The Children's Mercy Hospital
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 160 procedure codes: G0463 at 6.3× median, X4011 at 3.4× median.
High Cost Per Claim
Average payment per claim is much higher than peers billing the same procedures.
Spending Spike
Experienced a dramatic increase in billing over a short period.
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:
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.
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.
Spending Spike
Spending Spike means this provider experienced a dramatic, sudden increase in billing over a short period. Legitimate causes include new contracts or expanded services, but this pattern also appears in billing fraud ramp-ups.
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 $165.98 per claim for G0463 (Hospital outpatient clinic visit) — 6.3× the national median of $26.41.
Bills $902.14 per claim for X4011 (Healthcare procedure, code X4011) — 3.4× the national median of $268.66.
Bills $305.47 per claim for 99283 (Emergency dept visit, moderate complexity) — 7.2× the national median of $42.48.
Billing in the top 1% nationally for 20 procedure codes: X4011, X4014, 87400.
This is a statistical summary, not an accusation. See our methodology.
Compared to General Acute Care Hospital Children Peers
Total spending distribution among 16 providers in this specialty
This provider's total spending of $221.2M is at the 50th percentile among 16 General Acute Care Hospital Children providers.
Total Paid
$221.2M
$221,155,053
Total Claims
1.0M
Beneficiaries
998K
1.0 claims/patient
Avg Cost/Claim
$212
#384 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
The Children's Mercy Hospital is a General Acute Care Hospital Children provider based in Kansas City, MO. From the 2018–2024 period, this provider received $221.2M in Medicaid payments across 1.0M claims.
Why This Matters
This provider received $221.2M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 27,644 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 (G0463 (Hospital outpatient clinic visit)) accounts for 20% of total spending.
Hospital outpatient clinic visit
$44.6M
268K claims · 20.1%
Healthcare procedure, code X4011
$29.7M
33K claims · 13.4%
$24.3M
155K claims · 11.0%
$20.1M
66K claims
$305.47
$42.48
Emergency dept visit, moderate complexity
$20.1M
66K claims · 9.1%
$17.9M
13K claims · 8.1%
Emergency dept visit, high complexity
$7.3M
19K claims · 3.3%
$4.6M
100K claims
$46.34
$37.81
Office/outpatient visit, est. patient, low-mod complexity
$4.6M
100K claims · 2.1%
$4.4M
6K claims · 2.0%
$4.1M
12K claims
$354.34
$7.50
Electrocardiogram, tracing only, without interpretation
$4.1M
12K claims · 1.8%
$4.0M
7K claims · 1.8%
Basic metabolic panel
$4.0M
26K claims · 1.8%
$3.3M
22K claims
$152.63
$4.71
Complete blood count (CBC) with differential, automated
$3.3M
22K claims · 1.5%
$3.1M
5K claims
$596.44
$85.65
Emergency dept visit, high/urgent complexity
$3.1M
5K claims · 1.4%
$3.0M
4K claims · 1.3%
$2.7M
10K claims
$277.78
$65.64
Influenza virus detection, reverse transcription, amplified probe
$2.7M
10K claims · 1.2%
Hepatic function panel
$2.6M
20K claims · 1.2%
Emergency dept visit, low complexity
$2.6M
13K claims · 1.2%
$2.5M
11K claims
$226.58
$5.09
Culture screening for pathogenic organisms
$2.5M
11K claims · 1.1%
$1.6M
8K claims
$202.53
$91.47
Proprietary lab analysis, genomic sequencing
$1.6M
8K claims · 0.7%
Unclassified drugs
$1.4M
2K claims · 0.6%
$1.3M
45K claims
$28.79
$63.08
Infectious disease detection (COVID-19)
$1.3M
45K claims · 0.6%
$1.3M
256 claims
$4,951.95
$331.68
Tonsillectomy and adenoidectomy, under age 12
$1.3M
256 claims · 0.6%
MRI brain without contrast
$1.1M
3K claims · 0.5%
Chest X-ray, 2 views
$1.1M
3K claims · 0.5%
Complete blood count (CBC), automated
$1.1M
12K claims · 0.5%
$1.0M
1K claims
$739.27
$54.68
Echocardiography, transthoracic, complete, with Doppler
$1.0M
1K claims · 0.5%
$987K
1K claims
$961.14
$112.83
Echocardiography, transthoracic, limited
$987K
1K claims · 0.4%
$985K
7K claims · 0.4%
$943K
296 claims · 0.4%
Therapeutic exercises, each 15 min
$914K
3K claims · 0.4%
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