Commonwealth of Pennsylvania Department of Education
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 5 procedure codes: 97166 at 3.1× median, 96156 at 10.6× median.
High Claims Per Patient
Filing an unusually high number of claims per beneficiary compared to peers.
Spending Spike
Experienced a dramatic increase in billing over a short period.
Statistical flags are not proof of wrongdoing. Some entities (government agencies, home care programs) may legitimately bill at high rates. Hospitals, government entities, and large care organizations may legitimately bill at higher rates due to patient acuity, overhead costs, or specialized services. Read our methodology.
Red Flags Explained
▼
Each flag represents a statistical test that identified unusual billing patterns. Here's what each flag on this provider means in plain English:
Rate Outlier
Rate Outlier means this provider charges above the 90th percentile for multiple different procedure codes simultaneously. While one high-cost code could reflect specialization, consistently high rates across many codes may indicate systematic overbilling.
High Claims Per Patient
High Claims Per Patient means this provider files an unusually high number of claims per individual patient. This could indicate legitimate intensive treatment or a pattern of billing for services not actually rendered.
Spending Spike
Spending Spike means this provider experienced a dramatic, sudden increase in billing over a short period. Legitimate causes include new contracts or expanded services, but this pattern also appears in billing fraud ramp-ups.
These flags are statistical indicators only. Many flagged providers have legitimate explanations for their billing patterns. Learn more about our methodology.
Advanced Detection Signals
Additional statistical tests from advanced fraud detection methods
These signals use advanced statistical methods including digit distribution analysis, change-point detection, and market concentration metrics. Learn more.
Risk Assessment
Bills $151.76 per claim for 97166 (OT evaluation, moderate complexity) — 3.1× the national median of $48.74.
Bills $237.06 per claim for 96156 — 10.6× the national median of $22.36.
Bills $200.81 per claim for 96150 (Health behavior assessment, initial) — 11.3× the national median of $17.83.
Billing in the top 1% nationally for 2 procedure codes: 96156, 96151.
This is a statistical summary, not an accusation. See our methodology.
Compared to Local Education Agency (LEA) Peers
Total spending distribution among 12 providers in this specialty
This provider's total spending of $326.0M is at the 99th percentile among 12 Local Education Agency (LEA) providers.
Above 99th percentile for this specialty — higher spending than 11 of 12 peers
Total Paid
$326.0M
$326,016,792
Total Claims
13.0M
Beneficiaries
3.8M
3.4 claims/patient
Avg Cost/Claim
$25
#219 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
Commonwealth of Pennsylvania Department of Education is a Local Education Agency (LEA) provider based in West Hazleton, PA. From the 2018–2024 period, this provider received $326.0M in Medicaid payments across 13.0M claims.
Important Context
- ℹ️This is a government entity that may serve as a fiscal agent for large populations. Government providers often bill at high volumes due to the scale of public programs they administer.
Why This Matters
This provider received $326.0M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 40,752 Medicaid beneficiaries for a full year at average per-enrollee costs.
Monthly Spending Trend
Yearly Spending
Procedure Breakdown
Cost per claim compared to national benchmarks
This provider bills for 20 distinct procedure codes. The top code (T1019 (Personal care services, per 15 min)) accounts for 36% of total spending.
$117.4M
2.0M claims
$60.00
$82.47
Personal care services, per 15 min
$117.4M
2.0M claims · 36.0%
$58.5M
2.5M claims
$23.47
$33.11
Therapeutic activities, each 15 min
$58.5M
2.5M claims · 17.9%
$55.7M
1.8M claims
$30.60
$49.45
Speech/hearing/language treatment
$55.7M
1.8M claims · 17.1%
$37.3M
3.7M claims
$10.00
$13.22
Treatment of speech/language disorder, group, 2+ patients
$37.3M
3.7M claims · 11.4%
$24.6M
1.5M claims
$16.87
$252.36
Ambulance, specialty care transport
$24.6M
1.5M claims · 7.6%
$20.0M
733K claims
$27.36
$24.49
Therapeutic exercises, each 15 min
$20.0M
733K claims · 6.1%
$7.0M
361K claims
$19.40
$85.02
Mental health services, not otherwise specified
$7.0M
361K claims · 2.1%
$2.4M
380K claims
$6.26
$7.86
Administration of oral, intramuscular, or subcutaneous medication
$2.4M
380K claims · 0.7%
$1.2M
15K claims · 0.4%
RN services, per 15 minutes
$667K
7K claims · 0.2%
LPN/LVN services, per 15 minutes
$590K
8K claims · 0.2%
$220K
2K claims
$134.27
$110.87
Evaluation of speech sound production with language comprehension
$220K
2K claims · 0.1%
$184K
6K claims
$30.33
$82.72
Psychoeducational service, per 15 minutes
$184K
6K claims · 0.1%
OT evaluation, moderate complexity
$88K
578 claims · 0.0%
$67K
283 claims · 0.0%
Health behavior assessment, initial
$64K
319 claims · 0.0%
Health behavior reassessment
$55K
242 claims · 0.0%
Speech therapy, re-evaluation
$27K
208 claims · 0.0%
OT re-evaluation
$16K
166 claims · 0.0%
$1K
59 claims
$25.03
$106.70
Screening to determine appropriateness of consideration for program
$1K
59 claims · 0.0%
Other Top Providers in Pennsylvania
View all →Zoll Services LLC
Durable Medical Equipment & Medical Supplies
$504.0M
Excel Copmanion Care INC
Home Health
$308.4M
Childrens Hospital of Philadelphia
General Acute Care Hospital Children
$286.9M
Procare Pharmacy Direct, Llc.
Pharmacy, Community/Retail Pharmacy
$227.3M
Northeast Pennsylvania Center for Independent Living
Supports Brokerage
$227.2M
Similar Providers
Other top providers in Local Education Agency (LEA)