Upmc Presbyterian Shadyside
Billing Swing
Experienced over 200% change in year-over-year billing with >$1M absolute change.
Billing changed from $11.0M (2020) to $35.5M (2021) — a 223% swing with $24.5M absolute change.
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:
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.
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 $386.75 per claim for 90792 (Psychiatric diagnostic evaluation with medical services) — 3.5× the national median of $108.91.
Bills $337.60 per claim for H0004 (Behavioral health counseling & therapy, per 15 min) — 4.5× the national median of $74.63.
Bills $353.83 per claim for 90870 — 5.2× the national median of $68.07.
Billing above the 90th percentile for 6 procedure codes simultaneously.
This is a statistical summary, not an accusation. See our methodology.
Compared to Clinic/Center Peers
Total spending distribution among 13 providers in this specialty
This provider's total spending of $125.5M is at the 75th percentile among 13 Clinic/Center providers.
Total Paid
$125.5M
$125,540,871
Total Claims
1.7M
Beneficiaries
1.1M
1.5 claims/patient
Avg Cost/Claim
$74
#937 of 618K providers by total spending(top 0.2%)
🔍 Analysis
Provider Overview
Upmc Presbyterian Shadyside is a Clinic/Center provider based in Pittsburgh, PA. From the 2018–2024 period, this provider received $125.5M in Medicaid payments across 1.7M claims.
Why This Matters
This provider received $125.5M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 15,692 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 (H2011 (Crisis intervention service, per 15 minutes)) accounts for 11% of total spending.
$14.4M
51K claims
$279.54
$215.80
Crisis intervention service, per 15 minutes
$14.4M
51K claims · 11.4%
$14.0M
122K claims
$114.97
$69.56
Targeted case management, per 15 min
$14.0M
122K claims · 11.2%
$10.6M
78K claims
$135.47
$132.62
Assertive community treatment, per diem
$10.6M
78K claims · 8.4%
$7.5M
13K claims
$586.17
$501.33
Crisis intervention mental health services, per diem
$7.5M
13K claims · 6.0%
Psychotherapy, 45 minutes
$7.5M
85K claims · 5.9%
$6.7M
44K claims
$153.47
$69.51
Emergency dept visit, high complexity
$6.7M
44K claims · 5.3%
$6.6M
17K claims
$386.75
$108.91
Psychiatric diagnostic evaluation with medical services
$6.6M
17K claims · 5.3%
$5.7M
18K claims
$315.23
$225.50
Community psychiatric supportive treatment program, per diem
$5.7M
18K claims · 4.5%
$4.4M
13K claims
$337.60
$74.63
Behavioral health counseling & therapy, per 15 min
$4.4M
13K claims · 3.5%
Psychotherapy, 60 minutes
$3.9M
25K claims · 3.1%
$3.8M
28K claims
$134.11
$169.11
Community-based wrap-around services, per 15 min
$3.8M
28K claims · 3.0%
Group psychotherapy
$3.7M
52K claims · 2.9%
$3.5M
12K claims
$293.08
$99.39
Hospital observation service, per hour
$3.5M
12K claims · 2.8%
$2.9M
18K claims
$161.71
$148.53
Mental health partial hospitalization, treatment, per hour
$2.9M
18K claims · 2.3%
$2.3M
13K claims
$173.41
$85.65
Emergency dept visit, high/urgent complexity
$2.3M
13K claims · 1.8%
$2.2M
74K claims
$29.99
$121.16
Clinic visit/encounter, all-inclusive
$2.2M
74K claims · 1.8%
$1.9M
15K claims
$128.53
$85.02
Mental health services, not otherwise specified
$1.9M
15K claims · 1.5%
$1.5M
11K claims
$137.09
$167.38
Adaptive behavior treatment by protocol, per 15 min
$1.5M
11K claims · 1.2%
$1.4M
14K claims
$96.01
$42.48
Emergency dept visit, moderate complexity
$1.4M
14K claims · 1.1%
$1.3M
14K claims
$93.38
$77.33
Family psychotherapy with patient, 50 min
$1.3M
14K claims · 1.1%
Behavior identification assessment
$1.3M
5K claims · 1.0%
Psychotherapy, 30 minutes
$1.3M
33K claims · 1.0%
$1.1M
3K claims · 0.9%
$1.0M
14K claims
$73.01
$56.90
Medication training and management, per 15 min
$1.0M
14K claims · 0.8%
$931K
4K claims
$214.87
$146.45
Adaptive behavior treatment with protocol modification, per 15 minutes
$931K
4K claims · 0.7%
$921K
15K claims
$60.50
$12.93
Office/outpatient visit, minimal complexity
$921K
15K claims · 0.7%
$834K
5K claims
$164.61
$55.04
Self-help/peer services, per 15 minutes
$834K
5K claims · 0.7%
$727K
12K claims
$59.46
$76.05
Community psychiatric supportive treatment, per 15 min
$727K
12K claims · 0.6%
$547K
4K claims
$126.14
$65.76
CT abdomen and pelvis with contrast
$547K
4K claims · 0.4%
Case management, each 15 min
$494K
3K claims · 0.4%
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