St Lukes Roosevelt Hospital Center
Billing Swing
Experienced over 200% change in year-over-year billing with >$1M absolute change.
Billing changed from $2.2M (2018) to $17.0M (2019) — a 689% swing with $14.9M absolute change.
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 109 procedure codes: 99214 at 2.3× median, 99283 at 3.8× median.
Explosive Growth
Billing increased over 500% year-over-year — far beyond normal growth patterns.
Billing grew 689% 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 $290.76 per claim for G9005 (Coordinated care fee, risk-adjusted, ESRD) — 6.2× the national median of $47.08.
Bills $162.56 per claim for 99283 (Emergency dept visit, moderate complexity) — 3.8× the national median of $42.48.
Bills $120.30 per claim for 99213 (Office/outpatient visit, est. patient, low-mod complexity) — 3.2× the national median of $37.81.
Billing in the top 1% nationally for 1 procedure code: 90791.
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 $190.5M is at the 50th percentile among 137 Case Management providers.
Total Paid
$190.5M
$190,494,082
Total Claims
2.8M
Beneficiaries
2.3M
1.2 claims/patient
Avg Cost/Claim
$67
#489 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
St Lukes Roosevelt Hospital Center is a Case Management provider based in New York, NY. From the 2018–2024 period, this provider received $190.5M in Medicaid payments across 2.8M 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 $190.5M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 23,811 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 (G9005 (Coordinated care fee, risk-adjusted, ESRD)) accounts for 9% of total spending.
$17.9M
62K claims
$290.76
$47.08
Coordinated care fee, risk-adjusted, ESRD
$17.9M
62K claims · 9.4%
$14.1M
117K claims
$120.66
$53.41
Office/outpatient visit, est. patient, mod-high complexity
$14.1M
117K claims · 7.4%
$12.7M
78K claims
$162.56
$42.48
Emergency dept visit, moderate complexity
$12.7M
78K claims · 6.7%
$11.1M
93K claims
$120.30
$37.81
Office/outpatient visit, est. patient, low-mod complexity
$11.1M
93K claims · 5.9%
$9.5M
58K claims
$163.42
$69.51
Emergency dept visit, high complexity
$9.5M
58K claims · 5.0%
Psychiatric diagnostic evaluation
$8.9M
11K claims · 4.7%
Psychotherapy, 45 minutes
$8.9M
53K claims · 4.7%
$5.6M
38K claims
$147.08
$85.65
Emergency dept visit, high/urgent complexity
$5.6M
38K claims · 2.9%
$5.1M
33K claims
$152.94
$74.63
Behavioral health counseling & therapy, per 15 min
$5.1M
33K claims · 2.7%
Psychotherapy, 30 minutes
$5.1M
40K claims · 2.7%
Group psychotherapy
$4.9M
65K claims · 2.6%
$3.3M
20K claims
$163.30
$38.92
IV infusion, hydration, each additional hour
$3.3M
20K claims · 1.7%
$2.8M
1K claims · 1.5%
$2.4M
17K claims
$135.63
$74.09
Office/outpatient visit, high complexity
$2.4M
17K claims · 1.2%
$2.3M
15K claims
$153.61
$253.79
Alcohol/drug treatment, per hour
$2.3M
15K claims · 1.2%
Upper GI endoscopy with biopsy
$2.0M
3K claims · 1.1%
Colonoscopy with biopsy
$1.8M
3K claims · 1.0%
$1.8M
8K claims
$213.32
$73.29
Medication-assisted treatment, opioid use disorder, per month
$1.8M
8K claims · 0.9%
CT abdomen and pelvis with contrast
$1.7M
10K claims · 0.9%
CT head/brain without contrast
$1.7M
11K claims · 0.9%
$1.6M
8K claims
$195.32
$54.68
Echocardiography, transthoracic, complete, with Doppler
$1.6M
8K claims · 0.8%
$1.5M
949 claims
$1,575.05
$183.33
Left heart catheterization with imaging
$1.5M
949 claims · 0.8%
$1.4M
17K claims
$86.81
$47.35
Alcohol and/or drug services, group counseling
$1.4M
17K claims · 0.8%
$1.3M
12K claims
$108.20
$25.06
Office/outpatient visit, low complexity
$1.3M
12K claims · 0.7%
$1.3M
5K claims
$249.53
$77.33
Family psychotherapy with patient, 50 min
$1.3M
5K claims · 0.7%
Colonoscopy, diagnostic
$1.3M
2K claims · 0.7%
$1.3M
2K claims
$631.39
$99.39
Hospital observation service, per hour
$1.3M
2K claims · 0.7%
$1.2M
16K claims
$75.52
$51.73
HIV-1 detection by nucleic acid, quantitative
$1.2M
16K claims · 0.6%
$1.2M
24K claims
$48.45
$60.05
COVID-19 test, nucleic acid detection, CDC lab only
$1.2M
24K claims · 0.6%
Emergency dept visit, low complexity
$1.2M
7K claims · 0.6%
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