Statistical Outliers

Single-test outliers in Virginia 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

437

warning

760

info

6,790

Total

7,987

Outliers by Type

Severity Distribution

critical

437 (5.5%)

warning

760 (9.5%)

info

6,790 (85.0%)

5,666 results

criticalCost OutlierScore: 30.9

Cost-per-claim above average for 90686 (Influenza Vaccine (Quadrivalent))

UPPER MATTAPONI INDIAN TRIBE (1750969168) bills $654.00/claim for 90686 (Iiv4 vacc no prsv 0.5 ml im) vs avg $11.48 (+30.9σ). $26,814 across 41 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.

UPPER MATTAPONI INDIAN TRIBEAYLETTProvider total: $75.6M

criticalCost OutlierScore: 30.5

Cost-per-claim above average for 36415 (Blood Draw (Venipuncture))

FISHING POINT HEALTH CARE LLC (1679279046) bills $719.00/claim for 36415 (Coll venous bld venipuncture) vs avg $2.48 (+30.5σ). $117,916 across 164 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.

FISHING POINT HEALTH CARE LLCPORTSMOUTHProvider total: $169.8M

criticalCost OutlierScore: 29.3

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

FISHING POINT HEALTH CARE LLC (1679279046) bills $719.00/claim for 99213 (Office o/p est low 20 min) vs avg $46.45 (+29.3σ). $411,268 across 572 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.

FISHING POINT HEALTH CARE LLCPORTSMOUTHProvider total: $169.8M

criticalCost OutlierScore: 27.0

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

UPPER MATTAPONI INDIAN TRIBE (1750969168) bills $667.10/claim for 99213 (Office o/p est low 20 min) vs avg $46.45 (+27.0σ). $898,578 across 1,347 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.

UPPER MATTAPONI INDIAN TRIBEAYLETTProvider total: $75.6M

criticalCost OutlierScore: 24.2

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

FISHING POINT HEALTH CARE LLC (1679279046) bills $719.00/claim for 99214 (Office o/p est mod 30 min) vs avg $63.17 (+24.2σ). $312,765 across 435 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.

FISHING POINT HEALTH CARE LLCPORTSMOUTHProvider total: $169.8M

criticalCost OutlierScore: 23.0

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

UPPER MATTAPONI INDIAN TRIBE (1750969168) bills $687.69/claim for 99214 (Office o/p est mod 30 min) vs avg $63.17 (+23.0σ). $420,178 across 611 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.

UPPER MATTAPONI INDIAN TRIBEAYLETTProvider total: $75.6M

criticalCost OutlierScore: 19.3

Cost-per-claim above average for 99173

VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY (1437175734) bills $61.62/claim for 99173 (Visual acuity screen) vs avg $2.49 (+19.3σ). $352,225 across 5,716 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.

VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITYRICHMONDProvider total: $658.5M

criticalCost OutlierScore: 16.9

Cost-per-claim above average for T1005

1 MASTER HOME HEALTH (1902295397) bills $1,945.91/claim for T1005 (Respite care service 15 min) vs avg $104.55 (+16.9σ). $140,105 across 72 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.

1 MASTER HOME HEALTHPORTSMOUTHProvider total: $1.3M

criticalCost OutlierScore: 16.6

Cost-per-claim above average for 71046 (Chest X-ray (2 views, Frontal and Lateral))

1326447939 (1326447939) bills $212.60/claim for 71046 (X-ray exam chest 2 views) vs avg $12.13 (+16.6σ). $10,205 across 48 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.

GUAM HEALTHCARE DEVELOPMENT INCORPORATEDDEDEDOProvider total: $2.5M

criticalCost OutlierScore: 15.7

Cost-per-claim above average for 97530 (Therapeutic Activities (per 15 min))

BRANCHES OF LIFE (1487081337) bills $1,439.88/claim for 97530 (Therapeutic activities) vs avg $59.53 (+15.7σ). $996,396 across 692 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.

BRANCHES OF LIFECHESTERProvider total: $3.3M

criticalCost OutlierScore: 15.3

Cost-per-claim above average for T1019

COMFORT DEPENDABLE KARE HOME HEALTH SERVICES LLC (1346647161) bills $3,616.72/claim for T1019 (Personal care ser per 15 min) vs avg $190.56 (+15.3σ). $47,017 across 13 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.

COMFORT DEPENDABLE KARE HOME HEALTH SERVICES LLCNEWPORT NEWSProvider total: $47.0K

criticalCost OutlierScore: 14.4

Cost-per-claim above average for 71045 (Chest X-ray (Single View))

1326447939 (1326447939) bills $166.70/claim for 71045 (X-ray exam chest 1 view) vs avg $5.21 (+14.4σ). $50,843 across 305 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.

GUAM HEALTHCARE DEVELOPMENT INCORPORATEDDEDEDOProvider total: $2.5M

criticalCost OutlierScore: 14.1

Cost-per-claim above average for 92551

CHILDRENS HOSPITAL OF THE KINGS DAUGHTERS INC (1912919481) bills $172.63/claim for 92551 (Pure tone hearing test air) vs avg $10.45 (+14.1σ). $313,833 across 1,818 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.

CHILDRENS HOSPITAL OF THE KINGS DAUGHTERS INCNORFOLKProvider total: $288.2M

criticalCost OutlierScore: 12.6

Cost-per-claim above average for A0100

CENTRAL EXPRESS LLC (1316482581) bills $362.19/claim for A0100 (Nonemergency transport taxi) vs avg $26.57 (+12.6σ). $50,345 across 139 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.

CENTRAL EXPRESS LLCRICHMONDProvider total: $760.8K

criticalCost OutlierScore: 12.2

Cost-per-claim above average for T1019

HOMECARE CREW INC. (1124410717) bills $2,916.23/claim for T1019 (Personal care ser per 15 min) vs avg $190.56 (+12.1σ). $96,235 across 33 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.

HOMECARE CREW INC.STERLINGProvider total: $106.2K

criticalCost OutlierScore: 11.8

Cost-per-claim above average for H2012

FLOURISH HEALTH MEDICAL PRACTICE LLC (1780312686) bills $2,030.99/claim for H2012 (Behav hlth day treat, per hr) vs avg $247.44 (+11.8σ). $387,920 across 191 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.

FLOURISH HEALTH MEDICAL PRACTICE LLCARLINGTONProvider total: $600.7K

criticalCost OutlierScore: 11.5

Cost-per-claim above average for 96110

CHILDRENS HOSPITAL OF THE KINGS DAUGHTERS INC (1912919481) bills $705.22/claim for 96110 (Developmental screen w/score) vs avg $14.50 (+11.5σ). $1,747,539 across 2,478 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.

CHILDRENS HOSPITAL OF THE KINGS DAUGHTERS INCNORFOLKProvider total: $288.2M

criticalCost OutlierScore: 11.4

Cost-per-claim above average for 96127 (Brief Emotional/Behavioral Assessment)

CHILDRENS HOSPITAL OF THE KINGS DAUGHTERS INC (1912919481) bills $42.14/claim for 96127 (Brief emotional/behav assmt) vs avg $4.62 (+11.4σ). $209,756 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.

CHILDRENS HOSPITAL OF THE KINGS DAUGHTERS INCNORFOLKProvider total: $288.2M

criticalCost OutlierScore: 11.3

Cost-per-claim above average for 99283 (Emergency Dept Visit (Moderate Complexity))

1326447939 (1326447939) bills $679.29/claim for 99283 (Emergency dept visit low mdm) vs avg $63.76 (+11.3σ). $1,031,168 across 1,518 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.

GUAM HEALTHCARE DEVELOPMENT INCORPORATEDDEDEDOProvider total: $2.5M

criticalCost OutlierScore: 11.2

Cost-per-claim above average for D7140 (Tooth Extraction (Erupted Tooth, Simple))

SENTARA OBICI AMBULATORY SURGERY, LLC (1811101439) bills $377.26/claim for D7140 (Extraction erupted tooth or exposed root) vs avg $48.88 (+11.2σ). $12,827 across 34 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.

SENTARA OBICI AMBULATORY SURGERY, LLCSUFFOLKProvider total: $270.4K

criticalCost OutlierScore: 11.1

Cost-per-claim above average for J3490

SENTARA ENTERPRISES (1174693592) bills $1,863.30/claim for J3490 (Drugs unclassified injection) vs avg $17.66 (+11.1σ). $417,380 across 224 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.

SENTARA ENTERPRISESCHESAPEAKEProvider total: $38.7M

criticalCost OutlierScore: 11.1

Cost-per-claim above average for D8670

SIMPLY STRAIGHT, P.C. (1205220241) bills $3,433.99/claim for D8670 (Periodic orthodontic treatment visit) vs avg $326.69 (+11.1σ). $85,850 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.

SIMPLY STRAIGHT, P.C.ROANOKEProvider total: $107.1K

criticalCost OutlierScore: 11.0

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

UVA PRINCE WILLIAM MEDICAL CENTER (1417005760) bills $299.63/claim for 99213 (Office o/p est low 20 min) vs avg $46.45 (+11.0σ). $77,605 across 259 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.

UVA PRINCE WILLIAM MEDICAL CENTERMANASSASProvider total: $45.4M

criticalCost OutlierScore: 10.5

Cost-per-claim above average for 99202 (Office Visit, New Patient (15 min, Straightforward))

JEFFERY FLAGG (1043388465) bills $318.75/claim for 99202 (Office o/p new sf 15 min) vs avg $48.19 (+10.5σ). $21,675 across 68 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.

JEFFERY FLAGGBLACKSBURGProvider total: $36.0K

criticalCost OutlierScore: 10.4

Cost-per-claim above average for 99509

HEALTH & JOY SERVICES, LLC (1548759061) bills $255.14/claim for 99509 (Home visit day life activity) vs avg $52.24 (+10.4σ). $263,560 across 1,033 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.

HEALTH & JOY SERVICES, LLCALEXANDRIAProvider total: $1.6M

criticalCost OutlierScore: 9.9

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

UVA CULPEPER MEDICAL CENTER (1669538047) bills $273.59/claim for 99213 (Office o/p est low 20 min) vs avg $46.45 (+9.9σ). $2,958,275 across 10,813 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.

UVA CULPEPER MEDICAL CENTERCULPEPERProvider total: $53.9M

criticalCost OutlierScore: 9.5

Cost-per-claim above average for J2250

MONTGOMERY REGIONAL HOSPITAL INC (1275570376) bills $97.60/claim for J2250 (Inj midazolam hydrochloride) vs avg $1.40 (+9.5σ). $58,855 across 603 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.

MONTGOMERY REGIONAL HOSPITAL INCBLACKSBURGProvider total: $17.1M

criticalCost OutlierScore: 9.3

Cost-per-claim above average for T1005

ACCOMEDS HOME CARE LLC (1205241379) bills $1,114.17/claim for T1005 (Respite care service 15 min) vs avg $104.55 (+9.2σ). $41,224 across 37 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.

ACCOMEDS HOME CARE LLCFAIRFAXProvider total: $733.9K

criticalCost OutlierScore: 9.2

Cost-per-claim above average for D1999

JENNIFER CASTRO-CHABRIER (1285908046) bills $13.75/claim for D1999 (Unspecified preventive proc) vs avg $0.16 (+9.2σ). $35,890 across 2,610 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.

JENNIFER CASTRO-CHABRIERALEXANDRIAProvider total: $153.5K

criticalOverutilizationScore: 9.2

Unusually high claims-per-beneficiary ratio

1ST HOME CARE OF VA., INC. (1104537042): 53.9 claims/beneficiary (avg 3.8). 21,145 claims, 392 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.

1ST HOME CARE OF VA., INC.NORFOLKProvider total: $848.0K

criticalCost OutlierScore: 9.2

Cost-per-claim above average for A7038

APRIA HEALTHCARE LLC (1477562528) bills $12.87/claim for A7038 (Pos airway pressure filter) vs avg $1.72 (+9.2σ). $31,773 across 2,468 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.

APRIA HEALTHCARE LLCALEXANDRIAProvider total: $1.2M

criticalCost OutlierScore: 8.9

Cost-per-claim above average for J1100 (Dexamethasone Injection (1 mg))

MONTGOMERY REGIONAL HOSPITAL INC (1275570376) bills $22.59/claim for J1100 (Dexamethasone sodium phos) vs avg $0.81 (+9.0σ). $59,011 across 2,612 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.

MONTGOMERY REGIONAL HOSPITAL INCBLACKSBURGProvider total: $17.1M

criticalCost OutlierScore: 8.9

Cost-per-claim above average for 96110

BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC (1912969064) bills $549.32/claim for 96110 (Developmental screen w/score) vs avg $14.50 (+8.9σ). $186,769 across 340 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.

BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLCMECHANICSVILLEProvider total: $42.0M

criticalCost OutlierScore: 8.9

Cost-per-claim above average for 81002 (Urinalysis without Microscopy)

SYED AHMAD (1487654182) bills $11.75/claim for 81002 (Urinalysis nonauto w/o scope) vs avg $2.34 (+8.9σ). $33,752 across 2,873 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.

SYED AHMADBLUEFIELDProvider total: $226.5K

criticalCost OutlierScore: 8.8

Cost-per-claim above average for 86901

WINCHESTER MEDICAL CENTER (1619928017) bills $18.35/claim for 86901 (Blood typing serologic rh(d)) vs avg $1.07 (+8.8σ). $88,626 across 4,831 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.

WINCHESTER MEDICAL CENTERWINCHESTERProvider total: $69.8M

criticalCost OutlierScore: 8.7

Cost-per-claim above average for H0035 (Mental Health Partial Hospitalization (Under 24 hrs))

EMPOWERING FAMILIES PROGRAM DANIEL L. PRICE, PSY.D. (1447398011) bills $1,360.91/claim for H0035 (Mh partial hosp tx under 24h) vs avg $158.48 (+8.7σ). $144,257 across 106 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.

EMPOWERING FAMILIES PROGRAM DANIEL L. PRICE, PSY.D.CHARLOTTESVILLEProvider total: $4.5M

criticalCost OutlierScore: 8.5

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

BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC (1912969064) bills $157.64/claim for 99393 (Prev visit est age 5-11) vs avg $75.69 (+8.5σ). $192,640 across 1,222 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.

BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLCMECHANICSVILLEProvider total: $42.0M

criticalCost OutlierScore: 8.5

Cost-per-claim above average for 90460 (Immunization Administration (First Component))

NICOLE HARTVIGSEN (1184680241) bills $54.16/claim for 90460 (Im admin 1st/only component) vs avg $3.47 (+8.5σ). $49,013 across 905 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.

NICOLE HARTVIGSENFALLS CHURCHProvider total: $262.4K

criticalCost OutlierScore: 8.4

Cost-per-claim above average for 90834 (Psychotherapy (45 min))

TONYA JOHNSON (1750710232) bills $206.51/claim for 90834 (Psytx w pt 45 minutes) vs avg $57.45 (+8.4σ). $4,380,986 across 21,214 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.

TONYA JOHNSONNEWPORT NEWSProvider total: $4.5M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for 85041

QUEST DIAGNOSTICS NICHOLS INSTITUTE, INC. (1447296272) bills $2.07/claim for 85041 (Automated rbc count) vs avg $0.04 (+8.4σ). $16,302 across 7,872 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.

QUEST DIAGNOSTICS NICHOLS INSTITUTE, INC.CHANTILLYProvider total: $46.9M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for Q5001

CAPITAL HOSPICE (1568485894) bills $760.44/claim for Q5001 (Hospice or home hlth in home) vs avg $34.57 (+8.3σ). $5,323,067 across 7,000 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.

CAPITAL HOSPICEFALLS CHURCHProvider total: $5.8M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for J3475

DANVILLE REGIONAL MEDICAL CENTER LLC (1386720183) bills $16.85/claim for J3475 (Inj magnesium sulfate) vs avg $0.44 (+8.3σ). $20,535 across 1,219 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.

DANVILLE REGIONAL MEDICAL CENTER LLCMARTINSVILLEProvider total: $21.1M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for 97153

REIGN INTEGRATED SERVICES (1124686464) bills $1,797.05/claim for 97153 (Adaptive behavior tx by tech) vs avg $215.63 (+8.3σ). $2,070,197 across 1,152 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.

REIGN INTEGRATED SERVICESVIRGINIA BEACHProvider total: $8.3M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for J1170

MONTGOMERY REGIONAL HOSPITAL INC (1275570376) bills $22.30/claim for J1170 (Injection, hydromorphone, up to 4 mg) vs avg $0.64 (+8.3σ). $59,036 across 2,647 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.

MONTGOMERY REGIONAL HOSPITAL INCBLACKSBURGProvider total: $17.1M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for G8417

CARLOS A. CRUZ, MD, PC (1205221942) bills $8.87/claim for G8417 (Calc bmi abv up param f/u) vs avg $0.16 (+8.3σ). $31,439 across 3,546 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.

CARLOS A. CRUZ, MD, PCALEXANDRIAProvider total: $5.6M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for T2003

MUSEIF ALALLOUCH (1649784182) bills $286.69/claim for T2003 (N-et; encounter/trip) vs avg $33.24 (+8.3σ). $2,446,578 across 8,534 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.

MUSEIF ALALLOUCHHENRICOProvider total: $8.5M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for A0120

Z&G TRANSPORTATION LLC (1932863123) bills $257.50/claim for A0120 (Noner transport mini-bus) vs avg $22.40 (+8.3σ). $17,510 across 68 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.

Z&G TRANSPORTATION LLCHENRICOProvider total: $2.1M

criticalCost OutlierScore: 8.3

Cost-per-claim above average for J0690

HOMECHOICE PARTNERS LLC (1114099488) bills $29.84/claim for J0690 (Cefazolin sodium injection) vs avg $0.79 (+8.2σ). $18,203 across 610 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.

HOMECHOICE PARTNERS LLCHENRICOProvider total: $23.5M

criticalOverutilizationScore: 8.2

Unusually high claims-per-beneficiary ratio

ABP SENIOR HOME CARE INC (1407559842): 48.7 claims/beneficiary (avg 3.8). 2,337 claims, 48 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.

ABP SENIOR HOME CARE INCCHANTILLYProvider total: $256.4K

criticalCost OutlierScore: 8.2

Cost-per-claim above average for J2704

CRIPPLED CHILDREN'S HOSPITAL (1841258589) bills $67.86/claim for J2704 (Inj, propofol, 10 mg) vs avg $1.74 (+8.2σ). $51,165 across 754 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.

CRIPPLED CHILDREN'S HOSPITALRICHMONDProvider total: $20.9M

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Statistical Outliers

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