City Medical of Upper East Side PLLC
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 22 procedure codes: 99213 at 2.9× median, S9083 at 1.5× 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:
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.
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 $102.15 per claim for 99212 (Office/outpatient visit, low complexity) — 4.1× the national median of $25.06.
Bills $126.46 per claim for 99211 (Office/outpatient visit, minimal complexity) — 9.8× the national median of $12.93.
Bills $125.51 per claim for 99201 (Office/outpatient visit, new patient, straightforward) — 4.6× the national median of $27.38.
Billing above the 90th percentile for 8 procedure codes simultaneously.
This is a statistical summary, not an accusation. See our methodology.
Total Paid
$643.2M
$643,184,712
Total Claims
7.8M
Beneficiaries
7.3M
1.1 claims/patient
Avg Cost/Claim
$82
#78 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
City Medical of Upper East Side PLLC is a Clinic/Center Urgent Care provider based in New York, NY. From the 2018–2024 period, this provider received $643.2M in Medicaid payments across 7.8M claims.
Why This Matters
This provider received $643.2M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 80,398 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 30 distinct procedure codes. The top code (99213 (Office/outpatient visit, est. patient, low-mod complexity)) accounts for 35% of total spending.
$226.5M
2.0M claims
$110.49
$37.81
Office/outpatient visit, est. patient, low-mod complexity
$226.5M
2.0M claims · 35.2%
Global fee, urgent care centers
$135.4M
868K claims · 21.1%
$108.7M
900K claims
$120.73
$53.41
Office/outpatient visit, est. patient, mod-high complexity
$108.7M
900K claims · 16.9%
$66.7M
651K claims
$102.44
$57.85
Office/outpatient visit, new patient, low-mod complexity
$66.7M
651K claims · 10.4%
$33.2M
325K claims
$102.15
$25.06
Office/outpatient visit, low complexity
$33.2M
325K claims · 5.2%
$29.1M
263K claims
$110.66
$84.03
Office/outpatient visit, new patient, mod-high complexity
$29.1M
263K claims · 4.5%
$18.5M
1.0M claims
$18.49
$30.04
SARS-CoV-2 COVID-19 antigen detection, immunoassay
$18.5M
1.0M claims · 2.9%
$13.4M
145K claims
$92.46
$40.11
Office/outpatient visit, new patient, low complexity
$13.4M
145K claims · 2.1%
$1.8M
336K claims
$5.37
$12.59
Influenza virus detection, rapid test
$1.8M
336K claims · 0.3%
$1.2M
68K claims
$18.37
$39.63
SARS-CoV-2 COVID-19 antigen detection, immunoassay, each
$1.2M
68K claims · 0.2%
$991K
8K claims
$126.46
$12.93
Office/outpatient visit, minimal complexity
$991K
8K claims · 0.2%
$557K
63K claims
$8.84
$9.80
Immunization administration, 1 vaccine, percutaneous/ID/SC/IM
$557K
63K claims · 0.1%
$539K
33K claims
$16.57
$7.18
Influenza virus vaccine, quadrivalent, preservative-free, IM
$539K
33K claims · 0.1%
$474K
4K claims
$125.51
$27.38
Office/outpatient visit, new patient, straightforward
$474K
4K claims · 0.1%
$473K
4K claims
$128.39
$74.09
Office/outpatient visit, high complexity
$473K
4K claims · 0.1%
Chest X-ray, 2 views
$457K
48K claims · 0.1%
$406K
221K claims
$1.84
$11.48
Streptococcus, Group A, rapid antigen detection
$406K
221K claims · 0.1%
$234K
4K claims · 0.0%
$218K
5K claims · 0.0%
$206K
6K claims · 0.0%
$200K
18K claims · 0.0%
$193K
34K claims
$5.64
$9.70
Electrocardiogram, complete, with interpretation and report
$193K
34K claims · 0.0%
$188K
18K claims
$10.53
$12.06
X-ray, foot, complete, minimum 3 views
$188K
18K claims · 0.0%
$188K
2K claims · 0.0%
$183K
1K claims
$131.15
$111.09
Office/outpatient visit, new patient, high complexity
$183K
1K claims · 0.0%
Tdap vaccine
$181K
10K claims · 0.0%
$173K
7K claims · 0.0%
$156K
13K claims · 0.0%
$146K
4K claims · 0.0%
$145K
12K claims · 0.0%