North Shore University Hospital
Cost Outlier
Billing over 3× the national median for specific procedure codes.
This provider bills $309.83 per claim for G9005 (Coordinated care fee, risk-adjusted, ESRD), which is 6.6× the national median of $47.08.
Billing Swing
Experienced over 200% change in year-over-year billing with >$1M absolute change.
Billing changed from $6.1M (2019) to $19.6M (2020) — a 221% swing with $13.5M 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:
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.
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.
Risk Assessment
Bills $309.83 per claim for G9005 (Coordinated care fee, risk-adjusted, ESRD) — 6.6× the national median of $47.08.
Bills $178.34 per claim for G0506 (Comprehensive assessment of chronic care management) — 24.1× the national median of $7.41.
Billing above the 90th percentile for 2 procedure codes simultaneously.
This is a statistical summary, not an accusation. See our methodology.
Compared to Case Management Peers
Total spending distribution among 137 providers in this specialty
This provider's total spending of $166.5M is at the 50th percentile among 137 Case Management providers.
Total Paid
$166.5M
$166,534,128
Total Claims
506K
Beneficiaries
504K
1.0 claims/patient
Avg Cost/Claim
$329
#602 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
North Shore University Hospital is a Case Management provider based in New Hyde Park, NY. From the 2018–2024 period, this provider received $166.5M in Medicaid payments across 506K claims.
Important Context
- ℹ️This provider appears to operate as a fiscal intermediary or management organization, processing payments on behalf of many individual caregivers. High aggregate billing is expected for this type of entity.
Why This Matters
This provider received $166.5M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 20,816 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 5 distinct procedure codes. The top code (G9005 (Coordinated care fee, risk-adjusted, ESRD)) accounts for 79% of total spending.
$130.9M
422K claims
$309.83
$47.08
Coordinated care fee, risk-adjusted, ESRD
$130.9M
422K claims · 78.6%
Case management, per month
$34.0M
65K claims · 20.4%
$1.1M
15K claims · 0.6%
$542K
3K claims
$178.34
$7.41
Comprehensive assessment of chronic care management
$542K
3K claims · 0.3%
$0
394 claims · 0.0%
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