The New York and Presbyterian Hospital
Cost Outlier
Billing over 3× the national median for specific procedure codes.
This provider bills $189.62 per claim for 99213 (Office/outpatient visit, est. patient, low-mod complexity), which is 5.0× the national median of $37.81.
Billing Swing
Experienced over 200% change in year-over-year billing with >$1M absolute change.
Billing changed from $10.3M (2018) to $32.6M (2019) — a 217% swing with $22.3M absolute change.
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 212 procedure codes: 99213 at 5.0× median, 99283 at 4.3× median.
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.
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
These signals use advanced statistical methods including digit distribution analysis, change-point detection, and market concentration metrics. Learn more.
Risk Assessment
Bills $189.62 per claim for 99213 (Office/outpatient visit, est. patient, low-mod complexity) — 5.0× the national median of $37.81.
Bills $182.95 per claim for 99283 (Emergency dept visit, moderate complexity) — 4.3× the national median of $42.48.
Bills $180.96 per claim for 99214 (Office/outpatient visit, est. patient, mod-high complexity) — 3.4× the national median of $53.41.
Billing in the top 1% nationally for 3 procedure codes: 99213, 76700, 76856.
This is a statistical summary, not an accusation. See our methodology.
Compared to General Acute Care Hospital Peers
Total spending distribution among 156 providers in this specialty
This provider's total spending of $454.9M is at the 90th percentile among 156 General Acute Care Hospital providers.
Above 90th percentile for this specialty — higher spending than 140 of 156 peers
Total Paid
$454.9M
$454,946,329
Total Claims
7.1M
Beneficiaries
6.2M
1.1 claims/patient
Avg Cost/Claim
$64
#137 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
The New York and Presbyterian Hospital is a General Acute Care Hospital provider based in New York, NY. From the 2018–2024 period, this provider received $454.9M in Medicaid payments across 7.1M claims.
Why This Matters
This provider received $454.9M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 56,868 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 14% of total spending.
$65.1M
343K claims
$189.62
$37.81
Office/outpatient visit, est. patient, low-mod complexity
$65.1M
343K claims · 14.3%
$31.5M
172K claims
$182.95
$42.48
Emergency dept visit, moderate complexity
$31.5M
172K claims · 6.9%
$23.6M
132K claims
$178.55
$69.51
Emergency dept visit, high complexity
$23.6M
132K claims · 5.2%
$21.3M
118K claims
$180.96
$53.41
Office/outpatient visit, est. patient, mod-high complexity
$21.3M
118K claims · 4.7%
$15.1M
92K claims
$165.21
$85.65
Emergency dept visit, high/urgent complexity
$15.1M
92K claims · 3.3%
$13.2M
43K claims
$307.23
$47.08
Coordinated care fee, risk-adjusted, ESRD
$13.2M
43K claims · 2.9%
$12.7M
44K claims
$290.07
$38.92
IV infusion, hydration, each additional hour
$12.7M
44K claims · 2.8%
$12.5M
66K claims
$190.10
$25.06
Office/outpatient visit, low complexity
$12.5M
66K claims · 2.7%
Case management, each 15 min
$9.9M
43K claims · 2.2%
Injection, pembrolizumab, 1 mg
$9.0M
1K claims · 2.0%
$7.1M
3K claims
$2,602.87
$1,587.53
Injection, infliximab, excludes biosimilar, 10 mg
$7.1M
3K claims · 1.6%
$6.2M
34K claims
$183.19
$69.35
Preventive medicine, established patient, infant (under 1)
$6.2M
34K claims · 1.4%
$5.4M
44K claims
$122.92
$38.23
Ophthalmological exam, intermediate, established patient
$5.4M
44K claims · 1.2%
Ultrasound, abdominal, complete
$5.3M
9K claims · 1.2%
$5.2M
3K claims · 1.1%
Psychotherapy, 45 minutes
$5.0M
27K claims · 1.1%
$4.8M
26K claims
$180.34
$75.18
Preventive medicine, established patient, age 1-4
$4.8M
26K claims · 1.0%
Upper GI endoscopy with biopsy
$4.8M
7K claims · 1.0%
$4.4M
63K claims
$69.99
$169.17
Respiratory virus detection, 12-25 targets, nucleic acid
$4.4M
63K claims · 1.0%
$4.1M
31K claims
$132.84
$54.77
IV infusion, therapeutic/prophylactic/diagnostic, initial, up to 1 hour
$4.1M
31K claims · 0.9%
Emergency dept visit, low complexity
$4.1M
23K claims · 0.9%
CT head/brain without contrast
$4.0M
15K claims · 0.9%
Psychotherapy, 30 minutes
$3.8M
26K claims · 0.8%
Ultrasound, pelvic, complete
$3.8M
6K claims · 0.8%
$3.6M
23K claims
$157.26
$75.28
Chemotherapy administration, IV infusion, up to 1 hour
$3.6M
23K claims · 0.8%
$3.6M
6K claims
$559.68
$43.68
Chemotherapy infusion, each additional hour
$3.6M
6K claims · 0.8%
Colonoscopy with biopsy
$3.5M
5K claims · 0.8%
Therapeutic exercises, each 15 min
$3.5M
37K claims · 0.8%
$3.2M
18K claims
$180.55
$74.82
Preventive medicine, established patient, age 5-11
$3.2M
18K claims · 0.7%
CT abdomen and pelvis with contrast
$3.2M
12K claims · 0.7%
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