SIGRID Y ELSTON, Ph.D.

Sigrid Elston is listed in the national provider file as an individual provider with an Atlanta, Georgia address and a Medicaid home state of Indiana. Medicaid paid more than eleven million dollars on the applied behavior analysis technician code 97153 over thirty months, plus about two and a half million dollars on the related professional code 97155. In nine separate months, the claims tied to this provider add up to more hands-on service time than a calendar day contains, with one month reaching 31.4 implied hours in a day, and the claims in those months come from three different billing organizations. About 97 percent of the Medicaid dollars sit on code families that have a history of billing abuse. These are patterns in paid claims records only, and there is no finding here about intent or wrongdoing.

1. 01The national provider file lists NPI 1003839317 for Sigrid Elston as an individual provider in Atlanta, Georgia, with taxonomy 103TC1900X and a Medicaid home state of Indiana. records 1
2. 02Code 97153, adaptive behavior treatment by protocol delivered by a technician, was paid $11,177,970 over 30 months, representing 74 percent of this provider's Medicaid dollars, at $11,668 per patient-month against a typical $1,554, ranking at the 99th percentile of all providers billing that code. records 2
3. 03Code 97155, adaptive behavior treatment with protocol modification by a qualified health professional, was paid $2,467,114 over 26 months at $2,892 per patient-month against a typical $512, ranking at the 99th percentile. records 3
4. 04Code 90837, one hour of psychotherapy, was paid $1,083,772 over 57 months at $286 per patient-month against a typical $191, ranking at the 81st percentile. records 4
5. 05Code 97151, behavior identification assessment by a professional in 15 minute units, was paid $100,391 over 7 months at $930 per patient-month against a typical $389, ranking at the 91st percentile. records 6
6. 06The risk record places the provider at evidence tier 2 for impossible volume with concurrency, cites detector D2, and lists dollars at risk of $14,148,685, described as the figure of the detector that set the tier and not a sum. records 8
7. 07The stated reasons include billing more hands-on hours than a day holds in nine months, peaking at 31.4 hours per day across three billing organizations, and that 97 percent of Medicaid dollars fall on codes with a history of abuse. records 8
8. 08For the month beginning March 1, 2022, the flag records implied hours per clinician calendar day of 31.4 with a lower bound of 24.3 and a point estimate of 81.8, $1,029,378 in spending, three billing organizations, and codes 90837, 90846, 97151, 97153, 97155 and 97156. records 11
9. 09For the month beginning February 1, 2022, the flag records implied hours per clinician calendar day of 30.5 with a lower bound of 23.5 and a point estimate of 77.5, $867,138 in spending, and three billing organizations. records 17
10. 10For the month beginning March 1, 2021, the flag records implied hours per clinician calendar day of 27.6 with a lower bound of 27.1, $620,290 in spending, three billing organizations, and nine distinct procedure codes including 90791, 90832, 90834, 90837, 90846, 97151, 97153, 97155 and 97156. records 9
11. 11For the month beginning April 1, 2021, a flag based on line counts rather than a conservative rate records implied hours per clinician calendar day of 25.1 with a lower bound of 31.5, $636,309 in spending, and three billing organizations. records 15
12. 12Additional months carrying the same impossible conservative rate flag include November 2021 at 24.3 implied hours and $657,225, December 2021 at 25.7 implied hours and $583,226, October 2021 at 26.9 implied hours and $789,811, May 2021 at 24.1 implied hours and $656,037 across two billing organizations, and April 2022 at 24.8 implied hours and $797,258. records 10, 12, 16, 13, 14

Request from the state Medicaid agency and the three billing organizations the full claim detail for the nine flagged months, including rendering and billing provider identifiers on every line, service start and stop times, session notes, and technician supervision logs for codes 97153, 97155 and 97151. Obtain payroll and scheduling records for the technicians whose services were billed under this provider, along with the treatment plans and authorizations supporting the per patient-month amounts on code 97153. Verify enrollment, screening and revalidation status in Indiana and any other state of enrollment under 42 CFR 455.410, which requires screening under subpart E as a condition of enrollment and revalidation at least every five years, and confirm no excluded person furnished the services, which is relevant under 42 CFR 1003.200 covering claims for items or services not provided as claimed or furnished by an excluded person. If the records review supports a credible allegation of fraud, the state must refer the matter to the Medicaid Fraud Control Unit and address payment suspension under 42 CFR 455.23(a) and (d), including any good cause determination not to suspend or to suspend only in part.

• Applied behavior analysis is commonly delivered by technicians and billed under a supervising professional, so hours attributed to one individual identifier may represent the combined work of many staff; the rendering versus billing identifier on each line must be checked before any conclusion is drawn.
• The provider appears across three billing organizations, and group or agency billing conventions can concentrate an entire team's service time under a single individual identifier.
• The implied hours figures are derived from per line rate assumptions using median and trimmed fifth percentile per line rates, and in several months the stated lower bound and the reported implied hours diverge, so unit to minute conversions should be recomputed from actual claim units.
• Percentile comparisons on codes 97153 and 97155 can be distorted by a small or high intensity caseload, by authorized high hour treatment plans, or by patients receiving full day programming.
• Paid claims data can lag, and adjustments, voids, recoupments, appeals and reinstatements may change the paid amounts and the months in which services are counted.
• An Atlanta, Georgia practice address with an Indiana Medicaid home state may reflect a corporate or mailing address rather than the service location, and the national provider file may not be current.
• The note that certain code families have a history of abuse is a general statement about the codes and not an observation about this provider's claims.