ELENA MICHELLE WAGNER, MD

Elena Wagner is an individual provider in Seattle, Washington, enrolled with Washington Medicaid under taxonomy 207V00000X. In 16 different months her Medicaid claims add up to more clinical hours in a day than one person can work, with one month, July 2018, implying about 52.7 hours in a calendar day of personal services and $180,067 in office visit payments. During those months the claims came in through several different billing organizations at once, as many as seven, and the volume reached up to 1,133 patients in a month, so the pattern may reflect a supervising clinician listed on work done by others rather than one person's own hours. Separately, her Medicaid payments per patient-month on the moderate level established patient visit code 99214 are $210 against a typical $60, placing her in the top one percent of providers billing that code. In Medicare 2024 she submitted $4,250 per service for a uterine lining biopsy code against $243 allowed, a ratio of 17.5 times where the usual ratio is 4.7 times. None of this shows wrongdoing on its own, and records are needed to explain it.

1. 01NPI 1023351970 is registered to Elena Wagner, an individual provider in Seattle, Washington, with taxonomy 207V00000X and Medicaid home state Washington. records 1
2. 02The provider risk record places this subject at evidence tier 4 for structure or single-organization volume, with detector D2 and dollars at risk of $1,879,895, described as the figure of the detector that set the tier rather than a sum. records 12
3. 03The stated reason for the flag is hours beyond a day in 16 months, but with up to 1,133 patients a month across 7 billing organizations, which the record says points to a supervising clinician on the claims rather than one person's hours, and records are needed. records 12
4. 04For the month beginning July 1, 2018, the impossible conservative rate flag shows implied hours per clinician calendar day of personal services of 52.7, with a lower bound of 12.7 and a point estimate of 79.1, covering $180,067 across office visit codes 99201, 99202, 99203, 99211, 99212, 99213 and 99214 and 6 billing organizations. records 13
5. 05For the month beginning October 1, 2018, the same flag shows implied hours of 44.4, with a lower bound of 10.1 and a point estimate of 66.6, covering $140,070 across the same office visit codes and 7 billing organizations. records 17
6. 06For the month beginning June 1, 2018, the flag shows implied hours of 40.9, with a lower bound of 9.1 and a point estimate of 61.3, covering $127,445 and 5 billing organizations. records 19
7. 07For the month beginning April 1, 2018, the flag shows implied hours of 38.4, with a lower bound of 10.4 and a point estimate of 57.6, covering $122,096 and 5 billing organizations. records 23
8. 08For the month beginning June 1, 2019, the flag shows implied hours of 36.3, with a lower bound of 7.2 and a point estimate of 54.5, covering $95,812 and 7 billing organizations. records 24
9. 09Additional flagged months include March 2018 at 26.8 implied hours and $93,511, May 2018 at 33.8 implied hours and $110,691, August 2018 at 26.4 implied hours and $88,108, September 2018 at 29.0 implied hours and $88,126, November 2018 at 29.9 implied hours and $91,786, and December 2018 at 31.0 implied hours and $100,981. records 28, 26, 21, 20, 16, 18
10. 10Flagged months continue into 2019 and 2020, with January 2019 at 32.1 implied hours and $92,505, February 2019 at 31.8 implied hours and $81,418, March 2019 at 32.2 implied hours and $90,597, April 2019 at 28.5 implied hours and $74,702, and July 2020 at 25.9 implied hours and $61,628. records 27, 22, 15, 25, 14
11. 11In every flagged month the rate source is listed as the median per line, described in the records as p50 per line. records 13, 17, 19, 23, 24
12. 12Medicaid paid $840,525 over 29 months on code 99214, established patient office or other outpatient visit with moderate level of decision making, which is 30 percent of this provider's Medicaid dollars and $210 per patient-month against a typical $60, ranking at the 99th percentile of all providers billing that code. records 2, 12
13. 13Medicaid paid $481,248 over 28 months on code 99213 at $132 per patient-month against a typical $44, ranking at the 97th percentile. records 3
14. 14Medicaid paid $211,290 over 21 months on code 99202, a new patient visit with straightforward medical decision making, at $203 per patient-month against a typical $45, ranking at the 98th percentile. records 5
15. 15Medicaid paid $173,346 over 25 months on code 99212 at $101 per patient-month against a typical $28, ranking at the 91st percentile, and $168,514 over 26 months on code 87806, an HIV detection test by immunoassay, at $33 per patient-month against a typical $25, ranking at the 92nd percentile. records 6, 7
16. 16Medicaid paid $308,157 over 22 months on code S4993 at $129 per patient-month against a typical $77, ranking at the 77th percentile. records 4
17. 17In Medicare 2024, code 58558, biopsy of the lining of the uterus and or removal of a polyp using an endoscope, shows 14 services for 14 beneficiaries and $2,713 paid, with $4,250 submitted per service against $243 allowed, a ratio of 17.5 times where the usual ratio for that code is 4.7 times. records 9
18. 18In Medicare 2024, code 99214 shows 32 services for 22 beneficiaries and $2,936 paid at a submitted to allowed ratio of 2.5 times against a usual 2.3 times, code 99204 shows 15 services for 15 beneficiaries and $1,857 paid at 2.6 times against a usual 2.4 times, and code 99213 shows 21 services for 17 beneficiaries and $1,309 paid at 2.6 times against a usual 2.2 times. records 8, 10, 11

Open a records request before any payment action. First, obtain from the Washington Medicaid agency the full claim detail for the 16 flagged months from March 2018 through July 2020, including the rendering and billing provider identifiers on each line, so the seven billing organizations that submitted under this NPI can be identified and the rendering clinician on each claim confirmed. Second, request appointment schedules, sign-in logs, time records and the treatment notes for a sample of dates in the highest exposure months, July 2018, October 2018, June 2018 and April 2018, to test whether the services attributed to this provider were personally performed or performed by supervised staff. Third, request the documentation supporting the level of service on codes 99214, 99213, 99202 and 99212 for a sampled set of dates, given the top 5 percent standing on dollars per patient for code 99214. Fourth, obtain the chargemaster or fee schedule basis for the Medicare 2024 submitted amount of $4,250 per service on code 58558. Fifth, verify current enrollment, ownership and screening status for this provider and for each of the seven billing organizations, and confirm that revalidation is current, under 42 CFR 455.410, which requires all providers to be screened under subpart E as a condition of enrollment and requires states to revalidate enrollment at least every 5 years. If the records review establishes a credible allegation of fraud for which an investigation is pending, refer to the Medicaid Fraud Control Unit and evaluate payment suspension under 42 CFR 455.23(a) and (d), including whether good cause exists not to suspend or to suspend only in part. If the review shows claims were presented for items or services not provided as claimed, refer for consideration of civil monetary penalties under 42 CFR 1003.200. Do not take payment action on the detector output alone.

• The risk record itself states that with up to 1,133 patients a month across 7 billing organizations the pattern points to a supervising clinician on the claims rather than one person's own hours, so supervisory and incident to billing conventions must be ruled out first.
• The implied hours figures are model estimates built on a median time per line, and in every flagged month the stated lower bound is well below the point estimate, for example 12.7 hours against a point estimate of 79.1 in July 2018, so the conservative reading may not by itself be impossible for a staffed practice.
• Claims submitted through multiple billing organizations may reflect employment at several clinics, locum or coverage arrangements, or a group that reassigned benefits, rather than any single practice location.
• Submitted charge amounts, including the $4,250 per service on Medicare code 58558, do not determine payment; the Medicare allowed amount was $243 and total paid was $2,713, and high list prices can reflect a chargemaster convention.
• High dollars per patient-month on office visit codes can reflect a genuinely complex or high acuity panel, and the percentile comparison does not adjust for patient mix or specialty.
• Claims data is subject to lag, adjustments, voids and reprocessing, so month level totals and service counts should be refreshed before any action.
• Any prior enrollment action, appeal, reinstatement or settlement involving this provider or the associated billing organizations should be checked, since resolved matters may already explain part of the pattern.