We built DoltHub to share and collaborate on open data. The United States federal government released a very interesting dataset on all Medicaid payments made between January 2018 and December 2024. We imported the data into Dolt, the world’s first version-controlled SQL database. We pushed the data to DoltHub so you can clone and query it with SQL.
My intent today was to walk you through how to use the new agent mode in Dolt Workbench, powered by the Claude SDK, to explore the data to look for suspicious Medicaid payments. I’ll do that in an article next week. As I had an agent sift through the data, I decided to just share the analysis instead. It was that interesting.
Moreover, there were genuine moments where I thought I was working with Sherlock Holmes.
Fraud Score: Claude’s Findings#
At my request, our AI agent made a view that captures the analysis that went into scoring providers for fraud risk. The following is a summary table of the results and the agent’s analyses of the providers.
| Rank | NPI | Provider | Fraud Signals | Total Paid | Verdict |
|---|---|---|---|---|---|
| 1 | 1861568107 | Melmark, Inc. (PA) | 3 | $35.0M | Likely false positive — residential treatment |
| 2 | 1073569034 | Accredo Health Group (TX) | 3 | $27.7M | Real risk — $60M fraud settlement |
| 3 | 1568428621 | Mary M. Gooley Hemophilia (NY) | 3 | $22.9M | False positive — hemophilia drugs |
| 4 | 1851654909 | Diversified Children Youth (AR) | 3 | $14.4M | Suspicious — $15K/day community support |
| 5 | 1831567858 | DHEC Hemophilia Program (SC) | 3 | $13.3M | False positive — state government |
| 6 | 1124595764 | Safe Residential Care (ME) | 2 | $94.6M | Highly suspicious — Maine group home scandal |
| 7 | 1447745112 | Happy Haven (ME) | 2 | $65.3M | Borderline — same sector under investigation |
| 8 | 1013030808 | Marie Green Psychiatric (CA) | 2 | $47.6M | False positive — county government hospital |
| 9 | 1396956462 | Baker Hall / OLV Human Services (NY) | 2 | $47.3M | Suspicious — prior fraud + anomalous billing |
| 10 | 1811473291 | Serenity Residential Care (ME) | 2 | $34.4M | Borderline — third Maine group home in top 10 |
Now let’s dig into each of these providers individually.
#1 — NPI 1861568107 — Melmark, Inc.#
NPI 1861568107 belongs to Melmark, Inc., a nonprofit residential treatment facility for individuals with intellectual and developmental disabilities, located at 2600 Wayland Road, Berwyn, PA 19312. Their specialties include psychiatric residential treatment, intermediate care for intellectual disabilities, community-based residential treatment, nursing, physical therapy, occupational therapy, and child/adolescent psychiatry.
Data from Your Database#
| Metric | Value |
|---|---|
| Total Paid | ~$34.96 million |
| Total Claims | 1,204 |
| Total Beneficiaries | 977 |
| Distinct Procedures (HCPCS codes) | 1 |
| Distinct Servicing Providers | 1 |
The combination of nearly $35 million in total payments with only 1 HCPCS code and 1 servicing provider is notable — this is the kind of profile that would trigger the “low procedure diversity” fraud signal in your fraud_risk_score view.
Fraud Signals Triggered (3 of 5)#
| Signal | Threshold | Melmark’s Value | Triggered? |
|---|---|---|---|
| High pay per claim | >$15,000 avg per claim | $29,034 | Yes |
| High paid per beneficiary | >$27,156 per beneficiary | $35,780 | Yes |
| Low procedure diversity | >$10M total with <=3 HCPCS codes | $34.96M with only 1 code | Yes |
| High claims per beneficiary | >139 claims per beneficiary | 1.23 | No |
| Ghost billing | >500 servicing providers with >$1M | 1 servicing provider | No |
Lawsuits and Public Records#
I searched extensively but found no major fraud lawsuits, Medicaid billing investigations, or enforcement actions against Melmark, Inc. Here is what did turn up:
-
Melmark, Inc. v. Schutt (2019) — A Pennsylvania Supreme Court case, but it was a payment dispute about a New Jersey couple who failed to pay for their adult son’s residential care. It dealt with a choice-of-law question regarding filial-support statutes, not fraud or abuse. (Justia case link)
-
Employee reviews on Yelp — A former employee alleged workplace harassment, negligence by overnight staff (sleeping on shift), and poor facility cleaning during COVID-19. These are informal allegations, not formal legal actions. (Yelp reviews)
-
Melmark’s own abuse prevention policy — Published in Autism Spectrum News, Melmark outlined their organizational approach to preventing abuse and neglect, including mandatory reporting and immediate administrative leave for accused employees. (Autism Spectrum News article)
What Makes It Stand Out#
Melmark is the highest-paid provider in the fraud risk view at ~$35 million, and it achieved that through just 1 single HCPCS procedure code, 1 servicing provider, and 1,204 claims across 977 beneficiaries over 47 months. That works out to roughly $29,000 per claim on average.
Context#
That said, Melmark is a residential treatment facility for individuals with intellectual and developmental disabilities. Residential care billing can legitimately produce high per-claim amounts and low procedure diversity because the facility may bill under a single residential per-diem or bundled rate code. So while the statistical signals are real, the explanation could be entirely legitimate given the nature of the provider.
#2 — NPI 1073569034 — Accredo Health Group, Inc.#
Accredo Health Group is a specialty pharmacy headquartered in Memphis, Tennessee, and a subsidiary of Express Scripts/Cigna. This particular NPI is for their Irving, TX location.
What They Are Billing#
The overwhelming majority of their Medicaid claims are for HCPCS code J2326, which is Spinraza (nusinersen) — an injection used to treat spinal muscular atrophy (SMA). Spinraza is one of the most expensive drugs in the world, with a single dose costing roughly $125,000-$135,000.
That explains the eye-popping numbers:
| Metric | Value |
|---|---|
| Total Paid | ~$27.7 million |
| Total Claims | 333 |
| Total Beneficiaries | 277 |
| Distinct HCPCS codes | 3 (J2326, J0584, J7307) |
| Average Paid Per Claim | $83,133 |
| Paid Per Beneficiary | $99,939 |
| Fraud Signal Count | 3 |
The three fraud signals triggered are the same type as Melmark: high pay per claim, high paid per beneficiary, and low procedure diversity.
Known Lawsuits and Enforcement Actions#
Unlike Melmark, Accredo has a significant legal history:
-
$60 Million Civil Fraud Settlement (2015) — The Manhattan U.S. Attorney (Preet Bharara), FBI, and HHS-OIG settled a civil fraud lawsuit against Accredo over a kickback scheme with Novartis involving the drug Exjade (used for chronic iron overload). Accredo received patient referrals in exchange for keeping patients on Exjade the longest, while understating the drug’s serious and potentially life-threatening side effects. Accredo paid $45 million to the federal government and $14.9 million to a group of states. The case originated from a whistleblower (David Kester) under the False Claims Act. (DOJ announcement | FBI announcement | HHS-OIG)
-
Class Action Lawsuits — Additional lawsuits allege breaches of fiduciary duty under federal employee benefits laws, claiming that Accredo (as an in-house specialty pharmacy for a major PBM) overcharged health plans for specialty drugs. (LegalClarity overview)
-
State Enforcement — Delaware’s Attorney General resolved claims against Accredo related to customer service lapses, resulting in a $375,000 payment and operational improvement agreements. (Delaware AG announcement)
Assessment#
This is a case where both things can be true. Spinraza legitimately costs ~$125K per dose, so the high per-claim and per-beneficiary amounts may reflect the actual cost of the drug. However, Accredo has a proven history of participating in kickback schemes and fraudulent billing with other expensive drugs, which makes their billing patterns worth closer scrutiny. The prior $60 million settlement shows they have been willing to engage in schemes that inflate claims submitted to Medicare and Medicaid.
#3 — NPI 1568428621 — Mary M. Gooley Hemophilia Center, Inc.#
This is a federally designated Hemophilia Treatment Center located at 1415 Portland Ave, Suite 500, Rochester, NY 14621, serving the 14-county region around Rochester. It is a nonprofit 501(c)(3) organization led by President/CEO Tom Wilmarth. (Official website | ProPublica Nonprofit Explorer)
What They Are Billing#
Nearly all of their Medicaid claims are for a single code:
- J7170 — Hemlibra (emicizumab-kxwh), 0.5 mg — a bispecific monoclonal antibody used for prophylactic treatment of Hemophilia A. This is one of the most expensive ongoing treatments in medicine, costing $450,000 to $600,000 per patient per year.
- A tiny amount of billing for S9345 (likely a nursing/home infusion service code), totaling under $4,000.
| Metric | Value |
|---|---|
| Total Paid | ~$22.9 million |
| Total Claims | 1,379 |
| Total Beneficiaries | 777 |
| Distinct HCPCS codes | 2 (J7170 and S9345) |
| Months of activity | 47 |
| Avg Paid Per Claim | $16,595 |
| Paid Per Beneficiary | $29,453 |
| Fraud Signal Count | 3 |
Fraud Signals Triggered (3 of 5)#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High pay per claim | >$15,000 | $16,595 | Yes |
| High paid per beneficiary | >$27,156 | $29,453 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $22.9M with 2 codes | Yes |
| High claims per beneficiary | >139 | 1.77 | No |
| Ghost billing | >500 servicing providers | 1 | No |
Lawsuits and Public Records#
My searches found no lawsuits, fraud investigations, enforcement actions, or negative press about the Mary M. Gooley Hemophilia Center. Nothing on DOJ, HHS-OIG, FBI, or state attorney general sites.
Assessment#
This one looks like a legitimate specialty center that triggers the fraud signals purely because of the nature of hemophilia treatment:
- They are a federally designated Hemophilia Treatment Center — these are specifically authorized and funded through the federal 340B program.
- Hemlibra genuinely costs $450,000-$600,000/year per patient, so high per-claim and per-beneficiary amounts are expected.
- Low procedure diversity is inherent — a hemophilia center primarily administers clotting factor therapies.
- They have a clean public record, are a recognized nonprofit, and are affiliated with the National Bleeding Disorders Foundation (NBDF listing).
This is a good example of a false positive in the fraud risk model — the statistical signals are real, but the explanation is entirely legitimate given the provider’s specialty.
#4 — NPI 1851654909 — Diversified Children Youth & Families Development Program#
Also doing business as Diversified Developmental Services, Inc., located at 7815 Parkwood Dr, Little Rock, AR 72204. The CEO is Wanda Marie Hobbs. The organization is classified as a speech-language pathology multi-specialty group, but its primary business is providing community support services for individuals with developmental disabilities through the Arkansas Medicaid CES (Community and Employment Support) Waiver.
What They Are Billing#
Every single claim is for one code:
- H2016 — Comprehensive Community Support Services, per diem — This covers case management, skills training, medication management support, crisis intervention, and rehabilitation services for individuals with severe mental health conditions or developmental disabilities.
The billing pattern is notable:
| Metric | Value |
|---|---|
| Total Paid | ~$14.35 million |
| Total Claims | 907 |
| Total Beneficiaries | 363 |
| Distinct HCPCS codes | 1 |
| Months of activity | 19 |
| Avg Paid Per Claim | $15,827 |
| Paid Per Beneficiary | $39,545 |
| Fraud Signal Count | 3 |
Fraud Signals Triggered (3 of 5)#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High pay per claim | >$15,000 | $15,827 | Yes |
| High paid per beneficiary | >$27,156 | $39,545 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $14.35M with 1 code | Yes |
| High claims per beneficiary | >139 | 2.50 | No |
| Ghost billing | >500 servicing providers | 1 | No |
Red Flags#
This one looks more concerning than the previous providers:
-
H2016 is a community support per-diem code — this is not an expensive specialty drug or residential treatment. Typical reimbursement rates for H2016 range from roughly $50-$200 per diem depending on the state. Yet here, the average payment per claim is $15,827 — that is extremely high for a community support service.
-
Massive ramp-up in billing — The claims jump dramatically from ~$123K in January 2022 to over $2.7 million in a single month (November 2023). That kind of spike in a community support program is unusual.
-
Small organization, huge volume — This is a small developmental services provider in Little Rock serving 363 beneficiaries, yet billing $14.35 million over 19 months.
-
Federal lawsuit exists — There is a case Anderson v. Diversified Children Youth & Families Development Program (Case No. 4:2023cv00317) filed in the US District Court for the Eastern District of Arkansas in 2023. The full details are behind the PACER paywall, so the specific allegations are not publicly visible.
Assessment#
Unlike Melmark (#1, residential treatment) and Mary M. Gooley (#3, hemophilia drugs), the billing pattern here is difficult to explain through legitimate means. Community support services billed at $15,827 per diem per claim is orders of magnitude above typical rates for H2016. Combined with the rapid billing escalation, a single HCPCS code, and the existence of a federal lawsuit filed the same year billing peaked, this one warrants serious scrutiny.
This is the kind of provider the fraud risk model was designed to catch.
#5 — NPI 1831567858 — DHEC Hemophilia-CSHCN Program#
This is the South Carolina Department of Health and Environmental Control (DHEC) Hemophilia Program, part of the state’s Children with Special Health Care Needs (CSHCN) initiative. Located at 2100 Bull St, Columbia, SC 29201. This is a state government program — not a private company — classified as a pharmacy provider.
What They Are Billing#
Every single claim is for one code:
- J7189 — NovoSeven RT (Factor VIIa, recombinant), per 1 mcg — This is one of the most expensive hemophilia drugs available. It is used to prevent or control bleeding in patients with hemophilia A or B who have developed clotting factor inhibitors. A single dose can cost around $55,000 at retail, and patients with active bleeds may need multiple doses every 2-3 hours.
| Metric | Value |
|---|---|
| Total Paid | ~$13.3 million |
| Total Claims | 420 |
| Total Beneficiaries | 309 |
| Distinct HCPCS codes | 1 |
| Months of activity | 22 |
| Avg Paid Per Claim | $31,680 |
| Paid Per Beneficiary | $43,060 |
| Fraud Signal Count | 3 |
Fraud Signals Triggered (3 of 5)#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High pay per claim | >$15,000 | $31,680 | Yes |
| High paid per beneficiary | >$27,156 | $43,060 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $13.3M with 1 code | Yes |
| High claims per beneficiary | >139 | 1.36 | No |
| Ghost billing | >500 servicing providers | 1 | No |
Lawsuits and Public Records#
My search found no fraud lawsuits, investigations, or enforcement actions against the DHEC Hemophilia program. However, there is notable context:
-
As of March 1, 2023, SCDHHS transitioned the hemophilia factor program away from DHEC at DHEC’s own request, moving coverage to point-of-sale adjudication. The state estimated this would save approximately $131,000 annually. (SCDHHS notice)
-
The program historically served patients who were at or below 250% of the federal poverty level, ineligible for Medicaid/Medicare, and uninsured. (SC Hemophilia Assistance Program)
Assessment#
This is another clear false positive. This is literally a state government health department dispensing one of the most expensive drugs in medicine (NovoSeven RT at ~$55K per dose) to hemophilia patients. The high per-claim costs are entirely expected given the drug price, and the low procedure diversity is inherent — it is a single-purpose hemophilia pharmacy program.
Interestingly, the fact that South Carolina moved this program away from DHEC in 2023 and the billing data shows activity tapering around that time is consistent — the data corroborates the public record.
#6 — NPI 1124595764 — Safe Residential Care, LLC#
A residential treatment facility for individuals with physical disabilities, intellectual/developmental disabilities, and autism, located at 36 Patrick Dr, Westbrook, ME 04092. Manager is Karen Collins. Registered in November 2018.
What They Are Billing#
Every single claim is for one code:
- T2016 — Habilitation, Residential, Waiver; Per Diem — This is a daily rate for residential habilitation services provided under a Medicaid waiver (MaineCare Section 21), typically for adults with developmental disabilities or autism living in group home settings.
| Metric | Value |
|---|---|
| Total Paid | $94.6 million |
| Total Claims | 8,157 |
| Total Beneficiaries | 3,236 |
| Distinct HCPCS codes | 1 |
| Months of activity | 65 (Aug 2019 - Dec 2024) |
| Avg Paid Per Claim | $11,602 |
| Paid Per Beneficiary | $29,246 |
| Fraud Signal Count | 2 |
This is the highest total spend of any provider on the entire fraud risk list — nearly $95 million over about 5 years, all through a single billing code.
Red Flags#
-
$11,602 per claim for a residential per diem code. Maine’s base T2016 per diem rates historically range from roughly $23 to $288 depending on the modifier and support level. Even with COLA adjustments, $11,602 per claim is wildly above the published rate schedule. This suggests either very high-acuity modifiers, bundled multi-day claims, or billing anomalies.
-
Maine is currently in the middle of a Medicaid group home scandal. The Maine Wire reported in February 2026 that Maine’s Section 21 group home program is under intense scrutiny (Are Maine’s “Group Homes” the Next Medicaid Scandal to Unravel?). Key findings:
- Maine’s average T2016 claim is $1,671 vs. the national average of $482 — a 3.5x difference (MaineCare Fraud Risk Map)
- A $46 million HHS-OIG audit found suspected fraud in a related MaineCare program (Section 28, autism services)
- Law enforcement sources reported allegations of abuse, neglect, and sexual assault at group homes
- A Maine Wire reporter visited a MaineCare group home and found a disabled adult living in unsanitary conditions in an unfurnished house
-
Related fraud already confirmed in Maine. Gateway Community Services, another MaineCare provider, was found to have overbilled MaineCare by $1.6 million and was referred to a health care crime unit. A federal investigation was launched by Congressman James Comer. (Maine Public | NewsCenter Maine)
-
Only 52 oversight employees for 5,200 providers. Maine’s oversight capacity is extremely thin relative to the $5.4 billion MaineCare program.
Assessment#
While I did not find Safe Residential Care specifically named in any lawsuit or investigation, the context is damning. This is a $95 million provider billing a single residential per diem code at rates far above published fee schedules, operating in a state where the exact same type of program is currently under federal and state investigation for fraud. The broader Maine group home sector is being compared to the Minnesota Medicaid fraud scandal, which involved hundreds of millions in fraudulent claims.
This one deserves serious investigation.
#7 — NPI 1447745112 — Happy Haven, LLC#
A residential treatment facility for individuals with intellectual and developmental disabilities, located at 29 Fourth St, Auburn, ME 04210, with offices at 158 Court St, Suite 13, Auburn, ME. Owner/Manager is Amanda Karomba, who co-founded the company with her husband Gael Karomba in 2018. The Karombas are Rwandan immigrants; Amanda’s family fled the 1994 genocide.
Happy Haven currently operates over 30 group homes and employs more than 200 staff in the Lewiston-Auburn area, serving adults with intellectual and developmental disabilities under MaineCare Section 21. (Happy Haven website | NewsCenter Maine profile)
What They Are Billing#
Once again, every single claim is for one code:
- T2016 — Habilitation, Residential, Waiver; Per Diem — the same code as Safe Residential Care (#6).
| Metric | Value |
|---|---|
| Total Paid | $65.3 million |
| Total Claims | 10,325 |
| Total Beneficiaries | 2,336 |
| Distinct HCPCS codes | 1 |
| Months of activity | 73 |
| Avg Paid Per Claim | $6,326 |
| Paid Per Beneficiary | $27,961 |
| Fraud Signal Count | 2 |
The 158 Court St Connection#
Happy Haven’s office address is 158 Court St, Suite 13, Auburn, ME. That is the same address as Lighthouse Health Services, LLC, the Lewiston-based group home company that was specifically investigated by The Maine Wire in their February 2026 expose on Maine’s group home scandal. Lighthouse is registered to Lony Muguisha at 158 Court St, Auburn. (Maine Wire investigation)
I am not saying they are the same entity or that there is wrongdoing — 158 Court St appears to be a commercial office building with multiple suites. But the proximity is notable given the ongoing scrutiny of this address and the Maine group home sector broadly.
Context Within Maine’s T2016 Billing#
- Happy Haven: $6,326 per claim
- Safe Residential Care (#6): $11,602 per claim
- Maine statewide average: $1,671 per claim
- National average: $482 per claim
Both are well above the Maine average, and Maine itself is already 3.5x the national average.
Fraud Signals Triggered (2 of 5)#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High pay per claim | >$15,000 | $6,326 | No |
| High paid per beneficiary | >$27,156 | $27,961 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $65.3M with 1 code | Yes |
| High claims per beneficiary | >139 | 4.42 | No |
| Ghost billing | >500 servicing providers | 1 | No |
Lawsuits and Public Records#
My searches found no lawsuits, fraud investigations, or enforcement actions specifically naming Happy Haven or the Karombas. Amanda Karomba has testified before the Maine legislature advocating for higher MaineCare reimbursement rates and is active in community organizations including the Maine Association of Community Service Providers. (Legislative testimony)
Assessment#
This is a borderline case. Happy Haven is not named in any investigation, and the Karombas appear to be legitimate community members with a real operation serving a real population. The per-claim average of $6,326 is high but not as extreme as Safe Residential Care’s $11,602. However, $65.3 million flowing through a single billing code from a company founded in 2018 with ~30 group homes is a lot of money, and it exists squarely in the center of a sector that is currently under state and federal investigation in Maine.
#8 — NPI 1013030808 — Marie Green Psychiatric Healthcare Facility (County of Merced)#
A county-run psychiatric hospital located at 300 E 15th St, Merced, CA 95341, operated by the County of Merced Behavioral Health and Recovery Services. This is a government facility providing 24/7 acute inpatient psychiatric crisis care. Compliance Officer is Kurt Craig.
What They Are Billing#
Every claim is for one code:
- H2013 — Psychiatric Health Facility Service, Per Diem — inpatient psychiatric care billed on a daily rate.
| Metric | Value |
|---|---|
| Total Paid | $47.6 million |
| Total Claims | 2,578 |
| Total Beneficiaries | 2,248 |
| Distinct HCPCS codes | 1 |
| Months of activity | 73 |
| Avg Paid Per Claim | $18,464 |
| Paid Per Beneficiary | $21,175 |
| Fraud Signal Count | 2 |
Fraud Signals Triggered#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High pay per claim | >$15,000 | $18,464 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $47.6M with 1 code | Yes |
Lawsuits / Investigations#
No fraud lawsuits or Medicaid investigations found. Patient reviews mention understaffing and poor conditions, but no formal enforcement actions.
Assessment#
False positive. This is a county government psychiatric hospital — public sector, not a private billing operation. They bill a single per-diem code because that is how inpatient psychiatric facilities bill. The $18,464 per claim is high, but California Medi-Cal psychiatric inpatient per diem rates are set by the state’s Department of Health Care Services and vary by county. This is a legitimate government facility providing mandated crisis psychiatric services.
#9 — NPI 1396956462 — Baker Hall, Inc. (OLV Human Services)#
A psychiatric residential treatment facility located at 150 Martin Road, Lackawanna, NY 14218, doing business as OLV Human Services (formerly Baker Victory Services). CFO/COO is Laurel Parzych. This is a large nonprofit with nearly 1,000 employees providing residential treatment for youth ages 12-21 with mental health diagnoses, plus community-based and dental services. (OLV Human Services)
What They Are Billing#
Every claim is for one code, but the pattern is unique:
- 96150 — Health and Behavior Assessment/Intervention, per 15 minutes — a face-to-face behavioral health assessment code billed in 15-minute increments (note: this code was replaced by 96156 in 2020, but legacy claims may still appear).
The billing goes through a single servicing provider NPI (1568442465).
| Metric | Value |
|---|---|
| Total Paid | $47.3 million |
| Total Claims | 43,706 |
| Total Beneficiaries | 1,626 |
| Distinct HCPCS codes | 1 |
| Months of activity | 71 |
| Servicing providers | 2 |
| Avg Paid Per Claim | $1,083 |
| Claims Per Beneficiary | 26.9 |
| Paid Per Beneficiary | $29,103 |
| Fraud Signal Count | 2 |
Fraud Signals Triggered#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High paid per beneficiary | >$27,156 | $29,103 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $47.3M with 1 code | Yes |
Red Flags#
-
$47.3 million through a single 15-minute assessment code. Code 96150 is a health behavior assessment billed per 15 minutes. At $1,083 per claim, each “claim” represents roughly 7-10+ hours of face-to-face assessment time at typical reimbursement rates. That is an unusual volume.
-
26.9 claims per beneficiary — Each of the 1,626 beneficiaries averages nearly 27 claims over the period. For a 15-minute assessment code, that is a lot of repeated assessments on the same patients.
-
Prior fraud settlement. In 2012, the NY Attorney General’s Medicaid Fraud Control Unit settled with Baker Victory Health Services Dental Center for $325,000 over fraudulent dental billing — performing unnecessary procedures and splitting procedures across multiple visits to inflate billing. (AG Schneiderman announcement)
Assessment#
Suspicious. The prior $325K dental fraud settlement shows a pattern of billing manipulation (splitting services to inflate claims). The current billing — $47.3 million through a single 15-minute assessment code across 43,706 claims — is unusual for a residential treatment facility. Residential treatment would typically bill under per-diem or bundled service codes, not a high-volume 15-minute assessment code. The combination of prior fraud history and anomalous billing patterns makes this one worth investigating.
#10 — NPI 1811473291 — Serenity Residential Care, LLC#
A residential care provider for individuals with intellectual disabilities and cognitive disorders, located at 570 Brighton Ave, Portland, ME 04102, with homes in Windham, Westbrook, and South Portland. HR Director is Magda Darling. Registered July 2018. (Serenity Residential Cares)
What They Are Billing#
Once again, all claims are for one code:
- T2016 — Habilitation, Residential, Waiver; Per Diem — the same MaineCare Section 21 group home code as Safe Residential Care (#6) and Happy Haven (#7).
| Metric | Value |
|---|---|
| Total Paid | $34.4 million |
| Total Claims | 5,409 |
| Total Beneficiaries | 1,203 |
| Distinct HCPCS codes | 1 |
| Months of activity | 61 |
| Avg Paid Per Claim | $6,362 |
| Paid Per Beneficiary | $28,605 |
| Fraud Signal Count | 2 |
Fraud Signals Triggered#
| Signal | Threshold | Value | Triggered? |
|---|---|---|---|
| High paid per beneficiary | >$27,156 | $28,605 | Yes |
| Low procedure diversity | >$10M with <=3 codes | $34.4M with 1 code | Yes |
Lawsuits / Investigations#
No lawsuits or investigations found specifically naming Serenity Residential Care.
Assessment#
This is the third Maine T2016 group home in the top 10. Serenity Residential Care has a nearly identical profile to Happy Haven (#7) — same code, same state, same sector, similar per-claim averages, registered within months of each other (both mid-2018). The Maine group home sector is now three of the top ten fraud risk providers:
| Provider | Total Paid | Avg/Claim | Registered |
|---|---|---|---|
| Safe Residential Care (#6) | $94.6M | $11,602 | Nov 2018 |
| Happy Haven (#7) | $65.3M | $6,326 | Jun 2018 |
| Serenity Residential Care (#10) | $34.4M | $6,362 | Jul 2018 |
| Combined | $194.3M |
That is $194.3 million flowing through three Maine group home providers, all registered within a 6-month window in 2018, all billing exclusively T2016, in a state where the average T2016 claim is already 3.5x the national average and where the broader group home sector is under active state and federal investigation.
Conclusion#
Can Claude find fraud? I think the answer is yes.
This analysis took about five hours to generate. These are really promising results and we’re just getting started! Stay tuned for more to come.
If you want to discuss more use cases for Dolt and agent mode, come by our Discord.