Department of Health and Senior Services
Cost Outlier
Billing over 3× the national median for specific procedure codes.
This provider bills $299.43 per claim for T1018 (School-based IEP services, per encounter), which is 7.6× the national median of $39.53.
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 1 procedure codes: T1018 at 7.6× median.
Unusually High Spending
This provider's total payments are significantly above the median for their specialty.
High Cost Per Claim
Average payment per claim is much higher than peers billing the same procedures.
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
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Each flag represents a statistical test that identified unusual billing patterns. Here's what each flag on this provider means in plain English:
Cost Outlier
Cost Outlier means this provider charges significantly more per claim than other providers billing the same procedure codes. This could indicate upcoding, inflated charges, or specialized services that justify higher costs.
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.
Unusually High Spending
Unusually High Spending means this provider's total Medicaid payments are significantly above the median for their specialty. This doesn't necessarily indicate fraud — high volume practices and those serving complex populations may legitimately bill more.
High Cost Per Claim
High Cost Per Claim means each individual claim from this provider costs significantly more than what other providers charge for the same services. This could indicate upcoding (billing for more expensive services than provided) or legitimate specialized care.
These flags are statistical indicators only. Many flagged providers have legitimate explanations for their billing patterns. Learn more about our methodology.
Risk Assessment
Bills $299.43 per claim for T1018 (School-based IEP services, per encounter) — 7.6× the national median of $39.53.
Billing in the top 1% nationally for 1 procedure code: T1018.
This is a statistical summary, not an accusation. See our methodology.
Total Paid
$1.07B
$1,073,667,311
Total Claims
3.3M
Beneficiaries
622K
5.3 claims/patient
Avg Cost/Claim
$324
#29 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
Department of Health and Senior Services is a Specialist provider based in Trenton, NJ. From the 2018–2024 period, this provider received $1.1B in Medicaid payments across 3.3M 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 $1.1B in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 134,208 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 3 distinct procedure codes. The top code (T1018 (School-based IEP services, per encounter)) accounts for 87% of total spending.
$938.2M
3.1M claims
$299.43
$39.53
School-based IEP services, per encounter
$938.2M
3.1M claims · 87.4%
$86.7M
86K claims
$1,010.33
$1,788.55
Physician direction of emergency medical systems, online
$86.7M
86K claims · 8.1%
$48.8M
93K claims
$522.75
$300.13
Community transition, waiver; per service
$48.8M
93K claims · 4.5%
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