Statistical flags indicate unusual patterns — not proof of fraud or wrongdoing. Read our methodology

Mid Atlantic Pemanente Medical Group

Health Maintenance Organization·Rockville, MD·NPI: 1811062763SharePrint Report
View on Risk Watchlist →

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:

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Billing Swing

Billing Swing means this provider's total billing changed dramatically from one year to the next — increasing or decreasing by more than 200% with over $1M in absolute change. This could indicate a change in practice scope, a billing scheme ramping up, or legitimate growth.

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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.

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

Billing Velocity5472.3 claims/working day
Change PointBilling shifted 5.4x in 2020-08

These signals use advanced statistical methods including digit distribution analysis, change-point detection, and market concentration metrics. Learn more.

Risk Assessment

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Bills $222.19 per claim for 90670 — 37.4× the national median of $5.94.

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Bills $149.46 per claim for 77067 (Screening mammography, bilateral, including CAD) — 3.8× the national median of $39.33.

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Bills $123.50 per claim for 88305 (Surgical pathology, gross and microscopic examination) — 3.5× the national median of $35.80.

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Billing in the top 1% nationally for 3 procedure codes: 90670, 90677, 90723.

This is a statistical summary, not an accusation. See our methodology.

Compared to Health Maintenance Organization Peers

Total spending distribution among 10 providers in this specialty

P25MedianP75P90

This provider's total spending of $317.6M is at the 99th percentile among 10 Health Maintenance Organization providers.

Above 99th percentile for this specialty — higher spending than 9 of 10 peers

Active Billing Period:2018-01→2024-12(84 months)

Total Paid

$317.6M

$317,626,964

Total Claims

10.1M

Beneficiaries

9.6M

1.1 claims/patient

Avg Cost/Claim

$31

#226 of 618K providers by total spending(top <0.1%)

🔍 Analysis

Provider Overview

Mid Atlantic Pemanente Medical Group is a Health Maintenance Organization provider based in Rockville, MD. From the 2018–2024 period, this provider received $317.6M in Medicaid payments across 10.1M claims.

Why This Matters

This provider received $317.6M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 39,703 Medicaid beneficiaries for a full year at average per-enrollee costs.

↑ 1156% growthsince first billing year

Monthly Spending Trend

Yearly Spending

2018
$5.2M
+56%
2019
$8.1M
+361%
2020
$37.5M
+72%
2021
$64.6M
+3%
2022
$66.6M
+5%
2023
$69.9M
-6%
2024
$65.7M

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 16% of total spending.

99213Top 5%

Office/outpatient visit, est. patient, low-mod complexity

$50.8M

576K claims · 16.0%

Your Cost: $88.24/claim|Median: $37.81
2.3× median
99214Top 5%

Office/outpatient visit, est. patient, mod-high complexity

$22.6M

180K claims · 7.1%

Your Cost: $126.03/claim|Median: $53.41
2.4× median
90670Top 1%

$11.2M

51K claims · 3.5%

Your Cost: $222.19/claim|Median: $5.94
37.4× median
99392Top 10%

Preventive medicine, established patient, age 1-4

$10.1M

90K claims · 3.2%

Your Cost: $112.17/claim|Median: $75.18
1.5× median
87636Normal range

Respiratory virus detection, 6-11 targets, nucleic acid

$10.0M

107K claims · 3.1%

Your Cost: $93.76/claim|Median: $97.61
1.0× median
81420Top 5%

Fetal chromosomal aneuploidy genomic sequence analysis

$9.6M

13K claims · 3.0%

Your Cost: $728.05/claim|Median: $358.21
2.0× median
90471Top 5%

Immunization administration, 1 vaccine, percutaneous/ID/SC/IM

$9.1M

387K claims · 2.9%

Your Cost: $23.47/claim|Median: $9.80
2.4× median
99391Top 10%

Preventive medicine, established patient, infant (under 1)

$8.6M

85K claims · 2.7%

Your Cost: $100.48/claim|Median: $69.35
1.4× median
87635Top 10%

COVID-19 SARS-CoV-2 amplified probe detection

$6.8M

122K claims · 2.1%

Your Cost: $55.69/claim|Median: $39.70
1.4× median
92014Top 5%

Ophthalmological exam, comprehensive, established patient

$6.2M

50K claims · 1.9%

Your Cost: $122.73/claim|Median: $47.08
2.6× median
87591Top 25%

Neisseria gonorrhoeae detection, nucleic acid, amplified probe

$5.9M

155K claims · 1.9%

Your Cost: $38.04/claim|Median: $23.39
1.6× median
87491Top 25%

Chlamydia detection, nucleic acid, amplified probe

$5.9M

155K claims · 1.9%

Your Cost: $37.98/claim|Median: $24.95
1.5× median
99212Top 25%

Office/outpatient visit, low complexity

$5.7M

103K claims · 1.8%

Your Cost: $54.89/claim|Median: $25.06
2.2× median
87637Normal range

Respiratory virus detection, 3-5 targets, nucleic acid

$5.3M

54K claims · 1.7%

Your Cost: $97.52/claim|Median: $100.62
1.0× median
92004Top 5%

Ophthalmological exam, comprehensive, new patient

$5.3M

35K claims · 1.7%

Your Cost: $149.94/claim|Median: $59.72
2.5× median
77067Top 5%

Screening mammography, bilateral, including CAD

$5.1M

34K claims · 1.6%

Your Cost: $149.46/claim|Median: $39.33
3.8× median
90472Top 10%

Immunization administration, each additional vaccine

$4.7M

141K claims · 1.5%

Your Cost: $33.16/claim|Median: $11.79
2.8× median
99393Top 10%

Preventive medicine, established patient, age 5-11

$4.6M

42K claims · 1.5%

Your Cost: $110.40/claim|Median: $74.82
1.5× median
88305Top 5%

Surgical pathology, gross and microscopic examination

$3.4M

28K claims · 1.1%

Your Cost: $123.50/claim|Median: $35.80
3.5× median
90686Top 10%

Influenza virus vaccine, quadrivalent, preservative-free, IM

$3.4M

167K claims · 1.1%

Your Cost: $20.18/claim|Median: $7.18
2.8× median
36415Top 25%

Collection of venous blood by venipuncture

$3.2M

687K claims · 1.0%

Your Cost: $4.59/claim|Median: $1.57
2.9× median
84443Top 25%

Thyroid stimulating hormone (TSH)

$3.0M

176K claims · 0.9%

Your Cost: $16.84/claim|Median: $9.87
1.7× median
90677Top 1%

$2.9M

10K claims · 0.9%

Your Cost: $285.24/claim|Median: $12.96
22.0× median
87389Normal range

HIV-1 antigen with HIV-1 and HIV-2 antibodies

$2.8M

119K claims · 0.9%

Your Cost: $23.80/claim|Median: $18.03
1.3× median
V2020Top 10%

Frames, purchases

$2.6M

59K claims · 0.8%

Your Cost: $43.57/claim|Median: $19.33
2.3× median
80061Top 25%

Lipid panel

$2.6M

192K claims · 0.8%

Your Cost: $13.32/claim|Median: $8.41
1.6× median
99203Top 10%

Office/outpatient visit, new patient, low-mod complexity

$2.5M

22K claims · 0.8%

Your Cost: $115.11/claim|Median: $57.85
2.0× median
82306Top 25%

Vitamin D, 25 hydroxy

$2.5M

85K claims · 0.8%

Your Cost: $29.35/claim|Median: $18.18
1.6× median
90723Top 1%

DTaP-HepB-IPV vaccine

$2.4M

36K claims · 0.7%

Your Cost: $65.02/claim|Median: $5.78
11.3× median
99215Top 10%

Office/outpatient visit, high complexity

$2.3M

13K claims · 0.7%

Your Cost: $170.85/claim|Median: $74.09
2.3× median

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