Where Medicaid money concentrates.

In every year from 2018 to 2024, the top 1% of billing NPIs received nearly half of the paid dollars in the federal Medicaid provider-spending file. This note sets out what the file shows about concentration and growth, and what it cannot show.

Data as of
File dated April 6, 2026
By
Marque Analytics
Data
HHS, service years 2018–2024
Published

Key figures

HHS Medicaid Provider Spending by HCPCS, version 2026-02-09, file dated April 6, 2026

  1. K.1

    In each year from 2018 to 2024, the top 1% of billing NPIs (about 3,300 to 3,600 NPIs) received between 45.6% and 47.7% of paid dollars in the file.

  2. K.2

    The bottom half of billing NPIs received less than 0.8% of paid dollars in every year.

  3. K.3

    Across the seven years combined, 620 billing NPIs received 23.0% of $1,104.6 billion in paid claims.

  4. K.4

    Billing NPIs paid $100 million or more in a year rose from 31 in 2018 to 104 in 2023. Total paid rose 83% over the same years.

  5. K.5

    From 2019 to 2023, there were 604 instances in which a billing NPI paid in all 12 months of the prior year passed $1 million after growing more than tenfold, totaling $2.97 billion. Including preliminary 2024 data, the count is 706 and $3.56 billion.

How concentrated is Medicaid provider spending?

Highly concentrated, and the shape barely moves from year to year.

HHS publishes Medicaid payments by billing provider, servicing provider, procedure code and month for January 2018 through December 2024.1 We ranked every billing NPI by the amount it was paid in each service year and measured how the dollars divide.

In every year, the top 1% of billing NPIs received between 45.6% and 47.7% of paid dollars. That group is about 3,300 to 3,600 NPIs out of roughly 326,000 to 360,000. The top 0.1%, about 330 to 360 NPIs, received 18.4% to 20.2%. The bottom half of all billing NPIs received less than 0.8% combined.

Pooling the seven years gives the same picture. Over 2018 to 2024, 620 billing NPIs received 23.0% of $1,104.6 billion in paid claims, and 6,191 received 53.2%.

Share of paid dollars by billing-NPI rank

Percent of Medicaid paid dollars in each service year. Billing NPIs ranked by their annual paid amount, then grouped by percentile.

  • Bottom 50%
  • 50th to 90th percentile
  • 90th to 99th
  • 99th to 99.9th
  • Top 0.1%
YearTop 1%20182018 · Bottom 50%: 0.71% of paid dollars2018 · 50th to 90th percentile: 13.91% of paid dollars2018 · 90th to 99th: 39.17% of paid dollars2018 · 99th to 99.9th: 27.59% of paid dollars2018 · Top 0.1%: 18.62% of paid dollars46.2%20192019 · Bottom 50%: 0.75% of paid dollars2019 · 50th to 90th percentile: 14.59% of paid dollars2019 · 90th to 99th: 39.09% of paid dollars2019 · 99th to 99.9th: 27.18% of paid dollars2019 · Top 0.1%: 18.39% of paid dollars45.6%20202020 · Bottom 50%: 0.69% of paid dollars2020 · 50th to 90th percentile: 13.38% of paid dollars2020 · 90th to 99th: 38.27% of paid dollars2020 · 99th to 99.9th: 27.47% of paid dollars2020 · Top 0.1%: 20.19% of paid dollars47.7%20212021 · Bottom 50%: 0.77% of paid dollars2021 · 50th to 90th percentile: 14.41% of paid dollars2021 · 90th to 99th: 38.62% of paid dollars2021 · 99th to 99.9th: 27.11% of paid dollars2021 · Top 0.1%: 19.09% of paid dollars46.2%20222022 · Bottom 50%: 0.79% of paid dollars2022 · 50th to 90th percentile: 14.77% of paid dollars2022 · 90th to 99th: 38.78% of paid dollars2022 · 99th to 99.9th: 26.69% of paid dollars2022 · Top 0.1%: 18.97% of paid dollars45.7%20232023 · Bottom 50%: 0.77% of paid dollars2023 · 50th to 90th percentile: 14.59% of paid dollars14.6%2023 · 90th to 99th: 38.53% of paid dollars38.5%2023 · 99th to 99.9th: 26.86% of paid dollars26.9%2023 · Top 0.1%: 19.25% of paid dollars19.3%46.1%2024*2024 · Bottom 50%: 0.76% of paid dollars2024 · 50th to 90th percentile: 14.67% of paid dollars2024 · 90th to 99th: 38.65% of paid dollars2024 · 99th to 99.9th: 26.99% of paid dollars2024 · Top 0.1%: 18.93% of paid dollars45.9%Top 1% of NPIs YearTop 1%20182018 · Bottom 50%: 0.71% of paid dollars2018 · 50th to 90th percentile: 13.91% of paid dollars2018 · 90th to 99th: 39.17% of paid dollars2018 · 99th to 99.9th: 27.59% of paid dollars2018 · Top 0.1%: 18.62% of paid dollars46.2%20192019 · Bottom 50%: 0.75% of paid dollars2019 · 50th to 90th percentile: 14.59% of paid dollars2019 · 90th to 99th: 39.09% of paid dollars2019 · 99th to 99.9th: 27.18% of paid dollars2019 · Top 0.1%: 18.39% of paid dollars45.6%20202020 · Bottom 50%: 0.69% of paid dollars2020 · 50th to 90th percentile: 13.38% of paid dollars2020 · 90th to 99th: 38.27% of paid dollars2020 · 99th to 99.9th: 27.47% of paid dollars2020 · Top 0.1%: 20.19% of paid dollars47.7%20212021 · Bottom 50%: 0.77% of paid dollars2021 · 50th to 90th percentile: 14.41% of paid dollars2021 · 90th to 99th: 38.62% of paid dollars2021 · 99th to 99.9th: 27.11% of paid dollars2021 · Top 0.1%: 19.09% of paid dollars46.2%20222022 · Bottom 50%: 0.79% of paid dollars2022 · 50th to 90th percentile: 14.77% of paid dollars2022 · 90th to 99th: 38.78% of paid dollars2022 · 99th to 99.9th: 26.69% of paid dollars2022 · Top 0.1%: 18.97% of paid dollars45.7%20232023 · Bottom 50%: 0.77% of paid dollars2023 · 50th to 90th percentile: 14.59% of paid dollars2023 · 90th to 99th: 38.53% of paid dollars38.5%2023 · 99th to 99.9th: 26.86% of paid dollars26.9%2023 · Top 0.1%: 19.25% of paid dollars19.3%46.1%2024*2024 · Bottom 50%: 0.76% of paid dollars2024 · 50th to 90th percentile: 14.67% of paid dollars2024 · 90th to 99th: 38.65% of paid dollars2024 · 99th to 99.9th: 26.99% of paid dollars2024 · Top 0.1%: 18.93% of paid dollars45.9%Top 1% of NPIs
Data table
Share of paid dollars by billing-NPI rank group, percent
YearBilling NPIsTop 0.1%Top 1%Top 10%Bottom 50%
2018326,09518.6246.2185.380.71
2019328,63318.3945.5784.660.75
2020346,42920.1947.6685.930.69
2021359,15819.0946.2084.820.77
2022356,07718.9745.6684.440.79
2023359,57819.2546.1184.640.77
2024 (preliminary)341,47418.9345.9284.570.76
Fig. 1Data. In every year the top 1% of billing NPIs received 45.6% to 47.7% of paid dollars, and the bottom half under 0.8%. Labeled values are for 2023; figures may not sum due to rounding. Source: HHS, Medicaid Provider Spending by HCPCS, version 2026-02-09, file dated April 6, 2026; rows with a billing provider NPI. Marque Analytics analysis. *2024 is preliminary.

Much of this concentration is ordinary. Large systems legitimately bill a great deal of care under a small number of NPIs. The point for program integrity is practical. A review that covers a few thousand billing NPIs covers close to half of the dollars.

How many providers does Medicaid pay $100 million or more a year?

The count more than tripled. Billing NPIs paid at least $100 million in a service year rose from 31 in 2018 to 104 in 2023. The preliminary 2024 count is 99.

Spending grew over the same period, though more slowly. Total paid to billing NPIs rose 83%, from $110.0 billion in 2018 to $200.9 billion in 2023. The number of billing NPIs paid $1 million or more rose 66%, from 18,916 to 31,389. Those paid $10 million or more roughly doubled, from 1,466 to 3,073.

Billing NPIs paid $100 million or more in a year

Count of billing NPIs by service year. Nominal dollars.

  • Billing NPIs paid $100 million or more in the year
  • 2024, preliminary
02550751002018: 31 billing NPIs paid $100M or more3120182019: 46 billing NPIs paid $100M or more4620192020: 62 billing NPIs paid $100M or more6220202021: 78 billing NPIs paid $100M or more7820212022: 92 billing NPIs paid $100M or more9220222023: 104 billing NPIs paid $100M or more10420232024: 99 billing NPIs paid $100M or more (preliminary)992024* 02550751002018: 31 billing NPIs paid $100M or more3120182019: 46 billing NPIs paid $100M or more4620192020: 62 billing NPIs paid $100M or more6220202021: 78 billing NPIs paid $100M or more7820212022: 92 billing NPIs paid $100M or more9220222023: 104 billing NPIs paid $100M or more10420232024: 99 billing NPIs paid $100M or more (preliminary)992024*
Data table
Billing NPIs by annual paid amount
Year$1M or more$10M or more$100M or moreTotal paid, billing NPIs ($B)
201818,9161,46631110.0
201921,6031,74146128.3
202021,8391,83262133.6
202126,3542,37978163.4
202228,9722,66092181.1
202331,3893,073104200.9
2024 (preliminary)29,7282,82099187.3
Fig. 2Data. The number of very large billing NPIs rose from 31 to 104 between 2018 and 2023, faster than total paid, which rose 83%. Source: HHS, Medicaid Provider Spending by HCPCS, version 2026-02-09, file dated April 6, 2026; rows with a billing provider NPI. Marque Analytics analysis. *2024 is preliminary.

Two cautions apply. The figures are in nominal dollars, so some providers cross the line through price growth alone. And states improved how they report managed care encounters over this period, which can move payments into the data that were there all along. Both cautions bear on the national trend, not on any single provider.

How often does a provider’s Medicaid billing jump tenfold in a year?

Rarely, measured against the typical provider. Among billing NPIs paid more than $1 million that were also paid the year before, the median year-over-year change was about 1.1×. The 90th percentile ran from 1.7× to 3.6×, depending on the year.

We counted the instances at the far end: a billing NPI that passed $1 million in a year after growing more than tenfold from the prior year. The stricter count keeps only NPIs that were paid in all 12 months of the prior year. That removes providers whose first year was partial, which would otherwise look like explosive growth. On that basis there were 604 instances from 2019 to 2023, totaling $2.97 billion. Including preliminary 2024 data, the count is 706 and $3.56 billion.

The broader count, without the full-prior-year test, finds 2,670 instances from 2019 to 2023, totaling $9.56 billion. Lowering the bar to fivefold growth gives 5,409 instances and $19.44 billion over the same years. These broader counts can include new practices, mergers and NPI changes, so we treat them as an upper bound on what deserves a look.

Tenfold year-over-year jumps past $1 million

Billing NPIs paid more than $1 million in a service year after growing more than tenfold from the year before. Count of instances by year.

  • NPI paid in all 12 months of the prior year: 604 instances, $2.97 billion, 2019 to 2023
  • All instances: 2,670, $9.56 billion, 2019 to 2023
  • 2024, preliminary
03006009002019, NPIs paid in all 12 prior months: 247 instances, $1,074 million2472019, all instances: 832 instances, $3,006 million83220192020, NPIs paid in all 12 prior months: 143 instances, $520 million1432020, all instances: 503 instances, $1,519 million50320202021, NPIs paid in all 12 prior months: 57 instances, $471 million572021, all instances: 561 instances, $2,017 million56120212022, NPIs paid in all 12 prior months: 101 instances, $620 million1012022, all instances: 400 instances, $1,849 million40020222023, NPIs paid in all 12 prior months: 56 instances, $284 million562023, all instances: 374 instances, $1,170 million37420232024, NPIs paid in all 12 prior months: 102 instances, $591 million1022024, all instances: 445 instances, $1,474 million4452024* 20192019: 247 instances, $1,074 million2472019: 832 instances, $3,006 million83220202020: 143 instances, $520 million1432020: 503 instances, $1,519 million50320212021: 57 instances, $471 million572021: 561 instances, $2,017 million56120222022: 101 instances, $620 million1012022: 400 instances, $1,849 million40020232023: 56 instances, $284 million562023: 374 instances, $1,170 million3742024*2024: 102 instances, $591 million1022024: 445 instances, $1,474 million445
Data table
Billing NPIs that passed $1 million after growing more than tenfold in one year
YearAll instancesPaid, all instances ($M)Paid all 12 prior monthsPaid, those instances ($M)Median growth, NPIs over $1M90th percentile growth
20198323,0062471,0741.10×3.12×
20205031,5191435201.04×2.39×
20215612,017574711.22×3.56×
20224001,8491016201.12×1.86×
20233741,170562841.11×1.85×
2024 (preliminary)4451,4741025910.97×1.68×
2019 to 20232,6709,5606042,970
2019 to 2024, with preliminary 20243,11511,0347063,561
Fig. 3Data. The stricter count (dark) keeps only NPIs paid in every month of the prior year: 604 instances and $2.97 billion from 2019 to 2023. The broader count (light) is 2,670 instances and $9.56 billion. The 2024 bars are preliminary and are not included in the totals. Source: HHS, Medicaid Provider Spending by HCPCS, version 2026-02-09, file dated April 6, 2026; rows with a billing provider NPI. Marque Analytics analysis. *2024 is preliminary.

What concentration and growth mean for program integrity

Neither number identifies wrongdoing. A large share of dollars going to a small number of NPIs is what a payment system with hospitals and health systems in it looks like. A tenfold jump is also what a merger or an NPI change looks like. The national figures show where attention can pay off. Locating a problem takes entity-level evidence.

What they do establish is a baseline. A provider’s billing is read against peers in the same specialty, codes and period, across plans and states. Implausible growth is one of the ten signals Marque scores for every entity in a payment integrity engagement. It counts only when it converges with other independent signals, such as co-location, shared phones and billing agents, undisclosed affiliations or prior exclusions.

The same holds for improper payments generally. Medicaid’s improper payment rate for fiscal year 2025 was 6.12%, an estimated $37.39 billion, and CMS states that improper payment measurement is not a measure of fraud.2 Telling the two apart takes entity-level evidence.

Caveats

Read every figure in this note with these limits in mind.

i.An NPI is not a company.
Payments are attributed to the billing provider NPI on each claim line. One organization can bill under several NPIs, and a large system can bill a great deal of legitimate care under one.
ii.Growth is not fraud.
Mergers and NPI changes produce legitimate jumps, and the suppression of small cells produces artificial ones. The tenfold counts measure growth only.
iii.Dollars are nominal.
No adjustment for inflation or price changes. Part of the rise in large billers reflects price.
iv.Reporting changed.
States’ managed care encounter reporting improved over the period, which can raise later years’ totals without any change in care.
v.2024 is preliminary.
HHS labels 2024 data preliminary. Comparisons of very large billers stop at 2023; 2024 is shown for completeness.
vi.Small cells are missing.
HHS drops any provider, code and month cell with fewer than 12 claim lines or 12 beneficiaries, so low-volume activity is absent.3

Methodology and sources

Note on method

Aggregate statistics only. No provider is named.

Dataset
U.S. Department of Health and Human Services, “Medicaid Provider Spending by HCPCS,” HHS Open Data Platform, version 2026-02-09; file dated April 6, 2026; rows with a billing provider NPI.opendata.hhs.gov/datasets/medicaid-provider-spending
Coverage
Service months January 2018 to December 2024, all states and territories. Built from T-MSIS fee-for-service, managed care and CHIP claim lines.
Unit
Billing provider NPI by service year. Paid amounts are line-level paid amounts summed over the year. Years are service years.
Concentration
NPIs ranked by annual paid amount; the top 1% is the first 1% of that ranking. Checked with a second, independent percentile query; the two agree within 0.03 points.
Growth
An NPI paid more than $1 million in a year, paid in the prior year, and paid more than ten times the prior-year amount. The stricter version also requires payment in all 12 months of the prior year. Two independent query forms give identical results.
Replication
Every figure was also recomputed on a second, locally held copy carrying the same version label; results agree within about 4%.
  1. 1U.S. Department of Health and Human Services, Medicaid Provider Spending by HCPCS, HHS Open Data Platform, version 2026-02-09; file dated April 6, 2026; rows with a billing provider NPI; service months January 2018 to December 2024, 2024 preliminary.
  2. 2Centers for Medicare & Medicaid Services, Fiscal Year 2025 Improper Payments Fact Sheet, January 15, 2026.
  3. 3HHS documentation for the same dataset: cells with fewer than 12 claim lines or 12 beneficiaries are suppressed, and data quality varies by state.

Questions

What share of Medicaid spending goes to the top 1% of providers?

In HHS’s Medicaid Provider Spending by HCPCS data, the top 1% of billing NPIs received between 45.6% and 47.7% of paid dollars in each year from 2018 to 2024. The top 0.1% received 18.4% to 20.2%, and the bottom half of billing NPIs received less than 0.8%.

How many Medicaid providers are paid more than $100 million a year?

Counted by billing NPI, 104 were paid $100 million or more in service year 2023, up from 31 in 2018. The preliminary 2024 count is 99. Total paid to billing NPIs rose 83% over 2018 to 2023, so the number of very large billers grew faster than spending.

Does fast growth in Medicaid billing indicate fraud?

No. Mergers and NPI changes produce legitimate jumps, and the suppression of small cells produces artificial ones. Growth is one signal among several. It becomes meaningful when other, independent signals converge on the same entity.

Why count billing NPIs instead of organizations?

The federal file reports payments by NPI. An NPI is not a company: one organization can bill under several NPIs, and a large system can bill under one. Resolving NPIs to the entities and owners behind them is a separate step, and the figures here do not include it.

What data does this analysis use?

HHS’s “Medicaid Provider Spending by HCPCS” dataset on the HHS Open Data Platform, version 2026-02-09 (file dated April 6, 2026, rows with a billing provider NPI), covering service months from January 2018 through December 2024. It is built from T-MSIS fee-for-service, managed care and CHIP claim lines. Figures are in nominal dollars, and 2024 is preliminary.

More research notes

The NPI gap in exclusion screeningExclusion screening Only 10.25% of OIG exclusion records carry an NPI. What DOJ’s FOCUS initiative means for statistical evidence in False Claims Act mattersFalse Claims Act The April 2026 announcement, the July questionnaire and the case law behind them.

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