Statistical Outliers

Single-test outliers in Alabama Medicaid data. These are individual statistical flags — most are informational.

Important context: These findings identify statistically unusual billing patterns, not determinations of wrongdoing. Cost-per-claim comparisons may flag hospital outpatient departments whose reimbursements include facility fees, bundled services, or all-inclusive rates. High claims-per-beneficiary ratios may reflect legitimate care patterns at behavioral health facilities, pediatric specialty centers, or residential care programs. Additional investigation and clinical context are required before drawing any conclusions.

For provider level analytics using multiple independent tests, see the Watchlist — which flags providers only when 2+ different detection methods agree. These single-test outliers below are primarily informational; only Cost Outliers and Overutilization are flagged as critical/warning.

critical

105

warning

221

info

3,858

Total

4,184

Outliers by Type

Severity Distribution

critical

105 (2.5%)

warning

221 (5.3%)

info

3,858 (92.2%)

3,210 results

criticalCost OutlierScore: 31.0

Cost-per-claim above average for 99213 (Office Visit, Established Patient (20 min, Low Complexity))

ALABAMA DEPARTMENT OF REHABILITATION SERVICES (1891849725) bills $1,810.83/claim for 99213 (Office o/p est low 20 min) vs avg $34.79 (+31.0σ). $7,542,087 across 4,165 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF REHABILITATION SERVICESMONTGOMERYProvider total: $68.0M

criticalCost OutlierScore: 30.4

Cost-per-claim above average for 99214 (Office Visit, Established Patient (30 min, Moderate Complexi)

ALABAMA DEPARTMENT OF REHABILITATION SERVICES (1891849725) bills $1,873.62/claim for 99214 (Office o/p est mod 30 min) vs avg $47.04 (+30.4σ). $1,259,075 across 672 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF REHABILITATION SERVICESMONTGOMERYProvider total: $68.0M

criticalCost OutlierScore: 22.1

Cost-per-claim above average for 99212 (Office Visit, Established Patient (10 min, Straightforward))

ALABAMA DEPARTMENT OF REHABILITATION SERVICES (1891849725) bills $1,835.09/claim for 99212 (Office o/p est sf 10 min) vs avg $21.74 (+22.1σ). $17,117,763 across 9,328 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF REHABILITATION SERVICESMONTGOMERYProvider total: $68.0M

criticalCost OutlierScore: 12.9

Cost-per-claim above average for T1015 (Clinic Service)

MERCY LIFE OF ALABAMA (1952609059) bills $2,990.45/claim for T1015 (Clinic service) vs avg $94.94 (+12.9σ). $11,504,267 across 3,847 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

MERCY LIFE OF ALABAMAMOBILEProvider total: $11.5M

criticalCost OutlierScore: 12.7

Cost-per-claim above average for 99173

REHAB EARLY INTERVENTION (1811043649) bills $36.18/claim for 99173 (Visual acuity screen) vs avg $3.02 (+12.7σ). $39,073 across 1,080 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

REHAB EARLY INTERVENTIONMONTGOMERYProvider total: $39.2M

criticalCost OutlierScore: 8.9

Cost-per-claim above average for 92015

MARY WILSON (1396090163) bills $42.09/claim for 92015 (Determine refractive state) vs avg $7.34 (+8.9σ). $107,666 across 2,558 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

MARY WILSONMOBILEProvider total: $422.3K

criticalCost OutlierScore: 8.7

Cost-per-claim above average for G9008

ALABAMA DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION (1346846037) bills $372.43/claim for G9008 (Mccd,phys coor-care ovrsght) vs avg $56.97 (+8.7σ). $576,143 across 1,547 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATIONMONTGOMERYProvider total: $2.9M

criticalOverutilizationScore: 8.4

Unusually high claims-per-beneficiary ratio

HEALTHACTIONS OF TROY LLC (1992165864): 20.9 claims/beneficiary (avg 1.9). 57,172 claims, 2,735 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

HEALTHACTIONS OF TROY LLCTROYProvider total: $194.9K

criticalCost OutlierScore: 8.1

Cost-per-claim above average for 99205 (Office Visit, New Patient (60 min, High Complexity))

UNIVERSITY OF ALABAMA AT BIRMINGHAM (1447445135) bills $909.12/claim for 99205 (Office o/p new hi 60 min) vs avg $140.04 (+8.1σ). $1,404,595 across 1,545 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

UNIVERSITY OF ALABAMA AT BIRMINGHAMBIRMINGHAMProvider total: $4.8M

criticalOverutilizationScore: 8.1

Unusually high claims-per-beneficiary ratio

DVA HEALTHCARE RENAL CARE INC (1598738080): 20.2 claims/beneficiary (avg 1.9). 11,229 claims, 557 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

DVA HEALTHCARE RENAL CARE INCBIRMINGHAMProvider total: $234.5K

criticalCost OutlierScore: 7.7

Cost-per-claim above average for T1015 (Clinic Service)

ALABAMA DEPARTMENT OF REHABILITATION SERVICES (1811171614) bills $1,808.59/claim for T1015 (Clinic service) vs avg $94.94 (+7.7σ). $3,942,728 across 2,180 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF REHABILITATION SERVICESMONTGOMERYProvider total: $3.9M

criticalOverutilizationScore: 7.2

Unusually high claims-per-beneficiary ratio

DVA HEALTHCARE OF TUSCALOOSA LLC (1336112143): 18.1 claims/beneficiary (avg 1.9). 3,058 claims, 169 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

DVA HEALTHCARE OF TUSCALOOSA LLCEUTAWProvider total: $67.6K

criticalCost OutlierScore: 7.1

Cost-per-claim above average for A4657

DIALYSIS CLINIC INC. (1063445443) bills $12.15/claim for A4657 (Syringe w/wo needle) vs avg $0.87 (+7.1σ). $25,312 across 2,083 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DIALYSIS CLINIC INC.CULLMANProvider total: $348.2K

criticalCost OutlierScore: 7.1

Cost-per-claim above average for 99215 (Office Visit, Established Patient (40 min, High Complexity))

UNIVERSITY OF ALABAMA AT BIRMINGHAM (1447445135) bills $903.94/claim for 99215 (Office o/p est hi 40 min) vs avg $74.88 (+7.1σ). $1,627,997 across 1,801 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

UNIVERSITY OF ALABAMA AT BIRMINGHAMBIRMINGHAMProvider total: $4.8M

criticalOverutilizationScore: 6.8

Unusually high claims-per-beneficiary ratio

CONGRESS STREET PARTNERS, L.P. (1730166588): 17.1 claims/beneficiary (avg 1.9). 25,888 claims, 1,510 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

CONGRESS STREET PARTNERS, L.P.MOBILEProvider total: $175.8K

criticalCost OutlierScore: 6.6

Cost-per-claim above average for 90710

PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLC (1568901742) bills $248.57/claim for 90710 (Mmrv vaccine sc) vs avg $18.78 (+6.6σ). $174,496 across 702 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLCDOTHANProvider total: $4.2M

criticalCost OutlierScore: 6.5

Cost-per-claim above average for A0425 (Ground Ambulance Mileage (per mile))

THE CHILDREN'S HOSPITAL OF ALABAMA (1447369525) bills $333.27/claim for A0425 (Ground mileage) vs avg $46.97 (+6.5σ). $369,927 across 1,110 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

THE CHILDREN'S HOSPITAL OF ALABAMABIRMINGHAMProvider total: $2.7M

criticalCost OutlierScore: 6.4

Cost-per-claim above average for D0230 (Dental X-ray (Periapical, Each Additional))

JANNA ROUTH (1629563119) bills $27.66/claim for D0230 (Intraoral - periapical each addl image) vs avg $8.45 (+6.4σ). $22,708 across 821 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JANNA ROUTHENTERPRISEProvider total: $156.5K

criticalCost OutlierScore: 6.4

Cost-per-claim above average for 90723

PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLC (1568901742) bills $86.71/claim for 90723 (Dtap-hep b-ipv vaccine im) vs avg $13.89 (+6.4σ). $181,398 across 2,092 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLCDOTHANProvider total: $4.2M

criticalCost OutlierScore: 6.3

Cost-per-claim above average for 99406

USA HCA OBGYN SERVICES LLC (1689141665) bills $17.79/claim for 99406 (Behav chng smoking 3-10 min) vs avg $0.69 (+6.3σ). $19,569 across 1,100 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

USA HCA OBGYN SERVICES LLCMOBILEProvider total: $1.8M

criticalCost OutlierScore: 6.3

Cost-per-claim above average for T1019

ALABAMA DEPARTMENT OF SENIOR SERVICES (1285025411) bills $754.11/claim for T1019 (Personal care ser per 15 min) vs avg $31.59 (+6.3σ). $2,396,564 across 3,178 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF SENIOR SERVICESMONTGOMERYProvider total: $3.1M

criticalCost OutlierScore: 6.2

Cost-per-claim above average for 99309 (Subsequent Nursing Facility Care (Moderate Complexity))

JAVIER TAPIA (1629066691) bills $73.54/claim for 99309 (Sbsq nf care moderate mdm 30) vs avg $8.64 (+6.2σ). $114,939 across 1,563 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JAVIER TAPIAGREENVILLEProvider total: $114.9K

criticalOverutilizationScore: 6.1

Unusually high claims-per-beneficiary ratio

SUNBRIDGE GARDENDALE HEALTH CARE CENTER, LLC (1285684068): 15.7 claims/beneficiary (avg 1.9). 15,004 claims, 957 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

SUNBRIDGE GARDENDALE HEALTH CARE CENTER, LLCGARDENDALEProvider total: $218.8K

criticalCost OutlierScore: 6.1

Cost-per-claim above average for S5130

RIVIERA HEALTH SERVICES, LLC (1710356217) bills $52.36/claim for S5130 (Homaker service nos per 15m) vs avg $1.64 (+6.1σ). $12,619 across 241 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

RIVIERA HEALTH SERVICES, LLCMOBILEProvider total: $14.5M

criticalOverutilizationScore: 6.0

Unusually high claims-per-beneficiary ratio

RENAL TREATMENT CENTERS-SOUTHEAST, LP. (1336483478): 15.5 claims/beneficiary (avg 1.9). 2,315 claims, 149 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

RENAL TREATMENT CENTERS-SOUTHEAST, LP.BREWTONProvider total: $57.0K

criticalCost OutlierScore: 6.0

Cost-per-claim above average for 99394 (Preventive Visit, Established Patient (Ages 12-17))

CLAY COUNTY HEALTH DEPT EPSDT (1124161591) bills $286.83/claim for 99394 (Prev visit est age 12-17) vs avg $47.38 (+6.0σ). $32,986 across 115 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

CLAY COUNTY HEALTH DEPT EPSDTLINEVILLEProvider total: $56.8K

criticalCost OutlierScore: 5.9

Cost-per-claim above average for 99391 (Preventive Visit, Established Patient (Infant, <1 year))

JEFFERSON COUNTY BOARD OF HEALTH (1447285390) bills $255.06/claim for 99391 (Per pm reeval est pat infant) vs avg $49.18 (+5.9σ). $1,738,501 across 6,816 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JEFFERSON COUNTY BOARD OF HEALTHBIRMINGHAMProvider total: $11.7M

criticalCost OutlierScore: 5.8

Cost-per-claim above average for 59426

OB-GYN ASSOCIATES OF MONTGOMERY, P.C. (1932278652) bills $453.23/claim for 59426 (Antepartum care only) vs avg $17.34 (+5.8σ). $11,784 across 26 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

OB-GYN ASSOCIATES OF MONTGOMERY, P.C.MONTGOMERYProvider total: $2.6M

criticalCost OutlierScore: 5.8

Cost-per-claim above average for G9003

ALABAMA DEPARTMENT OF MENTAL HEALTH (1215577051) bills $563.52/claim for G9003 (Mccd, risk adj hi, initial) vs avg $62.60 (+5.8σ). $1,456,146 across 2,584 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF MENTAL HEALTHMONTGOMERYProvider total: $2.2M

criticalOverutilizationScore: 5.8

Unusually high claims-per-beneficiary ratio

MADISONS JOURNEY ABA THERAPY, LLC (1124775879): 15.0 claims/beneficiary (avg 1.9). 1,545 claims, 103 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

MADISONS JOURNEY ABA THERAPY, LLCDOTHANProvider total: $154.8K

criticalOverutilizationScore: 5.8

Unusually high claims-per-beneficiary ratio

RIVIERA HEALTH SERVICES, LLC (1710356217): 15.0 claims/beneficiary (avg 1.9). 21,481 claims, 1,436 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

RIVIERA HEALTH SERVICES, LLCMOBILEProvider total: $14.5M

criticalOverutilizationScore: 5.8

Unusually high claims-per-beneficiary ratio

PHYSICIANS CHOICE DIALYSIS OF ALABAMA LLC (1902860331): 14.9 claims/beneficiary (avg 1.9). 4,092 claims, 274 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

PHYSICIANS CHOICE DIALYSIS OF ALABAMA LLCPRATTVILLEProvider total: $109.2K

criticalCost OutlierScore: 5.7

Cost-per-claim above average for 99392 (Preventive Visit, Established Patient (Ages 1-4))

JEFFERSON COUNTY BOARD OF HEALTH (1447285390) bills $251.99/claim for 99392 (Prev visit est age 1-4) vs avg $49.15 (+5.7σ). $1,515,468 across 6,014 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JEFFERSON COUNTY BOARD OF HEALTHBIRMINGHAMProvider total: $11.7M

criticalCost OutlierScore: 5.7

Cost-per-claim above average for Q9967

HOUSTON COUNTY HEALTHCARE AUTHORITY (1164403861) bills $21.01/claim for Q9967 (Locm 300-399mg/ml iodine,1ml) vs avg $3.55 (+5.7σ). $24,409 across 1,162 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

HOUSTON COUNTY HEALTHCARE AUTHORITYDOTHANProvider total: $4.9M

criticalOverutilizationScore: 5.7

Unusually high claims-per-beneficiary ratio

DR. HARRISON ABA CENTER (1871066829): 14.7 claims/beneficiary (avg 1.9). 2,666 claims, 181 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

DR. HARRISON ABA CENTERDALEVILLEProvider total: $397.0K

criticalCost OutlierScore: 5.7

Cost-per-claim above average for Q4081

DVA RENAL HEALTHCARE INC (1629415609) bills $156.37/claim for Q4081 (Epoetin alfa, 100 units esrd) vs avg $20.49 (+5.7σ). $49,414 across 316 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

DVA RENAL HEALTHCARE INCBIRMINGHAMProvider total: $767.3K

criticalCost OutlierScore: 5.7

Cost-per-claim above average for 99391 (Preventive Visit, Established Patient (Infant, <1 year))

JEFFERSON COUNTY BOARD OF HEALTH (1942235825) bills $246.42/claim for 99391 (Per pm reeval est pat infant) vs avg $49.18 (+5.7σ). $1,377,979 across 5,592 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JEFFERSON COUNTY BOARD OF HEALTHMIDFIELDProvider total: $10.7M

criticalCost OutlierScore: 5.5

Cost-per-claim above average for 99392 (Preventive Visit, Established Patient (Ages 1-4))

JEFFERSON COUNTY BOARD OF HEALTH (1942235825) bills $244.99/claim for 99392 (Prev visit est age 1-4) vs avg $49.15 (+5.5σ). $1,219,584 across 4,978 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JEFFERSON COUNTY BOARD OF HEALTHMIDFIELDProvider total: $10.7M

criticalOverutilizationScore: 5.5

Unusually high claims-per-beneficiary ratio

DVA HEALTHCARE RENAL CARE INC (1215900444): 14.2 claims/beneficiary (avg 1.9). 2,293 claims, 161 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

DVA HEALTHCARE RENAL CARE INCGADSDENProvider total: $93.6K

criticalCost OutlierScore: 5.4

Cost-per-claim above average for 99393 (Preventive Visit, Established Patient (Ages 5-11))

CLAY COUNTY HEALTH DEPT EPSDT (1124161591) bills $247.95/claim for 99393 (Prev visit est age 5-11) vs avg $46.56 (+5.4σ). $23,804 across 96 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

CLAY COUNTY HEALTH DEPT EPSDTLINEVILLEProvider total: $56.8K

criticalCost OutlierScore: 5.4

Cost-per-claim above average for 90697

HUNTSVILLE PEDIATRIC ASSOCIATES, LLC (1922246842) bills $150.85/claim for 90697 (Dtap-ipv-hib-hepb vaccine im) vs avg $15.04 (+5.4σ). $14,331 across 95 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

HUNTSVILLE PEDIATRIC ASSOCIATES, LLCHUNTSVILLEProvider total: $4.8M

criticalCost OutlierScore: 5.4

Cost-per-claim above average for 90698

PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLC (1568901742) bills $108.12/claim for 90698 (Dtap-ipv/hib vaccine im) vs avg $16.56 (+5.4σ). $38,815 across 359 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

PHYSICIAN MANAGEMENT SERVICES OF ALABAMA LLCDOTHANProvider total: $4.2M

criticalCost OutlierScore: 5.3

Cost-per-claim above average for 59426

OBSTETRICS & GYNECOLOGY ASSOCIATES OF NORTHWEST ALABAMA, P.C. (1578669081) bills $412.44/claim for 59426 (Antepartum care only) vs avg $17.34 (+5.3σ). $10,311 across 25 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

OBSTETRICS & GYNECOLOGY ASSOCIATES OF NORTHWEST ALABAMA, P.C.FLORENCEProvider total: $97.0K

criticalOverutilizationScore: 5.2

Unusually high claims-per-beneficiary ratio

DIALYSIS CLINIC INC. (1669405049): 13.7 claims/beneficiary (avg 1.9). 6,541 claims, 476 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

DIALYSIS CLINIC INC.ENTERPRISEProvider total: $292.2K

criticalCost OutlierScore: 5.2

Cost-per-claim above average for 99392 (Preventive Visit, Established Patient (Ages 1-4))

JEFFERSON COUNTY BOARD OF HEALTH (1336167196) bills $233.22/claim for 99392 (Prev visit est age 1-4) vs avg $49.15 (+5.2σ). $1,877,857 across 8,052 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JEFFERSON COUNTY BOARD OF HEALTHBIRMINGHAMProvider total: $12.2M

criticalCost OutlierScore: 5.1

Cost-per-claim above average for 97535

ALABAMA DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION (1982757688) bills $36.80/claim for 97535 (Self care mngment training) vs avg $3.19 (+5.1σ). $310,529 across 8,438 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

ALABAMA DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATIONMONTGOMERYProvider total: $2.3B

criticalCost OutlierScore: 5.1

Cost-per-claim above average for 99391 (Preventive Visit, Established Patient (Infant, <1 year))

JEFFERSON COUNTY BOARD OF HEALTH (1336167196) bills $225.71/claim for 99391 (Per pm reeval est pat infant) vs avg $49.18 (+5.1σ). $2,247,883 across 9,959 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

JEFFERSON COUNTY BOARD OF HEALTHBIRMINGHAMProvider total: $12.2M

criticalOverutilizationScore: 5.0

Unusually high claims-per-beneficiary ratio

DVA HEALTHCARE RENAL CARE INC (1942272414): 13.3 claims/beneficiary (avg 1.9). 5,043 claims, 380 beneficiaries.

The ratio of claims to unique patients is unusually high, suggesting each patient receives many more services than average. May indicate overutilization or inappropriate repeat billing.

DVA HEALTHCARE RENAL CARE INCATHENSProvider total: $163.0K

criticalCost OutlierScore: 5.0

Cost-per-claim above average for 90791 (Psychiatric Diagnostic Evaluation)

LANECHA CONNER (1003337635) bills $220.48/claim for 90791 (Psych diagnostic evaluation) vs avg $57.94 (+5.0σ). $89,293 across 405 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

LANECHA CONNERHUNTSVILLEProvider total: $89.3K

criticalCost OutlierScore: 4.9

Cost-per-claim above average for 90698

CHILDREN'S MEDICAL GROUP, P.A. (1689639312) bills $100.57/claim for 90698 (Dtap-ipv/hib vaccine im) vs avg $16.56 (+4.9σ). $295,171 across 2,935 claims.

This provider charges significantly more (or less) per claim for a specific procedure code compared to peers in the same state. This can indicate upcoding, incorrect billing, or specialty services.

CHILDREN'S MEDICAL GROUP, P.A.MOBILEProvider total: $7.4M

Page 1 of 65

Statistical Outliers

Single-test outliers in Alabama Medicaid data. These are individual statistical flags — most are informational.