Commonwealth of Massachusets

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.

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.