PRIYANKA JAIN, MD

NPI 1275791881, individual, Merced, CA, Ophthalmology

Evidence tier

structure or single-organization volume

Hours beyond a day in 2 months, but with up to 506 patients a month, which points to a supervising clinician on the claims rather than one person's hours.
Records needed.
Medicaid dollars per patient on code 92004 ($134 per patient-month) sit in the top 5% of every provider billing that code.

score 55 of 100, rank 7905, $634K at stake

Hours billed per day

Medicaid billing converted into hours of hands-on care per day. The lower bound counts one unit per claim line and needs no price; the other two divide dollars by a unit price, the conservative one at 1.5 times the price. The clinician on the claim may be a supervisor under state rules, so billing organizations are counted too.

month	what was found	hours per day, lower bound	hours per day, at price	hours per day, conservative	per working day	patients	billing organizations	codes	paid
Oct 2024	More hours than a day holds at a conservative unit price	7.7	42.2	28.1	37.9	506	1	99204 99213 99214	$58K
Nov 2024	More hours than a day holds at a conservative unit price	6.0	44.1	29.4	42.0	392	1	99204 99213 99214	$57K

National provider registry

From the CMS NPPES Registry, refreshed daily.

Name	PRIYANKA JAIN, MD
Type	Individual
Status	Active
NPI issued	May 30, 2008, last updated April 24, 2023
Practice location	1100 OLIVEWOOD DR, Merced, CA 95348-1210, 209-325-4149
Specialties	Ophthalmology (207W00000X, license MD.206872 LA) Ophthalmology (207W00000X, primary, license C161938 CA)

Procedures billed

The specific codes behind the dollars. Medicaid figures come from T-MSIS (2018 to 2024) and are compared with every other provider billing the same code; Medicare figures come from the 2024 physician and supplier file and compare this provider's submitted charge with what Medicare allowed, against the usual ratio for that code.

Medicaid, largest codes

code	what it is	paid	share	per patient-month	typical	rank among providers
92004	New patient complete exam of visual system	$392K	19%	$134	$64 (top 5% from $129)	96th percentile
99204	New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more	$277K	13%	$140	$95 (top 5% from $171)	84th percentile
99214	Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	$246K	12%	$116	$60 (top 5% from $133)	92nd percentile
92012	Established patient problem focused exam of visual system	$239K	11%	$68	$39 (top 5% from $88)	85th percentile
99213	Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more	$207K	10%	$83	$44 (top 5% from $110)	89th percentile
66984	Removal of cataract with insertion of prosthetic lens	$172K	8%	$269	$332 (top 5% from $1K)	35th percentile
92134	Imaging of retina	$126K	6%	$28	$18 (top 5% from $37)	85th percentile
92250	Photography of the retina	$86K	4%	$35	$29 (top 5% from $52)	66th percentile

Medicare Part B 2024, largest codes

code	what it is	services	beneficiaries	paid	submitted per service	allowed per service	charge to allowed	usual for this code
J0178	Injection, aflibercept, 1 mg	210	31	$138K	$2K	$824	2.0x	1.8x (90th percentile 3.1x)
66984	Removal of cataract with insertion of prosthetic lens	215	156	$90K	$1K	$541	2.1x	3.2x (90th percentile 7.0x)
92014	Established patient complete exam of visual system	844	618	$77K	$265	$131	2.0x	1.4x (90th percentile 2.7x)
99214	Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more	688	485	$58K	$263	$130	2.0x	2.3x (90th percentile 3.8x)
92012	Established patient problem focused exam of visual system	845	498	$54K	$188	$93	2.0x	1.6x (90th percentile 2.9x)
66982	Complex removal of cataract with insertion of prosthetic lens	87	75	$50K	$2K	$745	2.0x	3.4x (90th percentile 6.7x)
92134	Imaging of retina	1,477	1,114	$42K	$85	$42	2.0x	2.5x (90th percentile 4.7x)
99204	New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more	417	417	$39K	$341	$169	2.0x	2.4x (90th percentile 3.9x)

A submitted charge many times the allowed amount is common and lawful; it matters when it is far above what other providers submit for the same code.

In this area

23 providers in Merced County, CA carry an indicator in the public record, with $29.5M at stake between them. The most common is more hours than a day holds, on 20 of them, followed by part of a provider network on 2. 1 is tier 1: documented action, then payment.

tier	provider	at stake	why
1	RODOLFO GARCIA Los Banos, CA, ranked 425	$288	Listed on the CA Medicaid exclusion list since May 10, 2019. Medicaid still paid claims in 1 later month, $288 in total.
3	BRISTOL HOSPICE - CALIFORNIA, LLC Merced, CA, ranked 1211	$338K	Part of provider network D1-00104, ranked 104 nationally.
3	AVALON CARE CENTER-MERCED FRANCISCAN LLC Merced, CA, ranked 4649	$0	Part of provider network D1-00104, ranked 104 nationally.
4	MIRANDA FURIE Merced, CA, ranked 7284	$7.6M	Hours beyond a day in 30 months, but with up to 742 patients a month, which points to a supervising clinician on the claims rather than one person's hours. Records needed. and 2 more
4	ABHILASHA SHARMA Merced, CA, ranked 7961	$423K	Hours beyond a day in 26 months, but with up to 4678 patients a month across 4 billing organizations, which points to a supervising clinician on the claims rather than one person's hours. Records needed. and 1 more
4	KARTHIKEYA DEVIREDDY Los Banos, CA, ranked 8509	$3.4M	Hours beyond a day in 80 months, but with up to 4201 patients a month across 4 billing organizations, which points to a supervising clinician on the claims rather than one person's hours. Records needed.
4	GEORGE ALKHOURI Merced, CA, ranked 8725	$2.0M	Hours beyond a day in 23 months, but with up to 1649 patients a month across 3 billing organizations, which points to a supervising clinician on the claims rather than one person's hours. Records needed.
4	ELLEN PIERNOT Merced, CA, ranked 8971	$1.0M	Hours beyond a day in 46 months, but with up to 9907 patients a month across 17 billing organizations, which points to a supervising clinician on the claims rather than one person's hours. Records needed.

All 23 in CA

Recent enforcement in CA

All releases

Department of Justice and HHS-OIG releases for this state, newest first. Each opens in a new tab.

DOJPleaded guiltyAug 27, 2026

Anaheim Woman Pleads Guilty to Submitting More Than $2.2 Million in Fraudulent Hospice Care Claims to Medicare

Galbraith submitted approximately $2,266,694 in claims to Medicare for hospice services for beneficiaries who did not have a terminal illness with a life expectancy of six months or less, and Medicare paid her company approximately $2,140,606.

DOJCivil settlementAug 26, 2026

DermTech Inc. to Pay Up to $5M to Resolve Allegations It Submitted False Claims to Medicare for Unreliable Skin Cancer Tests

DermTech Inc. submitted claims to Medicare for skin cancer tests conducted with an unvalidated positive control range and for tests lacking sufficient patient RNA, and did not retract results or adequately refund Medicare.

DOJCivil settlementAug 26, 2026

DermTech Inc. to Pay Up to $5M to Resolve Allegations It Submitted False Claims to Medicare for Unreliable Skin Cancer Tests

DermTech Inc. billed Medicare for skin cancer tests conducted using an unvalidated positive control range and for tests with insufficient patient RNA, and did not retract the results or adequately refund Medicare.

DOJCivil settlementAug 24, 2026

Medicare Advantage Provider Monogram Health Agrees to Pay $2.4 Million to Settle False Claims Act Lawsuit

Monogram knowingly submitted diagnosis codes in four HCCs that were not clinically accurate, not supported by medical record documentation, and/or did not require or affect patient care, inflating Medicare Advantage beneficiaries' risk scores and causing CMS to make higher capitated payments to Medicare Advantage Organizations.

DOJCivil settlementAug 24, 2026

Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit

Monogram Health knowingly submitted diagnosis codes within four HCCs that were not clinically accurate, not supported by medical record documentation, and/or did not require or affect patient care, inflating Medicare Advantage beneficiaries' risk scores and causing CMS to make higher capitated payments to MAOs.

Referral packet

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