Billing Swing
Experienced over 200% change in year-over-year billing with >$1M absolute change.
Billing changed from $2.1M (2018) to $17.0M (2019) — a 723% swing with $14.9M absolute change.
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 118 procedure codes: 99213 at 2.9× median, 99214 at 2.0× median.
Explosive Growth
Billing increased over 500% year-over-year — far beyond normal growth patterns.
Billing grew 723% from 2018 to 2019.
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.
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.
Explosive Growth
Explosive Growth means this provider's billing increased by more than 500% year-over-year. While rapid expansion can be legitimate, this pattern has been observed in fraud schemes that ramp up billing quickly before detection.
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 $162.30 per claim for 99283 (Emergency dept visit, moderate complexity) — 3.8× the national median of $42.48.
Bills $11.43 per claim for 36415 (Collection of venous blood by venipuncture) — 7.3× the national median of $1.57.
Bills $1,111.30 per claim for G0378 (Hospital observation service, per hour) — 11.2× the national median of $99.39.
Billing in the top 1% nationally for 1 procedure code: J1930.
This is a statistical summary, not an accusation. See our methodology.
Compared to Ambulance Peers
Total spending distribution among 12 providers in this specialty
This provider's total spending of $279.0M is at the 75th percentile among 12 Ambulance providers.
Total Paid
$279.0M
$278,959,195
Total Claims
5.0M
Beneficiaries
4.0M
1.2 claims/patient
Avg Cost/Claim
$56
#278 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
Mount Sinai Hospital is a Ambulance provider based in New York, NY. From the 2018–2024 period, this provider received $279.0M in Medicaid payments across 5.0M claims.
Why This Matters
This provider received $279.0M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 34,869 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 9% of total spending.
$24.2M
224K claims
$107.91
$37.81
Office/outpatient visit, est. patient, low-mod complexity
$24.2M
224K claims · 8.7%
$23.7M
221K claims
$107.18
$53.41
Office/outpatient visit, est. patient, mod-high complexity
$23.7M
221K claims · 8.5%
$13.9M
483 claims
$28,742.07
$17,264.74
Ocrelizumab (Ocrevus) injection, 1 mg
$13.9M
483 claims · 5.0%
Injection, pembrolizumab, 1 mg
$12.3M
1K claims · 4.4%
$11.7M
4K claims
$3,248.82
$1,587.53
Injection, infliximab, excludes biosimilar, 10 mg
$11.7M
4K claims · 4.2%
$8.2M
51K claims
$162.30
$42.48
Emergency dept visit, moderate complexity
$8.2M
51K claims · 2.9%
$7.4M
54K claims
$138.98
$74.09
Office/outpatient visit, high complexity
$7.4M
54K claims · 2.7%
$6.3M
2K claims · 2.2%
$6.0M
39K claims
$155.24
$85.65
Emergency dept visit, high/urgent complexity
$6.0M
39K claims · 2.2%
$6.0M
678 claims
$8,871.95
$3,562.28
Nivolumab (Opdivo) injection, 1 mg
$6.0M
678 claims · 2.2%
$5.7M
495K claims
$11.43
$1.57
Collection of venous blood by venipuncture
$5.7M
495K claims · 2.0%
$5.3M
33K claims
$161.26
$69.51
Emergency dept visit, high complexity
$5.3M
33K claims · 1.9%
$5.2M
5K claims
$1,111.30
$99.39
Hospital observation service, per hour
$5.2M
5K claims · 1.9%
$4.9M
1K claims · 1.8%
Psychotherapy, 45 minutes
$4.6M
33K claims · 1.7%
$4.3M
50K claims
$85.93
$25.06
Office/outpatient visit, low complexity
$4.3M
50K claims · 1.5%
$4.0M
2K claims · 1.4%
$3.6M
710 claims · 1.3%
$3.6M
2K claims · 1.3%
$3.6M
10K claims · 1.3%
$3.3M
23K claims
$146.90
$75.28
Chemotherapy administration, IV infusion, up to 1 hour
$3.3M
23K claims · 1.2%
$3.0M
815 claims · 1.1%
Psychotherapy, 30 minutes
$2.9M
24K claims · 1.0%
$2.6M
49K claims
$52.30
$60.05
COVID-19 test, nucleic acid detection, CDC lab only
$2.6M
49K claims · 0.9%
$2.0M
11K claims
$179.44
$106.14
Myocardial perfusion imaging, SPECT, multiple studies
$2.0M
11K claims · 0.7%
Comprehensive metabolic panel
$1.8M
132K claims · 0.7%
$1.7M
18K claims
$93.68
$54.77
IV infusion, therapeutic/prophylactic/diagnostic, initial, up to 1 hour
$1.7M
18K claims · 0.6%
$1.7M
16K claims
$111.09
$38.92
IV infusion, hydration, each additional hour
$1.7M
16K claims · 0.6%
$1.7M
12K claims
$146.79
$84.03
Office/outpatient visit, new patient, mod-high complexity
$1.7M
12K claims · 0.6%
$1.5M
331 claims · 0.5%
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