Mystic Valley Elder Services Inc.
Cost Outlier
Billing over 3× the national median for specific procedure codes.
This provider bills $440.00 per claim for T1019 (Personal care services, per 15 min), which is 5.3× the national median of $82.47.
Rate Outlier
Billing above the 90th percentile across multiple procedure codes simultaneously.
Billing above the 90th percentile for 5 procedure codes: G0156 at 90.8× median, T1019 at 5.3× 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.
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 $3,578.07 per claim for G0156 (Home health aide services, per visit) — 90.8× the national median of $39.42.
Bills $440.00 per claim for T1019 (Personal care services, per 15 min) — 5.3× the national median of $82.47.
Bills $2,523.60 per claim for S5125 (Attendant care services, per 15 min) — 30.6× the national median of $82.34.
Billing in the top 1% nationally for 1 procedure code: G0156.
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 $222.9M is at the 50th percentile among 137 Case Management providers.
Total Paid
$222.9M
$222,949,564
Total Claims
999K
Beneficiaries
220K
4.5 claims/patient
Avg Cost/Claim
$223
#380 of 618K providers by total spending(top <0.1%)
🔍 Analysis
Provider Overview
Mystic Valley Elder Services Inc. is a Case Management provider based in Malden, MA. From the 2018–2024 period, this provider received $222.9M in Medicaid payments across 999K 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 $222.9M in taxpayer-funded Medicaid payments — enough to fund healthcare for approximately 27,868 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 24 distinct procedure codes. The top code (G0156 (Home health aide services, per visit)) accounts for 38% of total spending.
$84.1M
24K claims
$3,578.07
$39.42
Home health aide services, per visit
$84.1M
24K claims · 37.7%
Personal care services, per 15 min
$73.3M
167K claims · 32.9%
$21.2M
8K claims
$2,523.60
$82.34
Attendant care services, per 15 min
$21.2M
8K claims · 9.5%
$19.2M
212K claims
$90.34
$48.76
Homemaker service, NOS; per 15 min
$19.2M
212K claims · 8.6%
$9.8M
357K claims
$27.37
$19.89
Homemaker service, NOS, per diem
$9.8M
357K claims · 4.4%
Day care services, adult; per 15 min
$3.9M
19K claims · 1.7%
Laundry service, per occasion
$2.8M
105K claims · 1.2%
$2.2M
20K claims
$108.96
$21.70
Non-emergency transport; encounter/trip
$2.2M
20K claims · 1.0%
Companion care, adult, per diem
$2.1M
22K claims · 1.0%
$1.4M
5K claims
$250.35
$2,196.32
Home modifications, per service
$1.4M
5K claims · 0.6%
Chore services, per 15 min
$1.2M
10K claims · 0.5%
$805K
31K claims
$26.24
$29.97
Emergency response system, per month
$805K
31K claims · 0.4%
Personal care services, per diem
$219K
5K claims · 0.1%
$202K
3K claims
$61.96
$66.43
Day care services, adult, per half day
$202K
3K claims · 0.1%
Case management, per month
$185K
3K claims · 0.1%
$166K
2K claims
$99.94
$300.13
Community transition, waiver; per service
$166K
2K claims · 0.1%
$150K
2K claims
$88.48
$51.67
Skilled nursing services, home health, per visit, RN
$150K
2K claims · 0.1%
$145K
3K claims
$43.15
$111.06
Attendant care services, in-home, per 15 min
$145K
3K claims · 0.1%
$100K
2K claims · 0.0%
$20K
383 claims
$52.75
$67.58
Day care services, adult, per half day
$20K
383 claims · 0.0%
$8K
202 claims
$39.46
$55.04
Self-help/peer services, per 15 minutes
$8K
202 claims · 0.0%
$5K
206 claims
$24.85
$17.67
Sign language or oral interpretive services, per 15 minutes
$5K
206 claims · 0.0%
$640
22 claims · 0.0%
$597
15 claims
$39.81
$38.52
Emergency response system, per month
$597
15 claims · 0.0%
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