Statistical Outliers

Single-test outliers in Tennessee 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

816

warning

1,088

info

13,558

Total

15,462

Outliers by Type

Severity Distribution

critical

816 (5.3%)

warning

1,088 (7.0%)

info

13,558 (87.7%)

8,782 results

criticalCost OutlierScore: 18.0

Cost-per-claim above average for 81003 (Urinalysis by Dipstick (Automated))

DYERSBURG HEALTH (1043282338) bills $16.40/claim for 81003 (Urinalysis auto w/o scope) vs avg $1.20 (+18.0σ). $27,946 across 1,704 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.

DYERSBURG HEALTHDYERSBURGProvider total: $13.2M

criticalCost OutlierScore: 18.0

Cost-per-claim above average for 81003 (Urinalysis by Dipstick (Automated))

DYERSBURG HEALTH (1043282338) bills $16.40/claim for 81003 (Urinalysis auto w/o scope) vs avg $1.20 (+18.0σ). $27,946 across 1,704 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.

DYERSBURG HEALTHDYERSBURGProvider total: $13.2M

criticalCost OutlierScore: 17.4

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

MATRIX MEDICAL PLUS (1376973461) bills $377.12/claim for 99309 (Sbsq nf care moderate mdm 30) vs avg $11.97 (+17.4σ). $447,640 across 1,187 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.

MATRIX MEDICAL PLUSNASHVILLEProvider total: $3.2M

criticalCost OutlierScore: 17.4

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

MATRIX MEDICAL PLUS (1376973461) bills $377.12/claim for 99309 (Sbsq nf care moderate mdm 30) vs avg $11.97 (+17.4σ). $447,640 across 1,187 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.

MATRIX MEDICAL PLUSNASHVILLEProvider total: $3.2M

criticalOverutilizationScore: 17.3

Unusually high claims-per-beneficiary ratio

GUARDIAN HOSPICE OF NASHVILLE, LLC (1770509051): 63.0 claims/beneficiary (avg 2.3). 2,959 claims, 47 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.

GUARDIAN HOSPICE OF NASHVILLE, LLCFRANKLINProvider total: $241.2K

criticalOverutilizationScore: 17.3

Unusually high claims-per-beneficiary ratio

GUARDIAN HOSPICE OF NASHVILLE, LLC (1770509051): 63.0 claims/beneficiary (avg 2.3). 2,959 claims, 47 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.

GUARDIAN HOSPICE OF NASHVILLE, LLCFRANKLINProvider total: $241.2K

criticalCost OutlierScore: 13.9

Cost-per-claim above average for G2211

KDPCTN (1679262737) bills $3,261.64/claim for G2211 (Complex e/m visit add on) vs avg $19.42 (+13.9σ). $1,350,320 across 414 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.

KDPCTNHERMITAGEProvider total: $1.4M

criticalCost OutlierScore: 13.9

Cost-per-claim above average for G2211

KDPCTN (1679262737) bills $3,261.64/claim for G2211 (Complex e/m visit add on) vs avg $19.42 (+13.9σ). $1,350,320 across 414 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.

KDPCTNHERMITAGEProvider total: $1.4M

criticalCost OutlierScore: 13.3

Cost-per-claim above average for D0220 (Dental X-ray (Periapical, First Film))

IOANA SOIMARU (1194100826) bills $52.74/claim for D0220 (Intraoral - periapical first image) vs avg $11.10 (+13.3σ). $22,624 across 429 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.

IOANA SOIMARUKNOXVILLEProvider total: $63.6K

criticalCost OutlierScore: 13.3

Cost-per-claim above average for D0220 (Dental X-ray (Periapical, First Film))

IOANA SOIMARU (1194100826) bills $52.74/claim for D0220 (Intraoral - periapical first image) vs avg $11.10 (+13.3σ). $22,624 across 429 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.

IOANA SOIMARUKNOXVILLEProvider total: $63.6K

criticalCost OutlierScore: 12.8

Cost-per-claim above average for D0120 (Periodic Oral Evaluation (Established Patient))

JOSEPH HALE (1396900866) bills $84.15/claim for D0120 (Periodic oral evaluation) vs avg $22.88 (+12.8σ). $424,954 across 5,050 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.

JOSEPH HALEMEMPHISProvider total: $2.6M

criticalCost OutlierScore: 12.8

Cost-per-claim above average for D0120 (Periodic Oral Evaluation (Established Patient))

JOSEPH HALE (1396900866) bills $84.15/claim for D0120 (Periodic oral evaluation) vs avg $22.88 (+12.8σ). $424,954 across 5,050 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.

JOSEPH HALEMEMPHISProvider total: $2.6M

criticalOverutilizationScore: 12.5

Unusually high claims-per-beneficiary ratio

ENHANCED SUPPORT SERVICES (1093231722): 46.0 claims/beneficiary (avg 2.3). 20,806 claims, 452 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.

ENHANCED SUPPORT SERVICESJOHNSON CITYProvider total: $3.8M

criticalOverutilizationScore: 12.1

Unusually high claims-per-beneficiary ratio

CONTEMPORARY COMMUNITY SOLUTION (1528577962): 44.6 claims/beneficiary (avg 2.3). 11,325 claims, 254 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.

CONTEMPORARY COMMUNITY SOLUTIONMEMPHISProvider total: $2.1M

criticalCost OutlierScore: 12.0

Cost-per-claim above average for D0150 (Comprehensive Oral Evaluation (New or Established Patient))

JOSEPH HALE (1396900866) bills $113.20/claim for D0150 (Comprehensive oral evaluation) vs avg $27.40 (+12.0σ). $346,283 across 3,059 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.

JOSEPH HALEMEMPHISProvider total: $2.6M

criticalCost OutlierScore: 12.0

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

COMMUNITY CARE HEALTH NETWORK LLC (1619368842) bills $262.89/claim for 99393 (Prev visit est age 5-11) vs avg $67.93 (+12.0σ). $11,830 across 45 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.

COMMUNITY CARE HEALTH NETWORK LLCNASHVILLEProvider total: $44.5M

criticalCost OutlierScore: 12.0

Cost-per-claim above average for D2392 (Dental Filling, Composite/Resin (Two Surfaces, Posterior))

FADY FARID (1447741251) bills $240.88/claim for D2392 (Resin composite - two surfaces posterior) vs avg $70.10 (+12.0σ). $32,760 across 136 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.

FADY FARIDHERMITAGEProvider total: $758.4K

criticalCost OutlierScore: 12.0

Cost-per-claim above average for D2392 (Dental Filling, Composite/Resin (Two Surfaces, Posterior))

FADY FARID (1447741251) bills $240.88/claim for D2392 (Resin composite - two surfaces posterior) vs avg $70.10 (+12.0σ). $32,760 across 136 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.

FADY FARIDHERMITAGEProvider total: $758.4K

criticalCost OutlierScore: 11.7

Cost-per-claim above average for J1885

VANDERBILT UNIVERSITY MEDICAL CENTER (1396882205) bills $25.70/claim for J1885 (Ketorolac tromethamine inj) vs avg $0.98 (+11.7σ). $75,597 across 2,942 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.

VANDERBILT UNIVERSITY MEDICAL CENTERNASHVILLEProvider total: $137.6M

criticalOverutilizationScore: 11.6

Unusually high claims-per-beneficiary ratio

MID-TN SUPPORTED LIVING, INC. (1568730554): 42.9 claims/beneficiary (avg 2.3). 6,482 claims, 151 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.

MID-TN SUPPORTED LIVING, INC.NASHVILLEProvider total: $1.4M

criticalCost OutlierScore: 11.6

Cost-per-claim above average for 99211 (Office Visit, Established Patient (May not require physician)

WELLMONT HEALTH SYSTEM (1124058615) bills $169.27/claim for 99211 (Off/op est may x req phy/qhp) vs avg $11.52 (+11.6σ). $22,683 across 134 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.

WELLMONT HEALTH SYSTEMBRISTOLProvider total: $27.3M

criticalCost OutlierScore: 11.6

Cost-per-claim above average for 99211 (Office Visit, Established Patient (May not require physician)

WELLMONT HEALTH SYSTEM (1124058615) bills $169.27/claim for 99211 (Off/op est may x req phy/qhp) vs avg $11.52 (+11.6σ). $22,683 across 134 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.

WELLMONT HEALTH SYSTEMBRISTOLProvider total: $27.3M

criticalCost OutlierScore: 11.1

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

TAVARES WILLIAMS (1669629531) bills $200.90/claim for 99391 (Per pm reeval est pat infant) vs avg $60.87 (+11.1σ). $47,815 across 238 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.

TAVARES WILLIAMSMC KENZIEProvider total: $346.4K

criticalCost OutlierScore: 11.1

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

TAVARES WILLIAMS (1669629531) bills $200.90/claim for 99391 (Per pm reeval est pat infant) vs avg $60.87 (+11.1σ). $47,815 across 238 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.

TAVARES WILLIAMSMC KENZIEProvider total: $346.4K

criticalCost OutlierScore: 10.9

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

KRIS HOUSER (1992798284) bills $265.23/claim for 99214 (Office o/p est mod 30 min) vs avg $36.93 (+10.9σ). $34,745 across 131 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.

KRIS HOUSERKNOXVILLEProvider total: $239.0K

criticalCost OutlierScore: 10.9

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

KRIS HOUSER (1992798284) bills $265.23/claim for 99214 (Office o/p est mod 30 min) vs avg $36.93 (+10.9σ). $34,745 across 131 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.

KRIS HOUSERKNOXVILLEProvider total: $239.0K

criticalCost OutlierScore: 10.8

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

TAVARES WILLIAMS (1669629531) bills $215.29/claim for 99392 (Prev visit est age 1-4) vs avg $68.55 (+10.8σ). $32,940 across 153 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.

TAVARES WILLIAMSMC KENZIEProvider total: $346.4K

criticalCost OutlierScore: 10.6

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

SAINT THOMAS HICKMAN HOSPITAL (1245275254) bills $10.06/claim for 36415 (Coll venous bld venipuncture) vs avg $1.24 (+10.6σ). $10,156 across 1,010 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.

SAINT THOMAS HICKMAN HOSPITALCENTERVILLEProvider total: $1.6M

criticalCost OutlierScore: 10.6

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

SAINT THOMAS HICKMAN HOSPITAL (1245275254) bills $10.06/claim for 36415 (Coll venous bld venipuncture) vs avg $1.24 (+10.6σ). $10,156 across 1,010 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.

SAINT THOMAS HICKMAN HOSPITALCENTERVILLEProvider total: $1.6M

criticalCost OutlierScore: 10.6

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

FADY FARID (1447741251) bills $178.82/claim for D7140 (Extraction erupted tooth or exposed root) vs avg $59.44 (+10.6σ). $161,120 across 901 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.

FADY FARIDHERMITAGEProvider total: $758.4K

criticalCost OutlierScore: 10.4

Cost-per-claim above average for 74176 (CT Abdomen and Pelvis without Contrast)

JELLICO COMMUNITY HOSPITAL INC. (1588679898) bills $614.77/claim for 74176 (Ct abd & pelvis w/o contrast) vs avg $47.36 (+10.4σ). $146,316 across 238 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.

JELLICO COMMUNITY HOSPITAL INC.JELLICOProvider total: $1.6M

criticalCost OutlierScore: 10.4

Cost-per-claim above average for 74176 (CT Abdomen and Pelvis without Contrast)

JELLICO COMMUNITY HOSPITAL INC. (1588679898) bills $614.77/claim for 74176 (Ct abd & pelvis w/o contrast) vs avg $47.36 (+10.4σ). $146,316 across 238 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.

JELLICO COMMUNITY HOSPITAL INC.JELLICOProvider total: $1.6M

criticalOverutilizationScore: 10.3

Unusually high claims-per-beneficiary ratio

ASERACARE HOSPICE - TENNESSEE, LLC (1750329181): 38.5 claims/beneficiary (avg 2.3). 7,961 claims, 207 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.

ASERACARE HOSPICE - TENNESSEE, LLCMC KENZIEProvider total: $944.0K

criticalOverutilizationScore: 10.3

Unusually high claims-per-beneficiary ratio

ASERACARE HOSPICE - TENNESSEE, LLC (1750329181): 38.5 claims/beneficiary (avg 2.3). 7,961 claims, 207 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.

ASERACARE HOSPICE - TENNESSEE, LLCMC KENZIEProvider total: $944.0K

criticalOverutilizationScore: 10.2

Unusually high claims-per-beneficiary ratio

ODYSSEY HEALTHCARE OPERATING A, LP (1649271578): 37.8 claims/beneficiary (avg 2.3). 7,750 claims, 205 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.

ODYSSEY HEALTHCARE OPERATING A, LPNASHVILLEProvider total: $575.8K

criticalOverutilizationScore: 10.2

Unusually high claims-per-beneficiary ratio

ODYSSEY HEALTHCARE OPERATING A, LP (1649271578): 37.8 claims/beneficiary (avg 2.3). 7,750 claims, 205 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.

ODYSSEY HEALTHCARE OPERATING A, LPNASHVILLEProvider total: $575.8K

criticalCost OutlierScore: 10.1

Cost-per-claim above average for A0100

THOMPSON DELIVERY SERVICES LLC (1437567674) bills $37.23/claim for A0100 (Nonemergency transport taxi) vs avg $2.36 (+10.1σ). $636,582 across 17,099 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.

THOMPSON DELIVERY SERVICES LLCKINGSPORTProvider total: $3.2M

criticalCost OutlierScore: 10.1

Cost-per-claim above average for A0100

THOMPSON DELIVERY SERVICES LLC (1437567674) bills $37.23/claim for A0100 (Nonemergency transport taxi) vs avg $2.36 (+10.1σ). $636,582 across 17,099 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.

THOMPSON DELIVERY SERVICES LLCKINGSPORTProvider total: $3.2M

criticalOverutilizationScore: 9.9

Unusually high claims-per-beneficiary ratio

BIOS OF TENNESSEE, LLC (1437364619): 36.9 claims/beneficiary (avg 2.3). 20,121 claims, 546 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.

BIOS OF TENNESSEE, LLCTHOMPSONS STATIONProvider total: $4.8M

criticalCost OutlierScore: 9.8

Cost-per-claim above average for J1885

RIVERVIEW MEDICAL CENTER LLC (1922319037) bills $21.74/claim for J1885 (Ketorolac tromethamine inj) vs avg $0.98 (+9.8σ). $26,365 across 1,213 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.

RIVERVIEW MEDICAL CENTER LLCCARTHAGEProvider total: $5.2M

criticalCost OutlierScore: 9.7

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

LESLIE WHALEY (1992042287) bills $25.75/claim for 96127 (Brief emotional/behav assmt) vs avg $3.62 (+9.7σ). $19,285 across 749 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.

LESLIE WHALEYMCMINNVILLEProvider total: $153.6K

criticalCost OutlierScore: 9.7

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

LESLIE WHALEY (1992042287) bills $25.75/claim for 96127 (Brief emotional/behav assmt) vs avg $3.62 (+9.7σ). $19,285 across 749 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.

LESLIE WHALEYMCMINNVILLEProvider total: $153.6K

criticalCost OutlierScore: 9.7

Cost-per-claim above average for 96372

HILLSIDE HOSPITAL LLC (1841388519) bills $63.55/claim for 96372 (Ther/proph/diag inj sc/im) vs avg $10.56 (+9.7σ). $270,072 across 4,250 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.

HILLSIDE HOSPITAL LLCPULASKIProvider total: $3.9M

criticalOverutilizationScore: 9.6

Unusually high claims-per-beneficiary ratio

WILLOWBROOK HOSPICE, INC. (1790782027): 36.0 claims/beneficiary (avg 2.3). 16,580 claims, 461 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.

WILLOWBROOK HOSPICE, INC.FRANKLINProvider total: $2.1M

criticalCost OutlierScore: 9.5

Cost-per-claim above average for 99305 (Nursing Facility Admission (Moderate Complexity))

MATRIX MEDICAL PLUS (1376973461) bills $374.77/claim for 99305 (1st nf care moderate mdm 35) vs avg $18.11 (+9.5σ). $81,700 across 218 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.

MATRIX MEDICAL PLUSNASHVILLEProvider total: $3.2M

criticalCost OutlierScore: 9.4

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

JENNIFER GOODWIN (1518185693) bills $25.03/claim for 96127 (Brief emotional/behav assmt) vs avg $3.62 (+9.4σ). $23,280 across 930 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 GOODWINTULLAHOMAProvider total: $202.9K

criticalCost OutlierScore: 9.4

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

JENNIFER GOODWIN (1518185693) bills $25.03/claim for 96127 (Brief emotional/behav assmt) vs avg $3.62 (+9.4σ). $23,280 across 930 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 GOODWINTULLAHOMAProvider total: $202.9K

criticalCost OutlierScore: 9.4

Cost-per-claim above average for 96372

SPRINGFIELD HEALTH SERVICES, LLC (1093397184) bills $62.05/claim for 96372 (Ther/proph/diag inj sc/im) vs avg $10.56 (+9.4σ). $74,957 across 1,208 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.

SPRINGFIELD HEALTH SERVICES, LLCSPRINGFIELDProvider total: $3.9M

criticalCost OutlierScore: 9.3

Cost-per-claim above average for 99211 (Office Visit, Established Patient (May not require physician)

MOUNTAIN STATES HEALTH ALLIANCE (1992813240) bills $138.43/claim for 99211 (Off/op est may x req phy/qhp) vs avg $11.52 (+9.3σ). $44,711 across 323 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.

MOUNTAIN STATES HEALTH ALLIANCEKINGSPORTProvider total: $15.5M

criticalCost OutlierScore: 9.3

Cost-per-claim above average for 99211 (Office Visit, Established Patient (May not require physician)

MOUNTAIN STATES HEALTH ALLIANCE (1992813240) bills $138.43/claim for 99211 (Off/op est may x req phy/qhp) vs avg $11.52 (+9.3σ). $44,711 across 323 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.

MOUNTAIN STATES HEALTH ALLIANCEKINGSPORTProvider total: $15.5M

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Statistical Outliers

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