Texas Mental Healthcare Counselor Pleads Guilty to Overbilling Medicare and Medicaid
A 59-year-old mental healthcare counselor recently pleaded guilty to healthcare fraud in a Texas federal district court.
Information presented in court showed that since 2007, the defendant had owned a counseling service and had been the provider of mental health counseling services for which he billed Medicaid, Medicare, and private insurance companies. Between 2007 and 2019, the defendant submitted over 10,000 claims for visits and received reimbursements of $591,600.69. The defendant used three different time-based counseling CPT codes—all for periods of 30 or more minutes. Medicaid rules require that all of that time be spent in face-to-face sessions with the patient. Including documentation and other administrative activities in that time is expressly forbidden.
The investigators, during a months-long period, discovered that the counselor had scheduled patient sessions in 30-minute increments; however, some were double-booked. Out of 10,215 claims submitted by the defendant, only one was for a 30-minute visit—the remainder were all billed under 45- or 60-minute CPT codes providing increased reimbursement rates. Instead of the $591,600.69 the defendant received, he was only entitled to $321,772.50. His fraudulently submitted claims resulted in overpayments by Medicaid of $269,828.
Consequently, the convicted mental healthcare counselor faces up to 10 years in federal prison.
Compliance Perspective
Deliberately submitting claims for reimbursement to Medicaid, Medicare, or an insurance provider for mental healthcare counseling or other services that were not provided or that were actually provided under codes paying lower reimbursement rates may be considered a violation of the federal False Claims Act and result in sanctions and possible prison time.
Discussion Points:
- Review policies and procedures designed to prevent violations of the False Claims Act and result in accurately submitted claims using appropriate reimbursement codes for services that were actually provided as billed.
- Train staff who are responsible for submitting claims to Medicare, Medicaid, and other insurance companies, to carefully review any claims to ensure that services were provided and that the amount of time involved in providing those services was not upcoded to a higher, incorrect reimbursement rate.
- Periodically audit claims submitted to ensure that services being billed have accurate codes, are necessary for the resident, and that documentation supports the time and service listed in the request for payment.
