraud with a ten-year federal sentence and a 2025 mandatory OIG exclusion. A Tampa dental practice carries two Florida Board of Dentistry disciplines including a 2021 sedation-safety settlement touching its top-billed sedation codes; that is shown as amber licensing context, not as a billing finding.

Of 29 Florida enforcement actions since January 2024, 3 named providers have claims in the source data, all 3 are on the watchlist or have anomaly rows, and 1 is watchlist high or critical. Florida's recent record is dominated by home-health and DME schemes billed through entities the source data does not carry. The network pass found no shared officer, address, phone, or non-generic registered agent across two roster NPIs.

At least eight Philadelphia behavioral-health nonprofits show 15x to 673x year-over-year growth between 2021 and 2022 with flat claim volume. The paid amounts flip from $0 to paid at January 2022, consistent with HealthChoices behavioral-health managed-care encounter data being reported with zero paid amounts before that date. This is a T-MSIS reporting artifact and has been added to the pipeline's suppression list as a Pennsylvania rule. Two dispositions were benign on that basis; most of the rest are warrants-review only because of small-dollar price residuals (96127 screening, 99211) that survive the artifact explanation.

Ten of thirty providers are dental groups. Growth flags trace to DSO acquisitions, multi-site expansion, and post-gap resumptions; the residual is sedation and anesthesia pricing (D9222 at about $1,600 against a $122 fee, D9223, D9920) that no published rate supports. One behavioral-health campus carries a 2019 federal controlled-substance recordkeeping settlement and one nonprofit a 2015 OIG civil monetary penalty settlement, both shown as amber context because neither is a Medicaid billing action; a home-care agency's wage-and-hour consent judgment was excluded as out of scope.

Of 35 Pennsylvania enforcement actions since January 2024, 2 named providers have claims in the source data, both on the watchlist or with anomaly rows; none is watchlist high or critical. The network pass found no shared person, address, or phone across roster NPIs; a called-off 2024 merger between two roster nonprofits and a shared dental campus in Pittston are noted as context. Pennsylvania's business registry is JavaScript-gated, so registered-agent clustering could not be tested. Validation-seeded research (tier V) added one provider the statistical roster had not carried: a Philadelphia home-health agency and its two owners charged federally in August 2026 with health-care fraud conspiracy, wire fraud, and aggravated identity theft over about $224,000 in allegedly false clock-ins (amber, pending). A wage-and-hour consent judgment surfaced on another provider was again left out as outside program-integrity scope.

Eight of the thirty researched New York providers are licensed home care agencies or Consumer Directed Personal Assistance Program fiscal intermediaries in Brooklyn and Queens. Unit prices resolve to New York's per-visit and fifteen-minute rate structure, but volume does not: one CDPAP intermediary grew about six times in 2024 to $102M, one certified home health agency shows a 606 percent 2023 to 2024 surge with a November 2023 change point, and one aide agency shows a 19 times surge from December 2023 that no published rate or footprint change explains. Two of these agencies carry prior False Claims Act or OIG settlements for aide-credential and aide-hour billing (2005, 2009, 2014), shown as amber context because they predate the claims window. New York's 2025 CDPAP consolidation to a single statewide fiscal intermediary is the policy backdrop for the 2024 census jumps.

Article 28 clinic Ambulatory Patient Group rates explain most cost-per-claim outliers at multispecialty clinics, and in-house pathology multi-unit claim lines explain gastroenterology outliers. Three dental practices show a de novo or resumed crown line driving 13 to 28 times level shifts with per-claim costs 2.2 to 2.5 times the fee schedule; those need claim-line review. One ABA provider and one multispecialty clinic in Brooklyn share an officer and two addresses, the only confirmed cross-roster network.

Of 31 New York enforcement actions since January 2024, 5 named providers have claims in the source data, 3 are on the watchlist or have anomaly rows, and 2 are watchlist high or critical, the best detection result of any state so far. New York's Medicaid Fraud Control Unit record is dominated by home care, transportation, and pharmacy cases, which the source data carries as billing NPIs more often than the personal-care attendants that dominate smaller states' records. Validation-seeded research (tier V) then added nine providers named in Attorney General or DOJ actions that the statistical roster had not carried: two social adult day care centers whose owner was sentenced in September 2026 to 76 months with $56 million restitution (red); NAE Edison Home Health Care's $17.25 million September 2024 settlement, $9.75 million of it to Medicaid for false Wage Parity certifications (red, two NPIs); three EyePic ophthalmology companies indicted in June 2026 over $9 million in allegedly fictitious eye surgeries (amber, pending); an adult day care named in a February 2026 federal $120 million conspiracy charge (amber); and Cornerstone Herkimer, which billed for two years while its owner was excluded, resolved by a $7.68 million restitution settlement paid by its managed-care plan (amber context).

Nine of thirty researched Illinois providers are independent laboratories or COVID-testing operations whose 2021 to 2024 surges price at or below the published Illinois fee schedule but whose volume (a 127 times surge into top-tier definitive drug testing in 2024, 37 times step-changes sustained for months, about 23,000 claims per month under one pathologist NPI) has no documented cause. Several individual NPIs show throughput implausible for a solo practitioner. Unit price is clean in almost every Illinois case; the review question is volume and who rendered it.

The referrals are an Oak Lawn counseling company whose CEO was charged in June 2026 in a federal complaint alleging about $92M in Medicaid counseling never provided (allegation only, amber), a physician excluded for ten years in December 2023 after a $353,578 kickback settlement over independent diagnostic testing billed under his NPI, and a Springfield oral surgeon sentenced to fifteen years for drug diversion and false health-care records. Four municipal fire-department ambulances (Cicero, Homewood, River Forest, Palatine) flagged only because Illinois's GEMT supplemental payment changed their per-claim amounts on flat volume; all four share one third-party biller and are now excluded from outlier surfaces. Validation-seeded research (tier V) then added four individual providers named by the Illinois Attorney General or DOJ that the statistical roster had not carried: a Cook County provider who pleaded guilty in May 2025 to Medicaid fraud and is now federally excluded (red); a dentist charged in June 2026 and a River Forest physician charged in November 2025 with felony Medicaid fraud (amber, pending); and a podiatrist named in an August 2026 joint federal and state False Claims Act complaint alleging $5.2 million in false claims (amber, allegation).

Of 33 Illinois enforcement actions since January 2024, 5 named providers have claims in the source data, 3 are on the watchlist or have anomaly rows, and 2 are watchlist high or critical. One confirmed cross-roster network: two Rockford practitioners bill through the same related organization under one officer and share three addresses. The GEMT billing vendor link across the four municipal ambulances is a vendor relationship, not a network.

Ohio raised community behavioral-health and home-care rates on January 1, 2024 (about 80 percent for some waiver services), and most Ohio cost-per-claim flags dissolve against the published schedule. What remains is intensity and volume: peer-support (H0038) and psychosocial rehabilitation (H0036) at 7 to 10 units per encounter across several providers, a residential surge-and-cliff of about $4.9M over seven months of 2023, a dental group billing 89,749 antigen tests in nine months of 2024, and personal-care census jumps of 5 to 16 times in late 2023 that rates do not explain.

A Youngstown provider and its owner are named in a June 2026 federal indictment alleging more than $20M in fraudulent therapeutic behavioral services; the indictment could not be retrieved from a primary source by the verification lane and the dossier stays at referral without a badge until it is. A Columbus clinic and its owner-physician were convicted of $1.5M in Medicaid fraud in October 2024 per the Ohio Attorney General, with sentencing in June 2025 and a mandatory exclusion; that badge is verified.

Of 29 Ohio enforcement actions since January 2024, none names a provider present in the source data as a billing NPI; Ohio's record is dominated by home health aides and individual beneficiaries. The network pass found two cross-roster connections in the dental and SUD lanes and otherwise unique officers, addresses, phones, and agents; the many multi-NPI systems named (hospice, OTP, hospital-system groups) point to sibling NPIs outside the roster.

North Carolina had four documented payment events inside the claims window: Tailored Care Management launched December 1, 2022; the weekly H0020 opioid-treatment bundle was repriced to $221.88; Medicaid expansion began December 1, 2023; and behavioral-health rates rose January 1, 2024. Twelve of thirty dispositions were benign because their growth or step-change flags land exactly on one of these dates, alongside de novo clinic ramps and two large health-system subpart NPIs (Duke, Novant). Review items are intensity questions the rates do not settle: per-diem residential (H2022) on a flat census, an unlisted code (99199) carrying 91 percent of a youth nonprofit's paid, and single-NPI throughput at COVID-era peaks.

The referral is a Mount Airy physician twice convicted in federal court, most recently in March 2025, for billing medically unnecessary definitive drug tests through his clinic; the packet's codes, address, and period match the convictions, and he is now excluded. A Harrisburg dentist's 2015 $2.2M Medicaid settlement for 2008 to 2011 billing on the same NPI is shown as amber context because it predates the claims window. An OTP operator is a live defendant in a separate matter recorded in its dossier as an open question.

Of 30 North Carolina enforcement actions since January 2024, 6 named providers have claims in the source data, 2 are on the watchlist or have anomaly rows, and none is watchlist high or critical. The network pass found three cross-roster ties: two counseling practices sharing an officer and an out-of-state address, two NPIs sharing an officer inside the Novant system, and one roster NPI named as a related entity of another. None indicates hidden control; the first is the only one that is not a corporate-structure fact. Validation-seeded research (tier V) then added six providers named in DOJ or Attorney General actions that the statistical roster had not carried: Life Touch, LLC, sentenced in February 2026 to a $15 million fine, dissolution, and $12.8 million restitution for 2018 to 2023 Medicaid fraud (red), four licensed clinicians who pleaded guilty in June 2025 to federal false-writings charges in the Our Treatment Center investigation (red), and a Burlington behavioral-health provider's $61,000 no-admission civil settlement (amber).

Michigan rebased dental rates on January 1, 2023 and expanded the adult benefit, adding crowns, on April 1, 2023. Sixteen of the thirty researched providers are dental practices, and eleven of the fourteen benign dispositions are dental practices whose 2022 to 2023 growth and spring 2023 change points land on those dates with unit costs at or below the published fee screens. This is now a Michigan suppression rule in the pipeline. The remaining dental review items are new-entrant surges whose magnitude exceeds the benefit change and one dental support organization's central-billing NPI with a November 2021 structural break.

The referral is a Shelby Township dental PLLC whose principal was charged by the Michigan Attorney General in March 2026 with racketeering and 131 counts of Medicaid fraud over crowns alleged to be unnecessary or never provided; the charges are allegations and the badge is amber. A Maryland-addressed mail-order COVID-test vendor billing $6.83M in Michigan on one code mirrors conduct that West Virginia reportedly settled, but no primary record of that settlement could be retrieved, so no badge. A statewide house-call physician group's network has a 2009 $9.5M settlement that includes Michigan Medicaid, recorded in its dossier as context. Validation-seeded research (tier V) added the same dentist's individual NPI, which the statistical roster had not carried, with the same amber pending-charge badge; this is the case the mi_dental_2023 suppression rule would otherwise have hidden.

Of 32 Michigan enforcement actions since January 2024, 1 named provider has claims in the source data, and it is on the watchlist at high or critical. Michigan's recent record is dominated by home health aides and individual dentists, the latter often billing under a practice NPI the matcher does not resolve by name. The network pass found no shared officer, agent, address, or phone across roster NPIs; the apparent repeats are brand collisions (numbered dental PLLCs with different owners, similar legal names) that need exact-NPI discipline rather than being networks.

Eight of the twenty-one researched Georgia providers carry a federal OIG exclusion or a Georgia Medicaid fraud conviction confirmed against a primary source: Georgia Attorney General Medicaid Fraud Division press releases, federal court records, and the OIG List of Excluded Individuals and Entities matched on NPI. In every case the claims in the source data fall before the exclusion took effect, and no post-exclusion billing was found. The research therefore confirms that these providers should not be billing today rather than discovering new conduct. One national supplier carries a 2016 False Claims Act kickback settlement (allegations only, no liability determination) recorded as historical context. Validation-seeded research (tier V) added six providers named in Georgia enforcement actions that the statistical roster missed: National Healthcare Center's owner pleaded guilty in June 2026 to Medicaid fraud over $330,000 in genetic-testing claims (red conviction badge); Rutledge Medical Associates (40-count federal indictment, June 2026), Family 360's owner (Fulton County indictment, August 2026), G.R.A.Y.S Group's owner (Richmond County indictment, May 2025), and K&S Clinical Diagnostics (indictment and civil complaint, June 2026) carry amber pending-charge badges. American Health Imaging of Georgia was left unbadged because the $5.25 million settlement names the parent company and its former CEO, not this NPI.

Nine flagged providers were explained by structure rather than conduct: a medically tailored meal vendor whose per-meal S5170 rate is billed in multi-meal bundles, partial-year new-biller ramps, urgent-care and pediatric practices scaling during the pandemic testing surge, LARC device pricing on a solo OB-GYN, and the Georgia Pediatric Program (GAPP) code design. Three review items remain without a documented explanation: a Brookhaven laboratory's December 2023 pivot to high-tier G0483 drug testing with 20x growth, a Hawaii-based telepsychiatry group billing about $764K through a Jasper mailing address, and a Savannah developmental-disability provider with a 2017 federal protection-and-advocacy records suit and an abrupt January 2019 billing stop.

Of 26 Georgia enforcement actions since January 2024, 1 named provider has claims in the source data (an Augusta counselor indicted in May 2025 with under $1,000 paid) and none is on the watchlist. Georgia's recent enforcement record centers on personal-care attendants, small behavioral-health LLCs, DME suppliers, and genetic-testing laboratories, most of which bill under entities the source data does not carry. The network pass found no shared officers, addresses, phones, or registered agents across the roster; apparent overlaps were surname collisions and agency boilerplate phone numbers.

Eleven of the thirty researched New Jersey providers were explained by structure: new Type-2 group NPIs consolidating hospital-based physician groups at RWJBarnabas, St. Joseph's, and Cooper; the 2021 conversion of opioid-treatment billing from H0020 to weekly G2067/G2068 bundles; the January 2023 observation-code merger; a national home-visit vendor's state billing affiliate; and partial-year baselines on a three-branch private-duty nursing chain. Unit prices for these providers sit at or below New Jersey averages.

Nineteen providers remain warrants-review, almost all because a per-claim cost premium of roughly 1.5x to 4x over the state average on E/M, H-code, or psychiatric evaluation codes could not be matched to a published New Jersey or managed-care rate. Two carry documents worth reading: a behavioral-health group's June 2024 Comptroller settlement of $166,001 over unsupported 90833 documentation (no admission), and a COVID laboratory whose legal entity received an FBI-ordered retest and a consumer settlement for misrepresented tests overlapping its spike window. An emergency-medicine staffing NPI received a small July 2025 state overpayment notice for duplicate billing, repaid without a fraud allegation.

Of 22 New Jersey enforcement actions since January 2024, 4 named providers have claims in the source data and 2 appear on the watchlist with anomaly rows, none rated high or critical. New Jersey publishes more actionable enforcement through the Office of the State Comptroller Medicaid Fraud Division than most states, including settlement agreements with named owners. The network pass found six cross-roster clusters, all common-ownership branches or system affiliates (the Preferred triad, the RWJBarnabas triad, a Pinnacle pair) rather than hidden links; the state business registry requires interactive lookup, so registered agents could not be assessed. Validation-seeded research (tier V) then added six providers named in Attorney General or DOJ actions that the statistical roster had not carried: the two Kwenyan Professional Health Services sites, whose entities admitted in open court to more than 10,000 false claims and were subject to a $6.4 million consent judgment (red); a physician who pleaded guilty in June 2025 to a $20.7 million kickback conspiracy (red); a Fair Lawn internist and his LLC under a 58-count federal indictment for ghost visits, with license suspended (amber); and Joyce Lopez & Associates, whose head was indicted in September 2025 over 34,000 allegedly false claims (amber).

Seven of the thirty researched Washington providers appear on the federal OIG exclusion list matched on NPI. Six are permissive 1128(b)(4) exclusions that follow a Washington Medical Commission, Board of Nursing, or dental license suspension or surrender; one is a mandatory exclusion after a federal kickback conviction. In every case the Medicaid footprint in the source data is small (often under $3,000) and ended years before the exclusion, and no post-exclusion billing was found. These badges are enrollment-hygiene confirmations rather than new findings. A private-duty nursing company's 2015 False Claims Act settlement, which expressly covered Washington Medicaid, is recorded as historical context.

Washington's Foundational Community Supports (FCS) housing and employment benefit, its 2023 enrollment surge, and per-diem or monthly bundled codes (T1041, H0017, FCS per-diems) explain most growth and change-point flags on nonprofits and crisis units. Ten providers were adjudicated benign on that basis. The remaining review items are per-claim premiums without a published rate: a national telehealth addiction group at roughly 10x to 20x published rates on three codes, a bilingual counseling agency at about 2x on per-session codes, and a behavioral-health PLLC whose Behavioral Health Agency application was denied in May 2025 while H-code volume continued. One NPI on the roster is a managed-care organization's own billing NPI, not a clinic.

Of 23 Washington enforcement actions since January 2024, 6 named providers have claims in the source data, 3 are on the watchlist, and 2 are rated critical: a large health system whose name matches a system-level settlement and an urgent-care chain. Washington's Health Care Authority and Medicaid Fraud Control Division publish named settlements, which gives this state the highest validation overlap so far. The network pass found no confirmed cross-roster ties; two plausible person-level links are governance and career-history ties to the Molina and BayMark corporate families, and one shared Seattle address is a multi-tenant building. Validation-seeded research (tier V) then confirmed the MultiCare and Health First settlements against their DOJ releases and added four more providers the statistical roster had not carried: Lincare Inc. (two NPIs), which paid $1.15 million to the Washington Attorney General in January 2025 over oxygen rentals billed past the 36-month cap; a Brewster sleep-clinic physician convicted federally for billing recalled CPAP devices as new; and a Felida dentist's $360,300 June 2026 civil Medicaid settlement (all red).

Three of the thirty researched Tennessee providers are referred: a Memphis podiatrist convicted by a federal jury in March 2024 of a roughly $4 million Medicare and TennCare foot-bath scheme, a Manchester nurse practitioner convicted in 2021 of unlawful oxycodone distribution, and an internist whose 2017 guilty plea to a false health-care statement carries a mandatory exclusion with about $290 billed in the month it took effect. Three further exclusions (two license-based, one after a 2025 felony drug plea) had no post-exclusion billing. A Nashville hospice's successor paid $19.43 million in July 2024 to resolve eligibility allegations covering 2010 to early 2020; that conduct predates the entity's 2022 to 2024 billing growth.

On July 1, 2024 Tennessee moved 1915(c) waiver billing for intellectual and developmental disability services into managed-care encounters through Therap and launched the Department of Disability and Aging. Twelve long-standing nonprofit IDD providers on the roster show 4x to 30x step changes in exactly that month, with residential per-diems appearing under their NPIs for the first time at published rates. Two were adjudicated benign; the rest are review items because the census increases (for example 39 to 242 beneficiaries) have a documented timing cause but no provider-specific capacity proof. The January 2023 adult dental expansion and the July 2023 Fiscal Employer Agent takeover explain two more flags. A stretcher-van company's mileage code at about 18x the state average is the strongest unexplained pricing pattern.

Of 25 Tennessee enforcement actions since January 2024, 8 named providers have claims in the source data, 2 have anomaly rows, and none is rated high or critical. The referred podiatrist was on the watchlist at moderate risk; the other matched names (a pharmacy, several individual prescribers) carry no statistical flags, which again shows that enforcement targets are mostly visible through public records rather than billing statistics. The network pass found no shared officers, phones, or agents; one shared Nashville address is a multi-tenant medical building. Validation-seeded research (tier V) then added four providers named in DOJ or state actions that the statistical roster had not carried: a physician convicted by a federal jury in January 2026 on 40 fraud and device counts and sentenced to 20 years (red), and three with pending charges: Hall Family Pharmacy's owner (December 2024 federal indictment, more than $6 million), a Gordonsville clinic physician (June 2026 federal indictment, 5.6 million pills), and a Shelby County provider charged with TennCare fraud in March 2025 (all amber).

Fifteen of the thirty researched Arizona providers appear on the AHCCCS provider suspensions and terminations list or the federal exclusion list. Eleven carry credible-allegation-of-fraud payment suspensions dated between February and December 2023, each falling within a month of the provider's last billing month in the source data, which is why the statistical tests flagged them as collapses and spikes. Four progressed to mandatory federal exclusions (two New Life Wellness entities, Cactus Wren, Nevada First Choice). A payment suspension is a preliminary administrative hold, not a finding of fraud, and is shown as an amber context badge; exclusions are shown in red. Several suspended providers billed H0015 intensive outpatient at $2,000 or more per claim and tens of millions of dollars in under two years, a pattern Arizona officials have publicly tied to billing for members recruited into unlicensed sober-living homes.

Seven roster NPIs belong to one hospital-affiliated freestanding emergency department network (AGH Laveen and AGH Mesa), sharing an officer, license, and Phoenix mailing address. Their pricing reconciles to the published AHCCCS freestanding-ED schedule and two were adjudicated benign; the rest carry unexplained volume steps in July 2022 and mid-2024. Other benign findings were an IDD group-home vendor, a rural ambulance startup at state-set rates, and a new-entrant HCBS provider whose nonprofit filings track its Medicaid dollars. A Phoenix physician's November 2024 Medical Board reprimand is shown as licensing context.

Of 38 Arizona enforcement actions since January 2024, 13 named providers have claims in the source data, 12 have anomaly rows, and 8 are rated high or critical on the watchlist. This is by far the strongest overlap of any state researched: Arizona's enforcement targets are large behavioral-health billers whose statistical profile the tests already catch. The network pass confirmed the seven-NPI AGH cluster and a two-NPI New Life Wellness cluster sharing an officer and phone; other same-date suspensions were co-indicted in prosecution batches without proven common ownership. Validation-seeded research (tier V) then added ten providers named in those actions that the statistical roster had not carried: five with owners convicted in federal or state court (1 Family Clinic, $12 million; Tusa Integrated Clinic, about $69.7 million alleged, owner sentenced May 2026; Harmony Family Services and Harmony Family Services II, $21.7 million restitution; New Horizons Behavioral Health, $3.3 million) shown in red, and three with pending charges (Happy House Behavioral Health, a $60 million state indictment; Community Hope Wellness Center, $57.7 million alleged; Motherland Counseling, $44.9 million alleged) shown in amber. Two more resolved benign or to review. Every one of these ten was on the watchlist, eight at high or critical risk.

Two of the thirty researched Indiana providers appear on the federal exclusion list matched on NPI: a physician excluded in February 2022 after a federal kickback prosecution, whose Indiana billing ended in April 2019, and an ambulance company excluded by agreement in February 2025 for medically unnecessary transports, whose billing ended in August 2020. Both are shown in red as exclusions; neither shows billing after the exclusion took effect. No Indiana provider on the roster carries a pending charge or a state Medicaid sanction. Validation-seeded research (tier V) then added two providers named by the Indiana Attorney General's Medicaid Fraud Control Unit that the statistical roster had not carried: Allpoints Home Health Care, whose October 2024 settlement of $217,020 over 1,055 false claims came with a felony-theft conviction (red), and TRUTH Treatment Centers, whose owner was charged in October 2025 with 43 counts of Medicaid fraud alleging more than $2.7 million (amber, pending).

Ten providers were adjudicated benign: five dental practices whose growth is the arithmetic of a newly enumerated group NPI combined with Indiana's January 2024 statewide dental rate rebasing, a residential detox campus opening, a psychiatric residential treatment facility takeover, a meal vendor at published per-meal rates, and franchise or chain location subparts. The remaining review items are volume steps without a published cause: a durable medical equipment supplier's roughly 6,700 new neuromuscular stimulator placements in 2022, a substance-use clinic billing a care-management code at about 22x the state average, an ABA provider at 2.25x on its core code, and a home-care agency whose claim intensity quadrupled in July 2023 while its beneficiary count stayed flat.

Of 26 Indiana enforcement actions since January 2024, 4 named providers have claims in the source data, 3 have anomaly rows, and none is rated high or critical. Indiana's recent enforcement record centers on home-health attendants, individual prescribers, and a treatment-center chain, mostly billing through entities the source data does not carry. The network pass found one shared Jeffersonville address with distinct officers, consistent with co-location or sequential tenancy rather than common ownership.

The one Missouri referral is a St. Louis laboratory whose owner pleaded guilty in federal court to wire fraud, admitting the lab was used to bill thousands of no-contact COVID test-kit claims funded by kickbacks; the packet's October to November 2023 spike sits in the same test codes. Two individual prescribers carry federal exclusions confirmed on the OIG list by NPI, one after a 2022 false-statement plea over telemedicine orders and one after a controlled-substance felony, both with billing that ended years before exclusion. A Waynesville psychiatric residential facility admitted in a December 2021 civil settlement that it billed MO HealthNet for twice-weekly therapy not provided to 13 children and paid $504,250; its later growth rides Missouri's new private PRTF benefit and is a review item. A 2005 transportation-broker settlement was left out as too old.

Missouri moved residential rehabilitation per-diem billing into Show-Me Healthy Kids and MO HealthNet in October 2022, rebased developmental-disability rates on July 1, 2022, and raised dental rates the same month. Nine providers were adjudicated benign on those events, health-system group NPIs (SSM/SLUCare), the CCBHO per-diem model (BJC), and documented acquisitions (KVC/Great Circle, Arc of the Ozarks/TheraCare). Review items are census jumps without a documented cause (13 to 82 beneficiaries in one month at a disability provider), an in-home agency whose per-beneficiary intensity roughly quadrupled, and the statewide NEMT broker whose paid claims became visible in T-MSIS only after its December 2022 contract.

Of 41 Missouri enforcement actions since January 2024, none names a provider with claims in the source data. Missouri's Medicaid Fraud Control Unit publishes many actions, but they concern personal-care attendants, individual beneficiaries, and pharmacies that bill through entities the data does not carry. The network pass found no shared officers, addresses, phones, or agents; the main cross-provider risk is name collision (several unrelated Ann's, Ozark, Good Samaritan, and Cornerstone entities).

Six of the thirty researched Wisconsin providers carry federal exclusions confirmed on the OIG list by NPI. Two follow adjudicated fraud: a Milwaukee physician against whom the United States took a $2.35 million False Claims Act default judgment in March 2023 over Vivitrol billing, and a Dane County chiropractor who pleaded guilty in 2022 to felony Medicaid fraud for about $40,000 in services not rendered. One follows a federal conviction for unlawful opiate distribution. Three are license-based 1128(b)(4) exclusions with billing that ended years earlier. The fourth referral is a Milwaukee prenatal care coordination entity named with its CEO in a 2023 federal search-warrant affidavit alleging that a group of providers billed more than $8.6 million for prenatal and child care coordination not provided; an affidavit is an allegation, no charge against the entity was found, and it is recorded as a review item rather than a badge.

Seven benign dispositions are managed-care or public entities whose billing looks anomalous only through a fee-for-service lens: three Family Care managed-care organizations and a PACE HMO reporting capitated encounters, a tri-county public community-programs department, a county-contracted case-management agency, and a long-term-care pharmacy with payment-timing artifacts. A cluster of review items shares one shape: long-standing nonprofit disability providers (Portage, Green Bay, Vernon County, Brown County) whose adult day, habilitation, or S5136 lines jumped 6x to 42x in April 2024 without a published trigger. A physician-owned house-call group paid at 5x to 10x published ForwardHealth levels, whose corporate family has three federal settlements for unnecessary visits, is the strongest unexplained pricing pattern.

Of 27 Wisconsin enforcement actions since January 2024, 4 named providers have claims in the source data and 3 have anomaly rows, none rated high or critical. Three of the four are prenatal care coordination agencies, matching the affidavit pattern above; Wisconsin's Department of Justice Medicaid Fraud Control unit has concentrated on that program since 2023. The network pass found one shared Milwaukee suite between a roster provider and a related entity of the affidavit-named provider, recorded as a co-location indicator pending a records check. Validation-seeded research (tier V) then added four of those providers, none of which the statistical roster had carried: Here For You Prenatal Care Coordination (owner convicted at trial, 121 months, $2.36 million), Caring Through Love (owner convicted on 17 counts, 111 months), Noah Associates (co-owners sentenced in 2025 for urine-testing kickbacks), all red, and Bundle of Love Prenatal, whose owner was charged by federal information in June 2026 over $5.4 million paid (amber, pending).

Three of the thirty researched Alabama providers are referred, all on federal convictions confirmed against Department of Justice releases: Capstone Medical Resources and its co-located owner Sharon Waltz, who pleaded guilty to Medicaid conspiracy (three years, $1.5 million restitution) alongside a $417.9 million civil False Claims Act judgment, with the packet's 2018 billing inside the charged window; and Hasan Pulliam, sentenced in April 2026 to 54 months for billing counseling never provided. Two of these came from the validation-seeded tier rather than the statistical roster. Three further providers carry federal exclusions after convictions (a 30-year drug-and-fraud sentence, the QBR laboratory kickback scheme) or a 2025 license surrender, all with billing that ended before exclusion. New Beacon Hospice's legal entity was named in Gentiva's July 2024 $19.4 million settlement (red); a 2015 wheelchair-supplier settlement and a 1990s dental-board discipline are shown as amber context.

Alabama Medicaid pays hospices a room-and-board pass-through at 95 percent of the nursing-facility per diem under code T2046, so hospice branches show high per-claim amounts and single-code concentration by design. Five hospice NPIs were adjudicated benign on that basis, as were the state's sole PACE program (monthly capitation billed as T1015), two startups with partial-year baselines, and a provider entering the statewide Nurse-Family Partnership benefit that began January 1, 2022. Review items are pricing and volume steps without a published cause: a Rainbow City clinic's December 2023 pivot to high-volume respiratory panels (22x), per-organism laboratory codes at 4x, complex-rehab wheelchair components (K0108) at 3.8x, and a hospice chain whose private-equity parent is a defendant in a pending federal eligibility case.

Of 17 Alabama enforcement actions since January 2024, 4 named providers have claims in the source data and 2 have anomaly rows, none rated high or critical; two of the four were seeded into the roster and both produced red badges. The network pass confirmed two clusters: Capstone and its owner share a person, phone, and address, and two Affinity hospice entities share officers and a mailing address. No other officer, phone, or agent recurs across the roster.

Three of the thirty-four researched Colorado providers are referred. Claro Scientific Laboratories in Lafayette is named in a September 2024 federal indictment alleging more than $40 million in Medicare and Colorado Medicaid kickbacks for medically unnecessary genetic tests (amber, pending); it was on the watchlist at high risk. Nadina Adult Daycare Center's co-owner was indicted in June 2026 on twelve counts of paying beneficiaries to attend (amber, pending; the packet's billing predates the alleged conduct). A physician who pleaded guilty in 2019 to illegally dispensing oxycodone is federally excluded (red). Vista Eye Care paid $250,000 to the Attorney General in September 2025 over about 3,000 claims for two lens sets where one was provided (red settlement), and a Colorado Springs rehabilitation clinic received a Medical Board cease-and-desist in October 2024 for unlicensed practice (amber licensing). Three of these five came from the validation-seeded tier.

On July 1, 2024 Colorado moved community mental health centers to a cost-based prospective payment system; three CMHC NPIs show paid amounts jumping ten-fold or more on flat claim counts in exactly that month and were adjudicated benign, as was a fourth CMHC site subpart. Colorado removed its $1,500 adult dental cap on July 1, 2023, explaining one dental practice's growth. Review items are volume steps and per-unit levels without a published cause: a non-emergency transport company's 22x ramp to $4.6 million at about $720 per claim with 1,441 zero-paid claims in late 2023, an IHSS agency's H0038 intensity near $7,300 per beneficiary-month, a laboratory's $241 multiplex panels with a same-address successor, and a home-care startup whose principal is tied to a separately suspended agency.

Of 25 Colorado enforcement actions since January 2024, 3 named providers have claims in the source data, all 3 have anomaly rows, and 1 (Claro) was rated high. All three were seeded into the roster and two produced badges; the third seeded match was a name collision (Monte Vista Eye Care versus Vista Eye Care) that the lanes caught and documented. The network pass found two same-enterprise pairs (Diversus Health, Aurora Comprehensive) and one dental brand pair sharing a founder but not ownership; no other person, address, or agent recurs.

Three of the forty researched California providers are referred: Golden Star Labs, whose owner pleaded guilty in federal court to a kickback-driven false-claims scheme covering the packet's spike period and test code (red); Southern California Medical Center, an FQHC corporation that paid $10 million in December 2024 to resolve marketer-kickback and self-referral allegations (red); and a San Diego dermatology corporation whose physician faces a May 2025 Attorney General felony complaint alleging $1.39 million in Medi-Cal billing for services never rendered (amber, pending). Oroville Hospital's $10.25 million December 2024 settlement over kickbacks and unnecessary admissions is shown in red on both its NPIs. Eight Kaiser Permanente medical-group NPIs carry an amber context badge for the January 2026 $556 million False Claims Act settlement over Medicare Advantage risk-adjustment coding; that conduct concerns Medicare Advantage, not Medi-Cal, and carried no admission. Two self-disclosed matters (a 340B overbilling settlement and a civil monetary penalty for employing an excluded individual) are amber context.

Kaiser Permanente began contracting directly with Medi-Cal on January 1, 2024, moving encounters that were previously reported through plan subcontracts into fee-for-service reporting; nine Kaiser group NPIs show 10x to 130x jumps in exactly that month. CalAIM's Enhanced Care Management and Community Supports benefits (January 2022 go-live, January 2023 expansion) explain nonprofits and agencies newly billing per-diem and case-rate codes. Six providers were adjudicated benign on those events. Review items are per-claim levels far above published rates with no explanation: a transport company at $617 against a $16 to $29 published range, allergy testing at about $1,800 per claim against a $96 average, a hospice with $3.8 million in new-patient home visits on the wrong payment method, and a home-care company billing $40.5 million at the 99th percentile with a footprint that does not match.

Of 26 California enforcement actions since January 2024, 8 named providers have claims in the source data, 7 have anomaly rows, and 6 are rated high or critical, second only to Arizona. Ten seeded roster rows came from those matches; four were name collisions between Southern California Medical Center and unrelated Kaiser, Easter Seals, and Providence entities, each documented by the lanes and left unbadged, which is the intended behaviour of the verification gate. The network pass found only benign system structures (Kaiser north and south groups, Oroville's two NPIs, Easter Seals' two NPIs).

Connecticut's Medicaid Fraud Control Unit and the U.S. Attorney publish named releases for individual behavioral-health providers, and the source data carries those individuals as billing NPIs, which is why this state converts so well. Twelve of the fourteen referred providers were convicted or pleaded guilty: psychologists, counselors, an acupuncturist, and small counseling LLCs billing sessions never provided, with restitution from $80,000 to $1.65 million and several now under mandatory federal exclusion. Ten of the badged providers were on the statistical roster already, most at high risk; ten more were seeded from the enforcement record. Genco Lab's $1.26 million August 2025 settlement over unnecessary urine drug tests is shown in red. Pending matters (an October 2024 arrest, a May 2026 allergy-immunotherapy charge against a Shelton clinic) are amber. A durable-medical-equipment branch's parent-company 2018 settlement and a self-disclosed excluded-employee penalty are amber context.

Connecticut began paying for substance-use residential treatment under its 1115 waiver on June 1, 2022; four nonprofits show 8x to 13x jumps in exactly that month as H2036 and H0011 per-diems appear from zero at published rates, and were adjudicated benign. Other benign findings are startup baselines (a practice compared over a 2- or 3-month first year) and a health system's May 2022 integration of a visiting-nurse agency into one NPI. Review items are volume steps without a published cause: about 1,500 partial-hospitalization days a month billed through one solo physician NPI, a hospice physician's abrupt 2023 shift to solo room-and-board billing, a 140x July 2023 waiver-code shift at a nonprofit site, and a DME supplier's 7x incontinence-supply regime change in February 2024.

Of 32 Connecticut enforcement actions since January 2024, 12 named providers have claims in the source data, 10 have anomaly rows, and 3 are rated high. That is the strongest conversion of any state after Arizona and, unlike Arizona, it comes from individual practitioners rather than large billers. The network pass found no shared officer, address, phone, or agent across roster providers; every apparent overlap resolved to a surname coincidence or the MFCU press contact number.

Three of the thirty-three researched Delaware providers are referred. Fast Care Medical Aid Unit pleaded guilty to federal health care fraud in November 2018 with a $3.07 million settlement and has been mandatorily excluded since June 2020 (red); its billing in the source data ends before the plea. Alpha Care Medical is named in a June 2026 DOJ civil False Claims Act complaint alleging false laboratory claims from 2021 to 2026, and the Center for Interventional Pain and Spine and its principal are named in a June 2024 civil complaint alleging thousands of false claims; both are allegations in pending civil suits and are shown as amber, with billing continuing after the suit month at the pain practice. A social worker excluded in November 2024 had no post-exclusion billing. All three seeded enforcement matches produced badges.

Delaware's roster is dominated by licensed personal-assistance and homemaker agencies billing S5130 in 15-minute units, assisted-living and residential providers billing monthly or per-diem waiver codes, and orthodontists paid under the state's published orthodontic model. Fifteen providers were adjudicated benign on those mechanics, on the July 1, 2019 fee-for-service to managed-care transition, on an October 2019 paid-amount reporting onset, and on a May 2024 retroactive rate reprocessing. Review items are intensity and price residuals: a homemaker franchise at 3.9x the peer median per claim, a residential provider at 19x peers per claim, a bariatric surgery center $3,000 to $5,000 above comparators per sleeve claim with round-number batch months, and an eye group's unexplained November 2021 step.

Of 13 Delaware enforcement actions since January 2024, 3 named providers have claims in the source data and 1 has anomaly rows, none rated high or critical; all three were seeded into the roster and all three produced badges. The network pass confirmed three same-enterprise pairs (a pain practice and its principal, Ingleside Homes' two NPIs, two Home Instead franchisees) and one plausible common acquirer (Care Advantage) behind two home-care agencies; a shared Newark street address is geographic only.

Three of the thirty-one researched District providers are referred. A dentist was convicted by a federal jury in March 2026, with a hygienist co-defendant, of a $4 million phantom-billing scheme on the packet's top codes (red); he was on the watchlist at high risk and was also the District's one seeded enforcement match. Goshen Healthcare and Management Services is named in an August 2024 federal indictment as the billing partner for an alleged $10 million scheme whose ramp matches the packet's 11x surge, and a May 2026 FBI affidavit charges the operator of a youth mental-health rehabilitation agency with billing community-support services not provided; both are pending and shown as amber.

The District launched a 1915(i) Housing Supportive Services benefit in 2022, paid as a per-member-per-month H0044 rate; five nonprofits and housing operators newly billing it were adjudicated benign, along with a new assisted-living build and a dental second site. The open pattern is different: at least eight Department of Behavioral Health certified Core Service Agencies billing community support (H0036) show 5x to 12x volume steps in October and November 2021 that no published rate change explains; several sit in the same office suites, and one is an identical-suite neighbour of an indicted entity. Those remain review items, and the timing cluster is a candidate for either a program explanation or a coordinated pattern that only claim-level review can settle.

Of 21 District enforcement actions since January 2024, 1 named provider has claims in the source data, on the watchlist at high risk; the District's other actions concern individuals and personal-care aides not carried as billing NPIs. The network pass found one confirmed officer link between two Core Service Agencies at a shared Pennsylvania Avenue SE address, one confirmed cross-citation with a plausible household bridge, and a plausible same-name link between an indicted entity's former billing partner and a same-suite provider. The District's business registry is login-gated, so formation and agent records could not be checked.

None of the twenty-two researched Idaho providers carries an exclusion, conviction, settlement, or pending charge. The one adverse record found is a 2022 Idaho Supreme Court decision affirming a Department of Health and Welfare recoupment of about $85,000 from a behavioral-health group for 2012 to 2013 psychotherapy documentation failures; it is recorded as a review item on both of that group's NPIs rather than a badge, because a recoupment is an administrative overpayment finding rather than a program-integrity sanction. Idaho's roster held 22 Tier 1 providers rather than 30 because fewer watchlist entries survived artifact suppression with a significant flag.

Idaho raised developmental-disability Targeted Service Coordination rates on April 1, 2023, and pediatric therapy groups bill timed codes in stacked units under one group NPI; five providers were adjudicated benign on those mechanics and on a documented 2022 office expansion. The main open pattern is a cluster of March and April 2023 volume steps of 11x to 37x at behavioral-health and durable-medical-equipment providers (three NORCO branches among them) that no published rate or policy event matches; two of those coincide with single anonymous allegations of billing without service, which the lanes graded anecdotal. A residential provider's January 2022 onset at 35x and a mobile dentist-anesthesiologist's per-claim cost are the other residuals.

Of 14 Idaho enforcement actions since January 2024, none names a provider with claims in the source data; the state's actions concern personal-care aides, individual beneficiaries, and pharmacies not carried as billing NPIs. The network pass confirmed two same-enterprise clusters (three NORCO branch NPIs under one officer, two Access Behavioral Health NPIs at one address) and found no other shared officer, address, phone, or agent.

One Hawaii provider is referred: a Kihei physician who pleaded guilty in July 2019 to health care fraud for billing face-to-face visits that never occurred, since excluded (red). Twelve roster NPIs belong to Liberty Dialysis - Hawaii, a Fresenius subsidiary that in June 2022 paid $13 million in restitution to extinguish a 2015 state order to repay $7.03 million in Medicaid Epogen overpayments from 2006 to 2010 and a companion Hawaii False Claims Act suit alleging it kept billing after learning of a state systems error. That chain-level matter is shown as one amber context badge on each Liberty site NPI; the conduct is historical and resolved, but the same drug class is involved in the 2024 pattern below.

Twelve Liberty Dialysis and nine U.S. Renal Care facility NPIs, two unrelated chains covering nearly every dialysis unit in the state, show paid amounts rising 10x to 30x in September and October 2024 with flat claim and beneficiary counts, concentrated in the dialysis encounter code (90999) and ESA drugs (J0887). Some sites post 42 percent of their all-period dollars in one month. A change hitting every facility of two chains at once is a payment event (a Med-QUEST rate rebasing, a retroactive lump-sum settlement, or an encounter-to-fee-for-service reporting change), not twenty-one coincident billing decisions, but no rate memo or notice was found. It is recorded as a review pattern for the state, not as an indicator against any facility, and is a candidate for a Hawaii suppression rule once the cause is documented.

Of 13 Hawaii enforcement actions since January 2024, none names a provider with claims in the source data; Hawaii's Medicaid Fraud Control Unit docket is dominated by adult residential care homes, personal-assistance aides, and abuse and neglect cases billed through entities the data does not carry. The network pass confirmed the two dialysis chains (shared officers, headquarters phones, and parents) as expected corporate structure and found no cross-chain or independent shared officer, address, or agent.

Three of the thirty-nine researched Iowa providers are referred, each a federal or state fraud conviction with a mandatory exclusion confirmed on the OIG list by NPI: a physician sentenced in 2020 for false statements with a companion False Claims Act settlement, a Sioux City counselor who pleaded guilty in January 2025, and a counselor excluded in April 2024. Five more exclusions (a patient-abuse conviction, license actions, and one 2018 loan-default exclusion shown amber) had no post-exclusion billing. Mercy Medical Center in Cedar Rapids paid $14.8 million in March 2026 to resolve a self-disclosed Civil Monetary Penalties Law matter over ambulatory surgery center fees, shown as amber context, and a plastic-surgery practice faces a June 2026 civil False Claims Act complaint over skin-substitute pricing (amber, pending).

Seven Iowa home-health and nursing agencies show 5x to 31x volume steps between October 2023 and January 2024 as they moved from homemaker-only billing to skilled nursing and aide codes, with beneficiary counts tripling in a month; the rates reconcile to fee schedules, but no published policy trigger was found, and two of the agencies share an officer and a Minnesota parent. Those remain review items. Fifteen providers were adjudicated benign on Iowa's July 2023 managed-care transition (a meals manufacturer's onboarding to waiver billing), H2016 per-diem policy, hospice mechanics, rural health clinic encounter billing, and startup ramps.

Of 20 Iowa enforcement actions since January 2024, 2 named providers have claims in the source data and 1 was rated high. The seeded tier illustrates the collision problem well: the $14.8 million Mercy settlement matched seven Mercy-named hospital NPIs across Iowa City, Oelwein, Council Bluffs, and Primghar, and the lanes established in every case that the settling entity was Mercy Medical Center in Cedar Rapids; only that NPI carries the badge. The network pass confirmed one common-ownership pair (two Open Arms home-health agencies) and one hospital-subpart pair.

Four of the twenty-seven researched Kansas providers carry federal exclusions confirmed on the OIG list by NPI: one mandatory exclusion in January 2023 coinciding with Kansas Medicaid termination, two license-based exclusions, and a counselor excluded in June 2025 more than five years after last billing. None shows billing after the exclusion date. A community mental health center's 2014 self-disclosed $10,000 settlement is amber context. One transportation company's packet indicates about $4.4 million billed from 2018 to 2020 after a 2010 exclusion record; the verification lane confirmed the exclusion record is the official OIG dataset matched on this NPI, so it is shown in red as the state's most significant finding: payments after exclusion. Whether the excluded entity and the billing entity are the same legal person is for the state to confirm.

Kansas certified its first Certified Community Behavioral Health Clinics between May 2022 and mid-2023 and pays them a prospective per-diem under code T1040, usually through a newly enumerated billing NPI. Five long-standing community mental health centers (founded 1956 to 1967) appear as new high-volume entrants for that reason and were adjudicated benign, along with a hospice's room-and-board per-diems, a meals vendor, a PRTF's rebound year, and startups. Review items are a December 2023 census tripling at a residential provider, a 27x 2024 surge at an accredited infusion pharmacy at benchmark prices, a hospice with a 2020 federal retaliation suit alleging referral kickbacks, and a personal-care startup with post-period tax warrants and a cemetery-coincident billing address.

Of 21 Kansas enforcement actions since January 2024, none names a provider with claims in the source data; the Kansas Attorney General's Medicaid Fraud and Abuse Division docket concerns personal-care attendants and individual beneficiaries. The network pass found no shared officer, address, phone, or agent across roster providers; the only tie is a co-founder's prior employment at another roster nonprofit. The Kansas business registry failed to load for most lookups.

Nine of the thirty-one researched Louisiana providers appear on the federal OIG exclusion list matched on NPI, the highest share of any state, and every one is explained by a documented conviction: the Canon hospice owner sentenced to 240 months with $42 million restitution, two psychiatrists who were co-defendants in the Progressive Home Health kickback scheme, a Baker social worker from the $1.8 million St. Gabriel scheme, a provider who pleaded guilty in 2024 to Provider Relief Fund theft, and counselors and an optometrist with mandatory exclusions. None shows billing after the exclusion date; the referrals are the four whose convictions match the packet's billing window. A New Orleans physician indicted in June 2026 on two health care fraud counts, found through the seeded tier with no statistical flags at all, is shown as amber pending.

Louisiana pays most services through managed care, and $0-paid encounter months depress year-over-year denominators for some providers; that, together with new-entrant ramps at published waiver rates (S5125 at $4.63 per 15 minutes), a faculty-practice billing NPI absorbing a hospital integration, and a home-sleep-test group at the published rate, explains the six benign dispositions. Review items are sustained volume steps at fee-schedule prices with no published trigger: a 16x April 2023 step at an OB-GYN practice with heavy STI-panel billing next to a same-owner laboratory, a 15x June 2024 shift to hourly home-health billing, a pain clinic's 2022 regime change, and a dental practice's crown intensity.

Of 29 Louisiana enforcement actions since January 2024, 1 named provider has claims in the source data; Louisiana's Attorney General publishes many Medicaid fraud arrests, but they concern personal-care attendants and behavioral-health aides billing through agencies the data does not carry as NPIs. The network pass confirmed one cross-roster tie, the two Progressive Home Health co-defendants, and one same-building address in New Orleans without common control. The Louisiana Secretary of State portal is JavaScript-gated, so registered agents were retrieved in only four lanes.

Two of the thirty-six researched Maine providers are referred: Gateway Community Services, whose MaineCare payments were suspended in December 2025 on a credible allegation of fraud after a Program Integrity audit alleged $1.07 million in overpayments, referred to the Attorney General (amber, preliminary); and a Kennebunk physician assistant convicted by a federal jury in June 2024 on fifteen counts of unlawful distribution (red). The Opportunity Alliance paid $346,369 in June 2025 to resolve False Claims Act allegations over urine drug testing (red, two NPIs), and SaVida Health's Biddeford clinic shares the legal entity that paid $2 million to the Massachusetts Attorney General in December 2024 (red). Two self-disclosed civil monetary penalties for excluded staff and a license-based exclusion with no post-exclusion billing are amber or red context. All six seeded enforcement matches produced badges.

Maine reformed MaineCare rates on January 1, 2023, raised the H0015 intensive outpatient rate to $192.83 on January 1, 2022, and launched Opioid Health Homes that several clinics joined in 2022; those events, together with per-15-minute unit stacking under Sections 19, 21, and 28 and startup stub years, explain fifteen benign dispositions. Review items are census expansions without a documented cause (a personal-care agency at 7.5x with a 2024 wage-and-hour finding, a residential provider going from 15 to 52 beneficiaries a month), a dental group's 6.4x surge after a 49-month billing silence, and two post-period events the lanes surfaced: a March 2026 emergency termination of a residential provider for immediate-jeopardy care failures and a pending federal suit invoking the False Claims Act against a school day-treatment company.

Of 14 Maine enforcement actions since January 2024, 4 named providers have claims in the source data, all 4 have anomaly rows, and 1 is rated high; every one was seeded into the roster and badged. The network pass found two dual-NPI entities (The Opportunity Alliance, KidsPeace's two campuses), a shared-address and officer network between a school and a day-treatment company, and a medical-director link between an addiction clinic and the convicted physician assistant. Maine's corporate registry detail is fee-gated, so registered agents could not be assessed.

Nebraska's roster held ten Tier 1 providers rather than thirty because few watchlist entries survived artifact suppression with a significant flag. One is referred: an Omaha counselor convicted of felony Medicaid fraud in November 2024 with $60,000 restitution, federally excluded since June 2025, and facing a pending civil False Claims suit (red). A physician excluded in November 2023 under the patient-abuse authority after a Nebraska license revocation and assault conviction had no post-exclusion billing (red exclusion). No Nebraska provider on the roster carries a settlement or pending charge.

Nebraska moved dental benefits into its Heritage Health managed-care plans on January 1, 2024, and the University of Nebraska Medical Center College of Dentistry, an orthodontic group, and a multi-site dental practice all show 14x to 21x growth with a November 2023 or January 2024 break as a result; they remain review items only for unit-cost residuals (an orthodontic code at about 2.4x the state average). Three providers were adjudicated benign: a homeless-services nonprofit's 2022 residential launch, a psychology group at published rates, and a county health department whose vaccine costs match CDC acquisition prices.

Of 20 Nebraska enforcement actions since January 2024, 1 named provider has claims in the source data, the referred counselor, who was already on the watchlist at moderate risk. The network pass found no shared officer, address, phone, or agent across the roster; Nebraska Secretary of State lookups are form-gated and returned nothing.

Four of the thirty-five researched Maryland providers are referred, all confirmed against Maryland Attorney General or DOJ releases. Two psychiatric rehabilitation program (PRP) providers at the same Belair Road address were operated by people sentenced in late 2025 for $3.67 million in ghost billing, one of them while already excluded (red). A speech-therapy LLC's owner pleaded guilty in 2024 to billing more than $1 million for juvenile therapy never provided (red). A durable medical equipment company's officers were sentenced in March 2024 for undelivered nebulizers billed to Maryland and D.C. Medicaid (red). Progressive Oncology and Hematology paid $1.45 million in July 2026 to resolve chemotherapy-drug billing allegations (red settlement), and a behavioral-health provider's authorized official is a defendant in the August 2024 D.C. federal indictment (amber). All five seeded matches produced badges.

Maryland extended full dental benefits to adults on January 1, 2023, and eleven of the thirty-five rostered providers are dental practices whose 8x to 23x growth breaks at December 2022 or January 2023 with unit costs inside the published Healthy Smiles fee schedule; eight were adjudicated benign and the rest are review items for per-code residuals only. This is a candidate suppression rule. The other Maryland pattern is PRP and supported-housing billers (H0044, H2036, OMHC tiers) ramping to $5 million to $8 million with thin visible staffing: a single-suite provider at 54x growth billing at the four-day-per-week cap, a 12.5x April 2022 step to about $759,000 a month, and a 98x June 2024 administrative jump remain review items.

Of 32 Maryland enforcement actions since January 2024, 5 named providers have claims in the source data, all 5 have anomaly rows, and 1 (the DME company) was rated high. The network pass confirmed the shared Belair Road PRP pair and a nonprofit's two NPIs, and found a plausible dental bridge through a shared Charles Street suite and license number; Maryland's business registry detail is JavaScript-gated, so agents could not be assessed.

None of the twenty-five researched New Hampshire providers carries an exclusion, conviction, or pending charge. LifeWorks Counseling Associates and its owner paid $300,000 in December 2025 to resolve False Claims Act allegations that they billed New Hampshire Medicaid for services rendered by a federally excluded clinician, with no admission of liability and the amount set by ability to pay (red settlement); it was the state's one seeded enforcement match. Review items are histories rather than billing findings: a residential provider with a 2019 abuse case, a 2020 staff conviction, and a 2025 settlement surfaced only by the community lane, a 2017 residential assault at another operator, and a treatment nonprofit's documented 2019 to 2020 billing-control failures.

On July 1, 2023 New Hampshire moved developmental-services providers from area-agency billing to direct Medicaid billing, a federally mandated cutover that makes long-standing nonprofits appear as new high-volume entrants; on April 1, 2023 it launched a comprehensive adult dental benefit, and the 2023 HB2 budget raised rates across the board. Fourteen providers were adjudicated benign on those events, on residential per-diem economics, and on startup ramps, including a national DME biller (Novocure) and a hospital system's new campus. Both 2023 events are candidates for New Hampshire suppression rules. Residual review items are census-driven volume surges beyond the rate increases at a home-care agency and a nursing staffing company, and T2021 intensity at a waiver provider.

Of 17 New Hampshire enforcement actions since January 2024, 1 named provider has claims in the source data and it was badged; the rest concern individual aides and beneficiaries. The network pass confirmed one cluster, Next Steps Community Services and Becket Academy sharing an officer, phone, and Orford mailing address under the Becket Family of Services, and documented a trade-name collision between two unrelated detox providers.

North Dakota's roster held eight Tier 1 providers because few watchlist entries survived artifact suppression with a significant flag. One is referred: Bismarck Transportation Services, itself a named criminal defendant in parallel June 2025 federal and Burleigh County Medicaid fraud cases alleging billing for rides never provided and upcharging vehicle types, methods that map directly to the packet's flags; the charges are allegations and the badge is amber. It was on the watchlist at critical risk and matched the state's validation set. A social worker excluded in October 2021 under the patient-abuse authority, mirrored by North Dakota Medicaid termination on the same date, had no post-exclusion billing (red exclusion). The network pass surfaced a same-official taxi company outside the roster that merits a records check.

Four providers were adjudicated benign on residential-habilitation and memory-care per-diem billing for stable censuses, a recovery center's documented 2023 capacity expansion, and North Dakota dental policy. Review items are a senior-services company whose per-diem billing began weeks after an agency foster home opened and cannot yet be sized to bed capacity, and a solo provider's multi-unit group billing.

Of 20 North Dakota enforcement actions since January 2024, 2 rows name a provider with claims in the source data, both the referred transportation company, which was already rated critical on the watchlist. The network pass found no shared officer, address, or phone across the roster; North Dakota's FirstStop corporate registry is JavaScript-gated.

Two of the thirty-two researched New Mexico providers are referred, both seeded from the enforcement record: Safeway Medical Transportation, named in a June 2026 federal civil forfeiture complaint seeking more than $2 million as alleged proceeds of Medicaid fraud and money laundering (amber, allegation), which was already on the watchlist at high risk; and Equine Assisted Programs of Southern New Mexico, whose owner pleaded guilty to Medicaid fraud, falsification, and identity theft over about $970,000 in false claims (red). A physician under a 13-year federal exclusion since 2016 appears to bill after exclusion, but the lanes documented an OIG access waiver covering his billing window through August 2022; that is shown as amber context rather than as post-exclusion billing.

New Mexico raised behavioral-health, primary-care, and dental rates on October 1, 2022 and launched its Turquoise Care managed-care program in 2024; those events, with new group and site NPIs at operating clinics, the state's COVID-testing agreements, and a hospital ED staffing takeover, explain fourteen benign dispositions, including the state's dominant reference laboratory re-enumerated in 2021. Review items are non-emergency transport carriers with 8x volume steps and per-leg pricing near the tariff cap, a clinic with about $1 million in multi-unit 87798 billing at roughly 10x the unit rate, a personal-care company with a documented 2017 to 2018 services-not-rendered investigation matching its current pattern, and a 31x 2024 respiratory-testing surge.

Of 20 New Mexico enforcement actions since January 2024, 2 named providers have claims in the source data, both seeded and both badged. The network pass confirmed one same-entity pair (Eye Associates of New Mexico's two NPIs) and found no shared person, address, or phone across the transport, behavioral-health, dental, or hospital-staffing clusters; the Secretary of State portal is CAPTCHA-gated.

Four of the thirty-one researched Oregon providers carry federal exclusions confirmed on the OIG list by NPI: a provider who pleaded guilty in 2022 to controlled-substance distribution overlapping the Medicaid window (the state's one referral), a 2020 felony false-claim conviction, and two license-based exclusions following Oregon Medical Board actions. None shows post-exclusion billing. Family Choice Urgent Care paid $489,280 to the Oregon Department of Justice in September 2025 to resolve allegations of billing higher-level and unprovided visits for asymptomatic patients (red settlement); its billing in the data ended in 2022 before the clinic was sold, so the badge attaches to the legal entity's history. That was the state's one seeded enforcement match.

Oregon raised behavioral-health rates by about 30 percent on July 1, 2022, reformed SUD residential reimbursement on January 1, 2022, and raised dental fees in October 2023; five providers were adjudicated benign on those events and startup ramps. Twenty-five remain review items, most for residual per-code premiums of 1.2x to 1.9x over the fee schedule that coordinated-care-organization contracts may explain. The network pass found two dental attribution clusters: one pediatric dentist's practices appearing under three individual roster NPIs, and a Portland-Oregon City practice pair sharing addresses. Those are billing-attribution indicators, not findings.

Of 30 Oregon enforcement actions since January 2024, 2 named providers have claims in the source data and 1 has anomaly rows; Oregon's Medicaid Fraud Control Unit docket centers on halfway-house enrollment fraud and individual caregivers billed through entities the data does not carry. No shared phone, roster cross-citation, or registered agent was found beyond the two dental clusters.

Oklahoma's Attorney General Medicaid Fraud Control Unit publishes named False Claims Act settlements and civil suits, and the source data carries those entities, so eight of the eleven badges came from the validation-seeded tier. Red settlements: Red Dirt Orthodontics ($583,090, November 2025, services billed under a falsely identified orthodontist), Stonewood Hills Oral Surgery ($532,056, July 2025), Urgent Care of Muskogee ($619,994, August 2024), a Watonga psychiatrist's PLLC ($173,143 for alleged E/M upcoding, two NPIs), and a pharmacy in a joint $157,000 COVID-test settlement; all resolved allegations without a liability determination. Pending civil complaints against a neuropathy clinic, a speech-language pathologist ($2.5 million alleged), and a laboratory doing business as HunterCare are amber. A counselor convicted of Medicaid fraud and identity theft and a physician with a 2023 controlled-substance conviction are federally excluded (red).

Oklahoma expanded Medicaid on July 1, 2021, made methadone treatment compensable in October 2020, moved community mental health centers to CCBHC bundled monthly payments, and launched SoonerSelect managed care in April 2024. Twenty-one providers were adjudicated benign on those events: state-operated and nonprofit CCBHCs under new billing NPIs, a tribal health center paid the federal encounter rate to the dollar, health-system physician groups, drive-through COVID testing, and new dental and family-practice offices ramping into the expansion. Review items are the statewide non-emergency transport broker's June 2023 change point, a clinic's October 2023 billing cliff, and an OTP's nine-month billing halt.

Of 30 Oklahoma enforcement actions since January 2024, 7 named providers have claims in the source data, 5 have anomaly rows, and 3 are rated high; every seeded match produced a badge. The network pass confirmed four same-enterprise pairs (two CCBHCs' dual NPIs, the Watonga psychiatrist and his PLLC, and a dental support organization) and one shared Oklahoma City post-office box between a laboratory and a dental group that merits a records check.

South Dakota's roster held six Tier 1 providers because few watchlist entries survived artifact suppression with a significant flag. None was found on the federal exclusion list, under state discipline, or named in any enforcement action. A Canton residential treatment campus, a Sioux Falls home-health branch, and a Sioux Falls recovery nonprofit are left for analyst review on volume questions only: a cost-per-claim elevation on residential treatment codes, a May 2024 census doubling with no documented business cause, and units-per-claim about twice the state average with sevenfold beneficiary growth across mid-2024. Nothing in the public record supports investigation of any of them.

A dentist's flags resolve to Medicaid dental payment policy and a documented office expansion. A pediatric private-duty nursing agency's spikes track published rate increases and electronic-visit-verification billing-rule changes; the only settlement found touches an Iowa sibling entity, not South Dakota claims. A Rosebud dialysis unit's flags follow the state's end-stage renal disease payment rules and a rebound from a low base.

Of 14 South Dakota enforcement actions since January 2024, none names a provider with claims in the source data; the cases are individuals (a Pierre nursing-agency owner, an adult-day-center board member, a medical biller), a Sioux City area surgical hospital settlement, and generic-drug price-fixing settlements. Public enforcement since 2024 is also consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass found one confirmed link: the nursing agency and the home-health branch share the same ultimate parent, Aveanna Healthcare, and the same headquarters mailing address.

Four providers are referred, each on a matter already resolved in public record. The Journey to Hope, Health and Healing and its former chief executive settled federal and state False Claims Act allegations over substance-use-disorder billing for $10.2 million in June 2026. Recovery Connection Centers of America and its de facto owner were convicted of health-care-fraud conspiracy for billing 45-minute counseling sessions that were delivered in five to ten minutes or not at all; both are now excluded under the mandatory authority. A physician entered a nolo contendere plea to medical assistance fraud in July 2026 with restitution and license surrender. In each case the packet's own statistical flags match the charged conduct. A Rotech medical-equipment branch carries an amber context badge for its parent's 2018 settlement; nothing names the Rhode Island branch.

Eight providers were adjudicated benign on published Rhode Island payment policy: the July 2022 adult dental rate increase, home-based therapeutic services rate actions, the November 2021 tiered assisted-living rate reform, the July 2023 developmental-disabilities rate overhaul, buy-and-bill multiple-sclerosis biologics at an academic neurology practice, and per-meal and per-15-minute billing models. Twenty remain for analyst review where a volume, unit-price, or census question has no published explanation, including a solo clinician whose peak monthly 60-minute session count exceeds what one person can deliver and an individual surgeon NPI carrying hospice room-and-board charges. None of the twenty has an exclusion, discipline, or enforcement record.

Of 21 Rhode Island enforcement actions since January 2024, 2 rows name a provider with claims in the source data: the Journey to Hope settlement and the physician plea. Neither was on the watchlist; both entered the roster because public enforcement since 2024 is consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass found three genuine clusters: a two-NPI Seven Hills entity, the two convicted co-defendants, and two assisted-living homes under related ownership.

Labtech Diagnostic is referred: its operator pleaded guilty to five Anti-Kickback Statute counts and agreed to pay at least $6.8 million to resolve False Claims Act allegations covering August 2018 through November 2021, with a federal exclusion effective December 2025. The packet's billing window overlaps the charged period. Three individual practitioners are excluded, two counselors under the mandatory authority and one under the controlled-substance authority after an oxycodone-distribution conviction; none shows billing after the exclusion date. Lutheran Family Services carries an amber licensing badge for the November 2022 revocation of all 35 of its disability-home licenses; its residential billing line opened and closed with that episode. A consulting firm seeded from the validation set stays unbadged because the June 2025 federal charge names its namesake individual and the corporate link is not established in public filings.

Ten disability providers, most of them county disabilities and special needs boards, showed hundredfold 2022 growth. All of it traces to South Carolina's April 1, 2022 move from DDSN pass-through funding to direct Medicaid billing, which made existing service volume visible in claims for the first time. Per-diem rates sit at published levels. Six other providers were adjudicated benign on startup ramps, hospice room-and-board pass-through, a school-Medicaid market entry, and a documented county 911 takeover by an ambulance service. Fourteen remain for analyst review where a volume step or solo throughput has no dated explanation.

Of 29 South Carolina enforcement actions since January 2024, 2 rows name a provider with claims in the source data. One is the seeded consulting firm; the other is a caregiver case that matched a disability nonprofit already adjudicated benign at the entity level. Public enforcement since 2024 is consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass found one confirmed cluster, two branches of the same national complex-rehab equipment chain.

Three individual practitioners are excluded: one after a $2.73 million Vermont False Claims Act judgment and dual license revocations, one after a guilty plea to Medicaid fraud with license surrender, and one counselor whose licensing stipulation confirms billing for psychotherapy sessions that did not occur. None shows billing after exclusion. Revolution Youth, operator of a Burlington clinic, settled state False Claims Act allegations in December 2025 for $200,000 over altered records and false claims spanning the packet window. United Counseling Service of Bennington County, a designated agency billing under two NPIs, settled with the Attorney General's Medicaid Fraud Unit in March 2026 for $483,464 over developmental-services supervision failures; both NPIs carry the same badge. Two practitioners face pending felony Medicaid-fraud charges and are badged amber; charges are allegations and both are presumed innocent.

A durable medical equipment supplier's 2016 Medicaid settlement and a designated agency's 2016 self-disclosed penalty for employing an excluded individual are shown as amber context; neither has any action since. Seven providers were adjudicated benign on Vermont's published orthodontic fee schedule, a retina practice's documented surgeon expansion with drug pass-through pricing, per-diem residential billing at published rates, and the bundled monthly Children's Integrated Services rate. Ten remain for analyst review, including a residence with a single-month $997,000 posting and a behavioral health company whose billing rose after its own site announced its Vermont offices had closed.

Of 24 Vermont enforcement actions since January 2024, 6 rows name a provider with claims in the source data, the highest match rate of any state. Two of the six were already on the watchlist; the other four entered the roster because public enforcement since 2024 is consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass found the two-NPI designated agency and a phone tie between an excluded counselor and a designated agency; the Vermont Secretary of State registry is JavaScript-gated.

Second Chance Family Services entered the roster from the validation set: the Attorney General's Medicaid Fraud Control Unit has charged its operators over more than $951,000 in alleged false claims from December 2023 to March 2025, and the packet's late-2024 billing falls inside that window. Creative Minds UT, also seeded, is named as the alleged vehicle in an August 2026 federal indictment of its owner involving more than $4 million in Medicaid payments. A dentist faces a pending state felony prosecution for 2019 false claims, but the primary court record could not be retrieved, so no badge is shown. All three are allegations; the defendants are presumed innocent, and the two verified matters are badged amber. Crimson Heights carries an amber licensing badge for a February 2026 program license revocation.

Twenty-three providers remain for analyst review, the largest share of any state. Common threads are early-2023 volume steps at anesthesia groups and a physician subpart with no confirmed operational trigger, a physician billing office visits at roughly $2,200 per claim with no published rate explanation, and residential per-diem programs whose growth outruns documented capacity. Three Intermountain Health NPIs and two Nomi Health NPIs are related entities whose flags trace to January 2023 coding changes and pandemic mass-testing. Six providers were adjudicated benign on Utah's dental-anesthesia rule, published fee schedules, and partial-year ramps.

Of 15 Utah enforcement actions since January 2024, 2 rows name a provider with claims in the source data, both the referred behavioral-health operators; neither was on the watchlist. Public enforcement since 2024 is consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass confirmed the Intermountain and Nomi clusters and flagged a shared surname across two residential-treatment orbits for human verification; Utah's business registry is login-gated.

Wyoming's roster held five Tier 1 providers because few watchlist entries survived artifact suppression with a significant flag. One practitioner carries a federal mandatory exclusion effective November 2023, corroborated by a second state list; all of her Wyoming Medicaid billing in the source data ended before the exclusion date, so the badge records the exclusion rather than post-exclusion payment. No other roster provider has an exclusion, discipline, settlement, or enforcement record.

Two providers were adjudicated benign: a case-management chain branch whose fragmented unit billing ended at a documented acquisition, and a new waiver agency whose 2022 growth is a caseload ramp at or below published rates. Two remain for analyst review, a therapy practice whose 64-fold 2023 growth is only partially explained despite below-average per-claim costs, and a virtual psychiatry group whose add-on psychotherapy payment exceeds the one published Wyoming rate.

Of 10 Wyoming enforcement actions since January 2024, none names a provider with claims in the source data. Public enforcement since 2024 is consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass found no shared officer, address, or phone across the roster; the Wyoming Secretary of State registry blocked automated lookups in every lane, so agent comparison rests on lane text.

Three individual physicians were convicted in federal court of unlawful controlled-substance distribution, one by jury verdict on 17 counts in 2020, one by guilty plea sentenced in January 2025, and one by jury verdict in February 2025 with forfeiture of his license and clinic; each carries a matching OIG exclusion, and none shows billing after exclusion. A fourth physician pleaded guilty to Medicaid fraud, paid a settlement of more than $200,000, surrendered his license, and was excluded under the mandatory authority; the packet's early-2018 billing overlaps the admitted fraud period. Med-Surg Physician Group and its owner settled civil False Claims Act allegations in April 2025 for $152,383 over telehealth facility fees billed while patients were at home; both of the group's NPIs carry the same red badge. A general practitioner's 2019 exclusion is shown as amber context because it rests on the health-education loan-default authority rather than fraud or patient harm.

Eleven providers were adjudicated benign on published West Virginia payment changes: the November 2021 ARPA 70 percent rate increase for licensed behavioral health centers, Certified Community Behavioral Health Clinic certification effective October 2024 with per-diem prospective payment, the 2021 intellectual-disability waiver reform, and Aged and Disabled Waiver rates that reproduce per-claim amounts to within one percent. The state's Birth to Three program bills centrally as provider of record, which explains its volume profile. Fifteen remain for analyst review, including a family-run attendant-care operation across three NPIs with unexplained billing gaps and an individual neurosurgery NPI carrying only ambulance-transport charges.

Of 15 West Virginia enforcement actions since January 2024, 3 rows name a provider with claims in the source data: the Med-Surg settlement, which was already on the watchlist at high risk, and the February 2025 conviction, which was not. Public enforcement since 2024 is consulted when building each state's roster, and any named provider with claims in Sentinel is researched regardless of watchlist rank. The network pass confirmed the two-NPI physician group and the three-NPI attendant-care family; West Virginia Secretary of State detail pages are JavaScript-gated.