Department of Intellectual and Developmental Disabilities, State of Tn

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.

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.

Consistent Billing

Consistent Billing means this provider's monthly billing amounts show almost no natural variation. Real medical practices tend to have some fluctuation in monthly billing, so unnaturally steady billing can indicate automated or fabricated claims.

Unusually High Spending

Unusually High Spending means this provider's total Medicaid payments are significantly above the median for their specialty. This doesn't necessarily indicate fraud — high volume practices and those serving complex populations may legitimately bill more.

High Cost Per Claim

High Cost Per Claim means each individual claim from this provider costs significantly more than what other providers charge for the same services. This could indicate upcoding (billing for more expensive services than provided) or legitimate specialized care.